United States District Court, N.D. Alabama, Western Division
MEMORANDUM OPINION I. INTRODUCTION
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.
September 19, 2014, the claimant, Sandra Wrenn, applied for a
period of disability, disability insurance benefits, and
supplemental security income, alleging that she became
disabled on April 22, 2014, because of glaucoma, diabetes,
back pain, carpal tunnel syndrome, high blood pressure,
anxiety, depression, and drowsiness from medication. (R.
39-50, 57-58, 80, 193). The commissioner denied the
claimant’s claims on December 24, 2014. (R. 101-105).
The claimant timely filed a request for a hearing before an
Administrative Law Judge, and the ALJ held a video hearing on
October 24, 2016. (R. 85-86).
decision dated April 18, 2017, the ALJ found that the
claimant was not disabled and, therefore, ineligible for the
requested benefits. (R. 16-33). On appeal, the Appeals
Council denied the claimant’s request for review on
March 8, 2018. (R. 1-6). The claimant has exhausted her
administrative remedies, and this court has jurisdiction
pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For
the reasons stated below, this court REVERSES and REMANDS the
decision of the Commissioner.
the ALJ’s residual functional capacity finding
regarding the claimant’s vision limitations lacks
STANDARD OF REVIEW
standard for reviewing the Commissioner’s decision is
limited. This court must affirm the ALJ’s decision if
he applied the correct legal standards and if substantial
evidence supports his factual conclusions. See 42
U.S.C. § 405(g); Graham v. Apfel, 129 F.3d
1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826
F.2d 996, 999 (11th Cir. 1987).
. . . presumption of validity attaches to the
[Commissioner’s] legal conclusions, including
determination of the proper standards to be applied in
evaluating claims.” Walker, 826 F.2d at 999.
This court does not review the Commissioner’s factual
determinations de novo. The court will affirm those
factual determinations that are supported by substantial
evidence. “Substantial evidence” is “more
than a mere scintilla. It means such relevant evidence as a
reasonable mind might accept as adequate to support a
conclusion.” Richardson v. Perales, 402 U.S.
389, 402 (1971).
court must keep in mind that opinions, such as whether a
claimant is disabled, the nature and extent of a
claimant’s residual functional capacity, and the
application of vocational factors, “are not medical
opinions, . . . but are, instead, opinions on issues reserved
to the Commissioner because they are administrative findings
that are dispositive of a case; i.e., that would direct the
determination or decision of disability.” 20 C.F.R.
§§ 404.1527(d), 416.927(d). Whether the claimant
meets the listing and is qualified for Social Security
disability benefits is a question reserved for the ALJ, and
the court “may not decide facts anew, reweigh the
evidence, or substitute [its] judgment for that of the
Commissioner.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Thus, even if the court were to
disagree with the ALJ about the significance of certain
facts, the court has no power to reverse that finding as
long as substantial evidence in the record supports it.
court must “scrutinize the record in its entirety to
determine the reasonableness of the [ALJ]’s factual
findings.” Walker, 826 F.2d at 999. A
reviewing court must not only look to those parts of the
record that support the decision of the ALJ but also must
view the record in its entirety and take account of evidence
that detracts from the evidence relied on by the ALJ.
Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir.
to 20 C.F.R. § 404.1520, an ALJ must follow a five-step
sequential process for determining disability. At step four,
the ALJ must assess the claimant’s residual functional
capacity. The RFC is an ALJ’s assessment, “based
on all the relevant medical and other evidence, of a
claimant’s remaining ability despite [her]
impairment.” Castle v. Colvin, 557 Fed.Appx.
849, 852 (11th Cir. 2014). In determining the
claimant’s RFC, the ALJ is required to consider the
claimant’s descriptions and observations of her
limitations resulting from her severe impairments.
See 20 C.F.R. § 404.1545(a)(3).
support his RFC determination with substantial evidence, the
ALJ must “provide a sufficient rationale to link
substantial record evidence to the legal conclusions
reached.” Dennison v. Saul, CA 18-0532-MU,
2019 WL 3468180 *3 (S.D. Ala. July 31, 2019). The ALJ must
“link the RFC assessment to specific evidence in the
record bearing upon the claimant’s ability to perform
the physical, mental, sensory, and other requirements of
work.” Packer v. Astrue, 2013 WL 593497, *4
(S.D. Ala. Feb. 14, 2013), aff’d, 542 Fed.Appx. 890
(11th Cir. Oct. 29, 2013).
claimant was fifty-one-years old with a high school
education when the ALJ rendered his decision. (R.
16, 193, 281). The claimant has past relevant work experience
as a machine packager and as a fish cleaner, machine tender.
(R. 68). The claimant alleged she was disabled beginning
April 22, 2014, from glaucoma, diabetes, back pain, carpal
tunnel syndrome, high blood pressure, anxiety, depression,
and drowsiness from medication. (R. 39-50, 57-58, 80, 193).
and Mental Impairments
March 25, 2011, the claimant sought treatment at the York
Health Clinic for back and wrist pain. The claimant’s
hand and fingers were swollen from using her hands at work.
Dr. Houston diagnosed the claimant with carpal tunnel
syndrome. (R. 312, 313).
Leroy Maxwell at the Eye Max Vision Center treated the
claimant on February 27 and March 6, 2014 for blurry vision
associated with glaucoma. Dr. Maxwell prescribed Alphagan and
Azopt eye drops to treat the increased eye pressure caused by
her glaucoma. (R. 328, 334).
claimant saw Dr. Colie Crutcher on April 24, 2014, at Colie
Crutcher, Jr., M.D. & Associates, complaining of lower
abdominal and back pain after twisting her back carrying
boxes at work. After a physical examination, Dr. Crutcher
noted the claimant’s lumbosacral spasms. Further, Dr.
Crutcher noted that the claimant’s neurological
examination was within normal limits. (R. 344, 345, 347,
returned to Dr. Crutcher on May 7 and 21, 2014, both times
complaining of back pain. Dr. Crutcher noted that the
claimant had back spasms during both physical examinations;
that her pain was a little better when she was lying down or
slightly bent over; that the claimant was unable to drive and
planned to take a leave of absence from work; that she could
not keep her shoes on long because of pain; that none of the
claimant’s medications were working; and that she could
not sit down for thirty minutes because of her pain. (R.
claimant went to Keen Health and Wellness Center on June 2,
2014 for back pain. The claimant reported to Nurse
Practitioner Terre Moore that on April 22, 2014, while
carrying boxes at work, she twisted her back. The claimant
explained to NP Moore that Dr. Crutcher gave her two
injections for her back pain, and that he ordered an MRI that
insurance would not approve. She described her lower back
pain at this visit as throbbing, sharp pain that radiated
down both legs. During the physical examination, NP Moore
indicated that the claimant “jumps when I touch
her” back, and that her straight leg raises were
positive. (R. 320-21).
Moore ordered an MRI of the thoracic spine that revealed mild
multilevel degenerative disc changes with a minimal disc
bulging at the lower thoracic level, with no focal disc
protrusion, cord impingement, or canal stenosis. An MRI of
the lumbar spine revealed a small central focal disc
protrusion at ¶ 5-S1 that mildly deformed the anterior
margin of the thecal sac without central canal narrowing or
nerve root displacement. The MRI records indicate a mild disc
bulging at ¶ 4-L5 and mild disc bulging and narrowing of
the neural foramina at ¶ 3-L4, slightly more on the
left. (R. 320, 325, 326).
the claimant returned to Dr. Crutcher for a follow-up visit
on June 18, 2014, he again noted that the claimant had back
spasms and had “months of pain.” During the July
23, 2014 follow-up, the claimant indicated she was in
“a great deal of discomfort.” Dr. Crutcher noted
the claimant’s back, leg and foot pain, and noted that
she had muscle spasms in her back upon physical examination.
He noted the claimant’s recent MRI that revealed
minimal disc bulging and referred her to neurosurgery
“ASAP.” During the August 25, 2014 follow-up, Dr.
Crutcher noted the claimant’s continued back pain and
spasms and noted “spinal injection approval.”
When the claimant returned to Keen Health & Wellness
Clinic on July 28, 2014 for a follow-up for her back pain,
the doctor noted that the claimant’s lower back was
tender upon physical examination; that the claimant’s
back pain persisted but was a “tiny bit better”;
and that he was referring her to a neurosurgeon. (R. 328).
follow-up visits with Dr. Maxwell on September 4 and 18,
2014, the claimant’s vision was blurry even on the
prescription eye drops and her glaucoma was “still
uncontrolled.” Dr. Maxwell noted “progression of
advanced glaucoma.” (R. 330-334).
September 24, 2014, Dr. Jason Swanner with the UAB
Ophthamology Service Glaucoma Center examined the claimant at
Dr. Maxwell’s referral and diagnosed the claimant with
glaucoma in both of her eyes. Dr. Swanner reported that the
claimant had advanced open-angle glaucoma and was on the
maximum tolerated medication, including Timolol, Simbrinza,
and Travatan. Dr. Swanner indicated that the claimant’s
“posterior segment examination shows significant optic
nerve cupping in both eyes.” He recommended dong a SLT
laser surgery on her right eye first to see if it would lower
her eye pressure and treat her glaucoma. If it was
successful, he would do the same procedure on the left eye.
If the SLT surgery was not effective, Dr. Swanner recommended
trabeculectomy surgery. (R. 519).
request of the Disability Determination Service, the Health
Department screened the claimant’s vision on October
12, 2014, and she had visual acuity without correction of
20/70 in both eyes and with correction 20/50 in both eyes,
indicating visual impairment. (R. 363).
December 9, 2014 and January 13, 2015, the claimant returned
to Dr. Cutcher complaining that she had back spasms and was
“hurting all over.” She reported that she wakes
at night because of her pain and has bilateral leg swelling.
At the January 13 visit, Dr. Cutcher noted the
claimant’s “loss of vision” as an
“Additional Problem.” (R. 404-405).
her follow-up visits with Dr. Maxwell on February 19, April
30, and May 4, 2015, the claimant still complained of blurry
vision and itchy eyes. Her medications listed to treat her
glaucoma included Simbrinza, Timolol, and Travz.
April 9, 2015, the claimant initially visited Hill Hospital
Physicians Clinic complaining of elevated blood pressure,
headaches, and back pain. Dr. Paul Marlo examined the patient
and diagnosed her with unspecified essential hypertension,
lumbago, anemia, glaucoma, and diabetes mellitus without
mention of complication. Dr. Marlo prescribed medication for
her hypertension. At her follow-up on May 4, 2015, her blood
pressure was elevated, but the claimant did not have acute
distress. Dr. Marlo continued the claimant on her blood
pressure medication. Dr. Marlo’s notes also indicate
that the claimant “states that she is having eye
surgery this month for glaucoma.” (R. 416, 419).
the claimant returned to Dr. Crutcher on May 12, 2015, he
noted her back pain, back spasms, and vision loss. He
indicated that she could lift 15 pounds occasionally, sit for
ten minutes, and stand for thirty minutes. (R. 402).
follow-up with Dr. Maxwell on August 6, 2015, the claimant
continued to have blurry vision even on her medications and
complained that the ...