Thompson v. Saul

          MEMORANDUM OPINION

          MADELINE HUGHES HAIKALA UNITED STATES DISTRICT JUDGE

         Pursuant to 42 U.S.C. § 405(g), plaintiff Marjorie Thompson seeks judicial review of a final adverse decision of the Commissioner of Social Security. The Commissioner denied Ms. Thompson’s claims for period of disability and disability insurance benefits. After careful review, the Court remands the Commissioner’s decision.

         I. PROCEDURAL HISTORY

         Ms. Thompson applied for disability insurance benefits. (Doc. 6-3, p. 12; Doc. 6-4, p. 19). She alleges her disability began on March 4, 2014. (Doc. 6-3, p. 12; Doc. 6-4, p. 19). The Commissioner initially denied Ms. Thompson’s claim. (Doc. 6-3, p. 12; Doc. 6-4, p. 19). Ms. Thompson requested a hearing before an Administrative Law Judge (ALJ). (Doc. 6-3, p. 19; Doc. 6-5, p. 8). The ALJ issued an unfavorable decision. (Doc. 6-3, pp. 12-33). On October 2, 2017, the Appeals Council declined Ms. Thompson’s request for review (Doc. 6-3, p. 2), making the Commissioner’s decision final for this Court’s judicial review. See 42 U.S.C. § 405(g).

         II. STANDARD OF REVIEW

         The scope of review in this matter is limited. “When, as in this case, the ALJ denies benefits and the Appeals Council denies review, ” the Court “review[s] the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close scrutiny.’” Riggs v. Comm’r, Soc. Sec. Admin., 522 F.App'x 509, 510-11 (11th Cir. 2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).

         The Court must determine whether there is substantial evidence in the record to support the ALJ’s factual findings. “Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Crawford v. Comm’r, Soc. Sec. Admin., 363 F.3d 1155, 1158 (11th Cir. 2004). In evaluating the administrative record, the Court may not “decide the facts anew, reweigh the evidence, ” or substitute its judgment for that of the ALJ. Winschel v. Comm’r, Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal quotations and citation omitted). If substantial evidence supports the ALJ’s factual findings, then the Court “must affirm even if evidence preponderates against the Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603 F.App'x 783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).

         With respect to the ALJ’s legal conclusions, the Court must determine whether the ALJ applied the correct legal standards. If the Court finds an error in the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis, then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).

         III. SUMMARY OF THE ALJ’S DECISION

         To determine whether a claimant has proven disability, an ALJ follows a five-step sequential evaluation process. The ALJ considers:

(1) whether the claimant is currently engaged in substantial gainful activity; (2) whether the claimant has a severe impairment or combination of impairments; (3) whether the impairment meets or equals the severity of the specified impairments in the Listing of Impairments; (4) based on a residual functional capacity (“RFC”) assessment, whether the claimant can perform any of his or her past relevant work despite the impairment; and (5) whether there are significant numbers of jobs in the national economy that the claimant can perform given the claimant’s RFC, age, education, and work experience.

Winschel, 631 F.3d at 1178.

         In this case, the ALJ found that Ms. Thompson meets the insured status requirements through December 31, 2018. (Doc. 6-3, p. 15). Ms. Thompson has not engaged in substantial gainful activity since March 4, 2014, the alleged onset date. (Doc. 6-3, p. 15). The ALJ determined that Ms. Thompson suffers from the following severe impairments: chronic lower back pain, meningitis, left shoulder pain, loss of visual acuity, and lower extremity neuropathy. (Doc. 6-3, p. 15).^[2]Based on review of the medical evidence, the ALJ found that Ms. Thompson does not have an impairment or combination of impairments that meets or medically equals the severity of any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 6-3, p. 24).

         The ALJ determined that Ms. Thompson has the RFC to perform light work as defined in 20 C.F.R. § 404.1567(b):

except for no more than occasional stooping or crouching; no climbing; no lower extremity pushing or pulling; no work at unprotected heights; and no driving. She is limited to simple, repetitive, non-complex tasks; work in temperature controlled environment; no reading of fine print or materials; and no left upper extremity overhead reaching, pushing, or pulling.

(Doc. 6-3, p. 26). “Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds.” 20 C.F.R. § 404.1567(b). The ALJ concluded that Ms. Thompson is unable to perform her past relevant work as a registered nurse or paramedic. (Doc. 6-3, pp. 30-31).

         Relying on testimony from a vocational expert, the ALJ found that other jobs existed in the national economy that Ms. Thompson could perform, including cleaner, ticket taker, and cashier. (Doc. 6-3, p. 32). Accordingly, the ALJ determined that Ms. Thompson was not under a disability within the meaning of the Social Security Act. (Doc. 6-3, p. 32).

         IV. ANALYSIS

         Ms. Thompson argues that the ALJ erred in denying her application for benefits because the ALJ failed to consider the opinion of Ms. Thompson’s treating neurosurgeon, Dr. Pickett; the ALJ misapplied the Eleventh Circuit pain standard; and the ALJ did not base his RFC determination on substantial evidence. (Doc. 9, p. 1). Because the ALJ failed to explain the weight he gave to Dr. Pickett’s opinion and because substantial evidence does not support the ALJ’s analysis of Ms. Thompson’s testimony concerning her pain, the Court remands this matter for additional proceedings.

         The Eleventh Circuit pain standard “applies when a disability claimant attempts to establish disability through his own testimony of pain or other subjective symptoms.” Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991); Coley v. Comm’r, Soc. Sec. Admin., No. 18-11954, 2019 WL 1975989, at *3 (11th Cir. May 3, 2019). When relying upon subjective symptoms to establish disability, “the claimant must satisfy two parts of a three-part test showing: (1) evidence of an underlying medical condition; and (2) either (a) objective medical evidence confirming the severity of the alleged [symptoms]; or (b) that the objectively determined medical condition can reasonably be expected to give rise to the claimed [symptoms].” Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002) (citing Holt, 921 F.2d at 1223); Chatham v. Comm’r, Soc. Sec. Admin., No. 18-11708, 2019 WL 1758438, at *2 (11th Cir. Apr. 18, 2019) (citing Wilson). If the ALJ does not properly apply the three-part standard, reversal is appropriate. McLain v. Comm’r, Soc. Sec. Admin., 676 F.App'x 935, 937 (11th Cir. 2017) (citing Holt).

         A claimant’s credible testimony coupled with medical evidence of an impairing condition “is itself sufficient to support a finding of disability.” Holt, 921 F.2d at 1223; see Gombash v. Comm’r, Soc. Sec. Admin., 566 F.App'x 857, 859 (11th Cir. 2014) (“A claimant may establish that he has a disability ‘through his own testimony of pain or other subjective symptoms.’”) (quoting Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)). If an ALJ rejects a claimant’s subjective testimony, the ALJ “must articulate explicit and adequate reasons for doing so.” Wilson, 284 F.3d at 1225; Coley, 2019 WL 1975989, at *3. As a matter of law, the Secretary must accept the claimant’s testimony if the ALJ inadequately or improperly discredits the testimony. Cannon v. Bowen, 858 F.2d 1541, 1545 (11th Cir. 1988); Kalishek v. Comm’r, Soc. Sec. Admin., 470 F.App'x 868, 871 (11th Cir. 2012) (citing Cannon); see Hale v. Bowen, 831 F.2d 1007, 1012 (11th Cir. 1987) (“It is established in this circuit if the Secretary fails to articulate reasons for refusing to credit a claimant’s subjective pain testimony, then the Secretary, as a matter of law, has accepted that testimony as true.”).

         When credibility is at issue, the provisions of Social Security Regulation 16-3p apply. SSR 16-3p provides:

[W]e recognize that some individuals may experience symptoms differently and may be limited by symptoms to a greater or lesser extent than other individuals with the same medical impairments, the same objective medical evidence, and the same non-medical evidence. In considering the intensity, persistence, and limiting effects of an individual’s symptoms, we examine the entire case record, including the objective medical evidence; an individual’s statements about the intensity, persistence, and limiting effects of symptoms; statements and other information provided by medical sources and other persons; and any other relevant evidence in the individual’s case record.

SSR 16-3p, 2016 WL 1119029, at *4. An ALJ must explain the basis for findings relating to a claimant’s description of symptoms:

[I]t is not sufficient . . . to make a single, conclusory statement that “the individual’s statements about his or her symptoms have been considered” or that “the statements about the individual’s symptoms are (or are not) supported or consistent.” It is also not enough . . . simply to recite the factors described in the regulations for evaluating symptoms. The determination or decision must contain specific reasons for the weight given to the individual’s symptoms, be consistent with and supported by the evidence, and be clearly articulated so the individual and any subsequent reviewer can assess how the adjudicator evaluated the individual’s symptoms.

SSR 16-3p, 2016 WL 1119029, at *10. In evaluating a claimant’s reported symptoms, an ALJ must consider:

(i) [the claimant’s] daily activities; (ii) [t]he location, duration, frequency, and intensity of [the claimant’s] pain or other symptoms; (iii) [p]recipitating and aggravating factors; (iv) [t]he type, dosage, effectiveness, and side effects of any medication [the claimant] take[s] or ha[s] taken to alleviate . . . pain or other symptoms; (v) [t]reatment, other than medication, [the claimant] receive[s] or ha[s] received for relief of . . . pain or other symptoms; (vi) [a]ny measures [the claimant] use[s] or ha[s] used to relieve . . . pain or other symptoms (e.g., lying flat on your back, standing for 15 to 20 minutes every hour, sleeping on a board, etc.); and (vii) [o]ther factors concerning [the claimant’s] functional limitations and restrictions due to pain or other symptoms.

20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3); Leiter v. Comm’r, Soc. Sec. Admin., 377 F.App'x 944, 947 (11th Cir. 2010).

         Here, the ALJ found that Ms. Thompson’s medical records and daily activities do not support her testimony regarding her pain and limitations. (Doc. 6-3, pp. 28-30). Accordingly, the Court first examines Ms. Thompson’s testimony and then compares her testimony to the medical evidence in the record and to the evidence relating to her daily activities. In evaluating the medical evidence, the Court addresses the ALJ’s treatment of Dr. Pickett’s opinion.

         A. Ms. Thompson’s Testimony

         Ms. Thompson was 49 years old when the ALJ rendered his opinion. Ms. Thompson had worked as a paramedic, a registered nurse in a neuro-intensive care unit, and an organ procurement coordinator. (Doc. 6-3, pp. 64-65). Ms. Thompson testified that after working a night shift at the hospital in March 2014, she fell asleep while driving, went down an embankment, and rolled her car three or four times. (Doc. 6-3, p. 66). Ms. Thompson suffered a burst fracture of her L1 vertebrae. (Doc. 6-3, p. 66). To repair the fracture, a surgeon inserted rods and screws into Ms. Thompson’s spine. (Doc. 6-3, p. 66). Ms. Thompson reported that the surgeon removed muscle tissue from her lower thoracic and lumbar spine during her surgery. (Doc. 6-3, p. 74).

         Ms. Thompson stated that she “still ha[s] all of [her] hardware” from the surgery. (Doc. 6-3, p. 78). She has “one set from T11 to L3 that’s rods and screws and then . . . another one that’s L5 to S1.” (Doc. 6-3, p. 78). Ms. Thompson testified that the surgery has limited her ability to bend and lift. (Doc. 6-3, p. 74). Ms. Thompson indicated that she cannot lift a gallon of milk and cannot pick things up from the floor. (Doc. 6-3, p. 74).

         After her spinal surgery, Ms. Thompson was diagnosed with meningitis. (Doc. 6-3, p. 66). Ms. Thompson underwent surgery to remove tissue damaged by the infection. (Doc. 6-3, p. 66). Ms. Thompson testified that she was put on an IV antibiotic pump for 12 weeks and completed physical therapy at home. (Doc. 6-3, p. 67). Ms. Thompson stated that as a result of the antibiotic treatment, her immune system is weakened, and she has difficulty “get[ting] over stuff” and healing. (Doc. 6-3, pp. 67-68). Ms. Thompson testified that the meningitis has affected her handwriting, sight and peripheral vision, speech, and cognitive abilities. (Doc. 6-3, p. 68). She is unable to read fine print. (Doc. 6-3, p. 80).

         Ms. Thompson stated that she has severe pain in her left leg and hip, and she has numbness in both of her legs and feet. (Doc. 6-3, p. 79). Ms. Thompson testified that she will be on oral pain medication for the rest of her life. (Doc. 6-3, p. 69).

         Ms. Thompson suffers from headaches two to three times weekly. (Doc. 6-3, pp. 71-72). Ms. Thompson takes pain medication and lies down in a dark, quiet room to alleviate her symptoms. (Doc. 6-3, pp. 71-72). Ms. Thompson stated that the only side effect of her medication is constipation. (Doc. 6-3, p. 72).

         Ms. Thompson has radicular neuropathy of her L5 vertebrae which radiates down the backside of her legs and into her feet. (Doc. 6-3, p. 69). Ms. Thompson stated that she avoids standing for three to four hours uninterrupted because her legs swell. (Doc. 6-3, p. 69). Ms. Thompson reported that she suffers from severe muscle spasms, especially in her ...