Garrett v. Saul

          MEMORANDUM OPINION

          MADELINE HUGHES HAIKALA UNITED STATES DISTRICT JUDGE

         Pursuant to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff Violet Denise Garrett seeks judicial review of a final adverse decision of the Commissioner of Social Security. The Commissioner denied Ms. Garrett's claims for disability insurance benefits and supplemental security income. After careful review, the Court affirms the Commissioner's decision.

         I. PROCEDURAL HISTORY

         Ms. Garrett applied for disability insurance benefits and supplemental security income. (Doc. 6-4, pp. 2, 20). Ms. Garrett alleges that her disability began on March 20, 2012. (Doc. 6-7, p. 39; Doc. 6-3, p. 44). The Commissioner initially denied Ms. Garrett's claims. (Doc. 6-4, pp. 2, 20). Ms. Garret requested a hearing before an Administrative Law Judge (ALJ). (Doc. 6-5, p. 2). The ALJ issued an unfavorable decision. (Doc. 6-4, pp. 41-49).

         Ms. Garrett filed an administrative appeal. (Doc. 6-6, p. 29, 31-32). The Appeals Council vacated the ALJ's decision and remanded Ms. Garrett's claims for further review. (Doc. 6-4, pp. 56-57). Following the Appeals Council's remand, a new ALJ held a supplemental hearing. (Doc. 6-3, p. 39). This ALJ issued an unfavorable decision. (Doc. 6-3, pp. 16-28). The Appeals Council declined Ms. Garrett's request for review, making the Commissioner's decision final for this Court's judicial review. (Doc. 6-3, p. 2). See 42 U.S.C. §§ 405(g) and 1383(c).

         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 of Soc. Sec., 522 Fed.Appx. 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 of Soc. Sec., 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 of 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 the evidence preponderates against the Commissioner's findings.” Costigan v. Comm'r, Soc. Sec. Admin., 603 Fed.Appx. 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 that she is disabled, 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.

         The ALJ determined that Ms. Garrett meets the Social Security Act's insured status requirements through March 31, 2013. (Doc. 6-3, p. 18). The ALJ found that Ms. Garrett has not engaged in substantial gainful activity since the alleged onset date of March 30, 2012. (Doc. 6-3, p. 18). The ALJ determined that Ms. Garrett suffers from the following severe impairments: osteoarthritis, bilateral foot pain, and mild degenerative joint disease. (Doc. 6-3, p. 18). The ALJ determined that Ms. Garrett suffers from the non-severe impairments of bilateral carpal tunnel syndrome, migraines, obesity, and major depressive disorder. (Doc. 6-3, pp. 19-22). Based on a review of the medical evidence, the ALJ concluded that Ms. Garrett 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. 23).

         In light of Ms. Garrett's impairments, the ALJ evaluated her residual functional capacity. The ALJ determined that Ms. Garrett has the RFC to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a) except she can occasionally balance, stoop, and climb ramps and stairs; but never kneel, crouch, crawl, or climb ladders, ropes, or scaffolds. (Doc. 6-3, p. 23). “Sedentary work involves lifting no more than ten pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools.” 20 C.F.R. §§ 404.1567(a), 416.967(a). “Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties.” 20 C.F.R. §§ 404.1567(a), 416.967(a). “Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.” 20 C.F.R. §§ 404.1567(a), 416.967(a). The ALJ found that Ms. Garrett can constantly handle, reach, finger, and feel but should avoid concentrated exposure to extreme heat and cold, humidity, wetness, and vibrations. (Doc. 6-3, p. 23). Based on this RFC, the ALJ concluded that Ms. Garett is unable to perform her past relevant work as a childcare worker, windshield inspector, cook, or home aide. (Doc. 6-3, p. 26). Relying on testimony from a vocational expert, the ALJ found that jobs exist in the national economy that Ms. Garrett can perform, including general office clerk, order clerk, receptionist, and information clerk. (Doc. 6-3, pp. 27-28). Accordingly, the ALJ determined that Ms. Garrett has not been under a disability within the meaning of the Social Security Act. (Doc. 6-3, p. 28).

         IV. ANALYSIS

         Ms. Garrett contends that she is entitled to relief from the ALJ's decision because the ALJ evaluated several medical opinions improperly. (Doc. 8, pp. 6, 10). After considering the record as a whole, the Court affirms the ALJ's decision.

         Dr. Howard's Opinion

         Ms. Garrett maintains that the ALJ should have accepted the physical capacities opinion of Dr. Howard, Ms. Garrett's treating doctor. (Doc. 6-15, pp. 2, 57). “Absent ‘good cause,' an ALJ is to give the medical opinions of treating physicians ‘substantial or considerable weight.'” Winschel, 631 F.3d at 1179 (quoting Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)). When declining to give a treating physician's opinion considerable weight, an ALJ must clearly articulate the reasons for her decision. Winschel, 631 F.3d at 1179. Good cause exists when:

(1) [the] treating physician's opinion was not bolstered by the evidence;

(2) evidence supported a contrary finding; or (3) [the] treating physician's opinion was conclusory or inconsistent with the doctor's own medical records.

Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004); Lustgarten v. Comm'r of Soc. Sec., No. 17-14763, 2019 WL 6048534, at *2 (11th Cir. Nov. 15, 2019) (quoting Phillips for good cause framework).

         The ALJ assigned minimal weight to Dr. Howard's opinion. (Doc. 6-3, p. 26). The ALJ found that Dr. Howard's functional assessment lacked support “in his own treatment records, the other medical evidence of record, [and Ms. Garrett's] admitted daily activities.” (Doc. 6-3, p. 26). The ALJ reasoned that Dr. Howard's “records do not contain evidence of the claimant having substantial restrictions in walking, standing, or sitting, or that the claimant experiences significant side effects from her prescribed medication.” (Doc. 6-3, p. 26). The ALJ found that the absence of “substantial changes to [Ms. Garrett's] pain management medication” undermined Dr. Howard's opinion. (Doc. 6-3, p. 26). The ALJ pointed out that prior treatment records showed that Ms. Garrett had a normal gait. (Doc. 6-3, p. 26). To determine whether the ALJ has demonstrated good cause, the Court begins with a review of Dr. Howard's treatment records.

         Ms. Garrett visited Dr. Howard in August 2014 and complained of migraine headaches and chronic back pain. (Doc. 6-15, p. 57).^[2] According to Dr. Howard's notes, Ms. Garrett's back pain began after “[s]he had extensive surgery on [her] right foot which altered her gait.” (Doc. 6-15, p. 57). Ms. Garrett told Dr. Howard that she could not “deal with [her back pain] through the day” and that it was “worse at night.” (Doc. 6-15, p. 58).

         Ms. Garrett reported undergoing an orthopedic evaluation “which was essentially negative.” (Doc. 6-15, p. 57). Ms. Garrett told Dr. Howard that she had been through “extensive physical therapy, ” but she still had “a lot of discomfort.” (Doc. 6-15, p. 57).

         Ms. Garrett reported having prescriptions for Norco (one 7.5-325 mg tablet every 12 hours) and Ultram (two 50 mg tablets every eight hours) for pain. (Doc. 6-15, p. 57).^[3] Ms. Garrett told Dr. Howard that she had taken “multiple types of opioids in the past, but all of these made her feel bad.” (Doc. 6-15, p. 57). Ms. Garrett told Dr. Howard that because of those negative side effects, “she does not take [opioids] very often.” (Doc. 6-15, p. 57).

         Ms. Garrett reported taking “Aleve intermittently for this pain.” (Doc. 6-15, p. 57). According to Ms. Garrett, she suffers from migraines, but “Topamax has been very effective” in treating this condition. (Doc. 6-15, p. 57).

         Dr. Howard provided the following assessments relevant to Ms. Garrett's appeal:

1. Chronic pain management. The patient only takes hydrocodone every other day, but I am concerned about escalating need for this medication due to use I have asked her to try Mobic intermittently. I have also given her trigger-point injection x3 of DKL into the right gluteal piriformis musculature. This is secondary to spasm. The patient does have a muscle prominence on the right gluteal piriformis musculature with significant tender points. Trigger points are injected at 2-cm intervals; 3 injections were given. Family support is excellent. She is married. Her relationship is very stable at this time. Psychological state is excellent. She is doing very well at this point. Mental status is good. She has no evidence of depression at this point. Diagnosis is myofascial back pain aggravated by mild scoliosis with unstable gait. Orthopedic evaluation has been completed. Pain options are physical therapy, which will be initiated. She has undergone physical therapy in the past, but I do not feel that she has continued physical therapy on a daily basis at home. I would like to institute DS form [of] treatment. The patient has been transiently on medications to include hydrocodone, one every other day, as well as Ultram intermittently. I feel comfortable with Ultram but would like her to continue to limit the hydrocodone. Continue the gabapentin at night, which has been very effective for her. I would like her to hold the Zocor, as this may well cause myofascial pain that would mimic underlying pathology. Epidural is a consideration at later date. Next visit, consider physical therapy. Lidoderm patch is added, as well as a prescription for Norco 7.5 mg, #30 tablets, 0 refills.

2. Migraine headaches, on Topamax, doing extremely well at this time. She has been on ...