United States District Court, N.D. Alabama, Middle Division
MADELINE HUGHES HAIKALA UNITED STATES DISTRICT JUDGE
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.
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).
STANDARD OF REVIEW
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
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
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).
SUMMARY OF THE ALJ’S DECISION
determine whether a claimant has proven disability, an ALJ
follows a five-step sequential evaluation process. The ALJ
(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.
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).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).
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).
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).
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
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)
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.”).
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
[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).
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.
Ms. Thompson’s Testimony
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).
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).
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.
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).
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).
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 ...