Worthington v. Colvin
Filing
17
MEMORANDUM OPINION AND ORDER that the decision of the Commissioner is AFFIRMED, as further set out. Signed by Honorable Judge Terry F. Moorer on 7/16/15. (djy, )
IN THE DISTRICT COURT OF THE UNITED STATES
FOR THE MIDDLE DISTRICT OF ALABAMA
SOUTHERN DIVISION
DEBRA ELAINE WORTHINGTON,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
Defendant.
)
)
)
)
)
)
)
)
)
)
CASE NO. 1:13-cv-889-TFM
[wo]
MEMORANDUM OPINION AND ORDER
Debra Elaine Worthington (APlaintiff@ or AWorthington@) applied for disability
insurance benefits under Title II of the Social Security Act (“the Act”), 42 U.S.C. §§ 401
et seq. on January 13, 2011. R. 13. After being denied on April 5, 2011, Worthington
timely filed for and received a hearing before an administrative law judge (AALJ@) who
rendered an unfavorable decision on June 13, 2012.
R. 13, 26.
Worthington
subsequently petitioned for review to the Appeals Council who rejected review of
Worthington’s case on October 11, 2013. R. 1. As a result, the ALJ’s decision became
the final decision of the Commissioner of Social Security (ACommissioner@). Id. Judicial
review proceeds pursuant to 42 U.S.C. ' 405(g), and 28 U.S.C. ' 636(c). After careful
scrutiny of the record and briefs, for reasons herein explained, the Court AFFIRMS the
Commissioner’s decision.
I. NATURE OF THE CASE
Worthington seeks judicial review of the Commissioner’s decision denying her
application for disability insurance benefits. United States District Courts may conduct
limited review of such decisions to determine whether they comply with applicable law
and are supported by substantial evidence. 42 U.S.C. ' 405. The court may affirm,
reverse and remand with instructions, or reverse and render a judgment. Id.
II. STANDARD OF REVIEW
The Court’s review of the Commissioner’s decision is a limited one. The Court’s
sole function is to determine whether the ALJ’s opinion is supported by substantial
evidence and whether the proper legal standards were applied. See Jones v. Apfel, 190
F.3d 1224, 1228 (11th Cir. 1999); Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th
Cir. 1983).
AThe Social Security Act mandates that >findings of the Secretary as to any fact, if
supported by substantial evidence, shall be conclusive.’@ Foote v. Chater, 67 F.3d 1553,
1560 (11th Cir. 1995) (quoting 42 U.S.C. '405(g)). Thus, this Court must find the
Commissioner’s decision conclusive if it is supported by substantial evidence. Graham
v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). Substantial evidence is more than a
scintilla C
i.e., the evidence must do more than merely create a suspicion of the
existence of a fact, and must include such relevant evidence as a reasonable person would
accept as adequate to support the conclusion. Lewis v. Callahan, 125 F.3d 1436, 1440
(11th Cir. 1997) (citing Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427,
28 L.Ed.2d 842 (1971)); Foote, 67 F.3d at 1560 (citing Walden v. Schweiker, 672 F.2d
Page 2 of 22
835, 838 (11th Cir. 1982)).
If the Commissioner’s decision is supported by substantial evidence, the district
court will affirm, even if the court would have reached a contrary result as finder of fact,
and even if the evidence preponderates against the Commissioner’s findings. Ellison v.
Barnhart, 355 F.3d 1272, 1275 (11th Cir. 2003); Edwards v. Sullivan, 937 F.2d 580, 584
n.3 (11th Cir. 1991) (quoting MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir.
1986)). The Court must view the evidence as a whole, taking into account evidence
favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560 (citing Chester
v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The Court Amay not decide facts anew,
reweigh the evidence, or substitute [its] judgment for that of the [Commissioner],@ but
rather it Amust defer to the Commissioner=s decision if it is supported by substantial
evidence.@ Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1997) (quoting Bloodsworth,
703 F.2d at 1239).
The Court will also reverse a Commissioner’s decision on plenary review if the
decision applies incorrect law, or if the decision fails to provide the district court with
sufficient reasoning to determine that the Commissioner properly applied the law.
Keeton v. Dep’t of Health and Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994) (citing
Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991)). There is no presumption
that the Commissioner’s conclusions of law are valid. Id.; Brown v. Sullivan, 921 F.2d
1233, 1236 (11th Cir. 1991) (quoting MacGregor, 786 F.2d at 1053).
III. STATUTORY AND REGULATORY FRAMEWORK
The Social Security Act’s general disability insurance benefits program (ADIB@)
Page 3 of 22
provides income to individuals who are forced into involuntary, premature retirement,
provided they are both insured and disabled, regardless of indigence. 1 See 42 U.S.C. '
423(a). The Social Security Act’s Supplemental Security Income (ASSI@) is a separate
and distinct program. SSI is a general public assistance measure providing an additional
resource to the aged, blind, and disabled to assure that their income does not fall below
the poverty line. 2 Eligibility for SSI is based upon proof of indigence and disability. See
42 U.S.C. '' 1382(a), 1382c(a)(3)(A)-(C). However, despite the fact they are separate
programs, the law and regulations governing a claim for DIB and a claim for SSI are
identical; therefore, claims for DIB and SSI are treated identically for the purpose of
determining whether a claimant is disabled. Patterson v. Bowen, 799 F.2d 1455, 1456 n.
1 (11th Cir. 1986). Applicants under DIB and SSI must provide Adisability@ within the
meaning of the Social Security Act which defines disability in virtually identical
language for both programs. See 42 U.S.C. '' 423(d), 1382c(a)(3), 1382c(a)(3)(G); 20
C.F.R. '' 404.1505(a), 416.905(a). A person is entitled to disability benefits when the
person is unable to
Engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.
1
DIB is authorized by Title II of the Social Security Act, and is funded by Social Security taxes.
See Social Security Administration, Social Security Handbook, ' 136.1, available at
http://www.ssa.gov/OP_Home/handbook/handbook.html
2
SSI benefits are authorized by Title XVI of the Social Security Act and are funded by general tax
revenues. See Social Security Administration, Social Security Handbook, '' 136.2, 2100, available at
http://www.ssa.gov/OP_Home/handbook/handbook.html
Page 4 of 22
42 U.S.C. '' 423(d)(1)(A), 1382c(a)(3)(A). A Aphysical or mental impairment@ is one
resulting from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques. 42
U.S.C. '' 423(d)(3), 1382c(a)(3)(D).
The Commissioner of Social Security employs a five-step, sequential evaluation
process to determine whether a claimant is entitled to benefits.
See 20 C.F.R. ''
404.1520, 416.920 (2010).
(1) Is the person presently unemployed?
(2) Is the person’s impairment(s) severe?
(3) Does the person’s impairment(s) meet or equal one of the specific impairments
set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1? 3
(4) Is the person unable to perform his or her former occupation?
(5) Is the person unable to perform any other work within the economy?
An affirmative answer to any of the questions leads either to the next
question, or, on steps three and five, to a finding of disability. A negative
answer to any question, other than step three, leads to a determination of
Anot disabled.@
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).
The burden of proof rests on a claimant through Step 4. See Phillips v. Barnhart,
357 F.3d 1232, 1237-39 (11th Cir. 2004). Claimants establish a prima facie case of
qualifying disability once they meet the burden of proof from Step 1 through Step 4. At
Step 5, the burden shifts to the Commissioner, who must then show there are a significant
3
This subpart is also referred to as Athe Listing of Impairments@ or Athe Listings.@
Page 5 of 22
number of jobs in the national economy the claimant can perform. Id.
To perform the fourth and fifth steps, the ALJ must determine the claimant’s
Residual Functional Capacity (ARFC@). Id. at 1238-39. RFC is what the claimant is still
able to do despite his impairments and is based on all relevant medical and other
evidence. Id. It also can contain both exertional and nonexertional limitations. Id. at
1242-43. At the fifth step, the ALJ considers the claimant’s RFC, age, education, and
work experience to determine if there are jobs available in the national economy the
claimant can perform. Id. at 1239. To do this, the ALJ can either use the Medical
Vocational Guidelines 4 (Agrids@) or hear testimony from a vocational expert (AVE@). Id.
at 1239-40.
The grids allow the ALJ to consider factors such as age, confinement to sedentary
or light work, inability to speak English, educational deficiencies, and lack of job
experience. Each factor can independently limit the number of jobs realistically available
to an individual. Id. at 1240. Combinations of these factors yield a statutorily-required
finding of ADisabled@ or ANot Disabled.@ Id.
IV. ADMINISTRATIVE FINDINGS AND CONCLUSIONS
Worthington, age 53 at the time of the hearing, has completed the General
Educational Development degree (“G.E.D.”) and at least one year of college, and is able
to read and write.
R. 25, 33-34, 260.
Worthington has past relevant work as a
receptionist (semi-skilled, sedentary), administrative assistant (skilled, sedentary), and
secretary (skilled, sedentary). R. 24, 47-48. Worthington’s alleged disability onset date
4
See 20 C.F.R. pt. 404 subpt. P, app. 2; see also 20 C.F.R. ' 416.969 (use of the grids in SSI cases).
Page 6 of 22
is March 15, 2008. R. 13. Worthington has not engaged in substantial gainful work
activity since her alleged disability onset date. R. 15. Worthington meets the insured
status requirements of the Social Security Act through June 30, 2012. Id. Worthington
claims she is unable to work because of back and right knee pain, seizures, bi-polar
disorder, depression, and anxiety.
Worthington received treatment from various medical practitioners and the ALJ
considered the medical records from these practitioners. Worthington went to the Halifax
Health Emergency Department in February of 2009 after being involved in a motor
vehicle accident. R. 187-91. Worthington complained of a headache, nausea, slight
dizziness, one episode of vomiting, and pain in her lower back where she has had chronic
back problems. R. 188. A physical examination revealed no clubbing, cyanosis, edema
or joint tenderness in her extremities. R. 18, 190. Worthington’s back was tender in the
low lumbar paravertebral areas, but without deformity or crepitance, and there was no
flank tenderness.
Id.
X-rays of Worthington’s lumbar spine revealed a slight
degenerative change with no appreciable compression deformity, spondylolisthesis, or
spondylitis. R. 18, 192. Worthington was diagnosed with cervical strain, and paralumbar
strain, and was discharged in stable condition. R. 191.
On August 11, 2009, Worthington went to Gulf Coast Mental Health Center on a
referral seeking treatment for chronic depression and mood swings, bipolar disorder,
obsessive compulsive disorder (“OCD”) with “schizophrenic tendencies,” and Post
Traumatic Stress Disorder (“PTSD”). R. 256. Worthington explained that she suffered a
childhood trauma that contributes to her depression. R. 259. Additionally, when she was
Page 7 of 22
ten years old, Worthington’s father was killed in a car accident. Id. Worthington said
she still blames herself for her father’s death which has led to severe depression from the
guilt. Id. Additionally, her mother died in a fire about twenty years ago while they were
estranged, which she also feels guilt and depression over. Id. At the age of twenty,
Worthington was diagnosed with PTSD that led to stress-induced seizures, which began
at the age of ten. Id. However, she no longer experiences the seizures. Id. During
Worthington’s second marriage, she experienced physical and verbal abuse from her
husband for several years until they got divorced. Id. Worthington stated that her
depression is also exacerbated by marital difficulties due to her current husband's refusal
to receive treatment for a serious medical condition. Id. Worthington said when she is
experiences a bout of depression, she sits alone, “shuts down,” and does not speak with
anyone. Id.
Worthington also said that she suffers from OCD with schizophrenic tendencies.
R. 259.
The obsessive compulsive behavior causes Worthington to check locks,
electronics, and appliances on a regular basis, including throughout the night which
prevents her from sleeping through the night. R. 256, 259. Worthington also exhibits
“germaphobic” tendencies when out in public. R. 259.
The doctor noted that Worthington appears to be in good physical health. Id.
Worthington does not drink or do drugs, but she does smoke cigarettes. R. 217, 259-260.
Worthington said she believes her current medicine regime is controlling all of her
symptoms. R. 256. The doctor also noted that Worthington said she is an “avid reader,
loves to swim [and] lay on the beach, take walks on starry nights, Native American crafts,
Page 8 of 22
crochets[, and is c]urrently ‘writing a novel.’” R. 260. Worthington was diagnosed
based on her history with OCD, bipolar I, and severe depression with psychotic features.
Id. The doctor prescribed refills for Paroxetine, Hydroxyzine Pamoate, and Diazepam.
R. 261. Worthington moved to Alabama prior to her next appointment at Gulf Coast
Mental Health Center.
In December of 2010, Worthington began seeing Steven Davis, M.D. (“Dr.
Davis”) after moving to Alabama from Florida. R. 251. Dr. Davis indicated he will
request Worthington’s prior medical records, and refilled her prescriptions. Id. On June
7, 2011, Worthington saw Dr. Davis for the purpose of having him fill out a disability
form for her attorney. R. 250. Dr. Davis asked Worthington several questions, noted that
she “[a]nswers all questions well as we ask them,” and then filled out the form. R. 247250. Worthington returned on December 13, 2011 to have her prescriptions refilled. R.
245. Dr. Davis noted that Worthington is “doing quite well,” “[s]he said she is not
having any depression,” she has had “[n]o bad mood swings whatsoever,” and that her
“[m]edications seem to be working quite well.” R. 245.
On March 8, 2011, Mark B. Ellis, D.O. (“Dr. Ellis”) conducted a disability exam
at Worthington’s request. R. 217-219. Worthington said that she is unable to work due
to PTSD, bipolar, chronic depression, and neck, back, and knee pain.
R. 217.
Worthington said she is unable to sit or stand for more than fifteen minutes at a time, and
is only able to walk a few blocks due to the pain. Id. Worthington reported her average
pain to be four or five on a pain scale ranging from one to ten, but upon activity her pain
rises to a seven. Id. Worthington said she has “pseudo-seizures,” but she does not take
Page 9 of 22
any anti-seizure medications. Id. Worthington said she is able to drive herself, do light
housework, dress and care for herself, and does not use any assistance devices. Id. Upon
examination Dr. Ellis found:
Well-developed, well-nourished, obese white female in no apparent
distress, cooperative, alert and oriented to person, place, and time. The
patient ambulates with a normal gait, which is not unsteady, lurching or
unpredictable. The patient does not require the use of an ambulatory aid.
The patient appears stable at station and comfortable in the supine and
sitting positions. Intellectual functioning appears to be normal during
examination. The patient is able to hear and understand conversational
voices without difficulty. Recent and remote memory for medical events is
good. The patient is able to follow simple commands and instructions
without difficulty.
R. 218. Dr. Ellis also found that Worthington’s range of motion on flexion in her knees
and ankles were normal bilaterally; extremities showed no signs of atrophy, wasting, or
deformity; no clubbing, cyanosis, or edema; her grip strength was 5/5 in each hand; no
muscle spasms; she was able to toe and heel walk, and squat, but with some lower back
pain; no tenderness to palpation and movement of the lumbar spine, and no abnormal
curvature of the spine, no spasms or deformity, and straight leg raise was negative
bilaterally, but she complained of tenderness with palpation and movement of the lumbar
spine. R. 218-19. Dr. Ellis found that Worthington’s neurological findings were within
normal ranges; no gross motor or sensory deficits; she was able to perform a normal
finger to nose; Romberg was normal bilaterally; and she was able to handle, manipulate,
and transfer objects from one hand to another. R. 219.
On March 17, 2011, Worthington was referred to a consultative examination by
Fred George, Ph.D. (“Dr. George”). R. 223. Worthington described her mood to be
Page 10 of 22
depressed, and her range of affect was restricted; however, her affect and was “stable and
appropriate.” R. 224. Worthington had proper hygiene and was appropriately dressed
and groomed. Id. Dr. George found Worthington to be “alert and oriented to time, place,
person, and situation.” Id. Worthington’s speech and conversation was within normal
limits, but her activity level was “somewhat slowed.” Id. Dr. George found that her
attention and concentration was significantly impaired based on the results of the serial
7’s test, but she was able to spell backwards. Id. Dr. George found Worthington’s
immediate and recent memory to be intact, but her remote memory appeared impaired.
Id. Worthington’s fund of information appeared below average. R. 224. Worthington’s
verbal conceptual thinking was in the average range, and her insight into her difficulties
and judgment appeared intact with no “loose associations, tangential or circumstantial
thinking hallucinations, delusions, or ideas of reference were observed.
Id.
Worthington reported daily activities of preparing meals, listening to music,
reading, resting, sewing, watching television, working in the garden, doing light
housework, and taking walks. R. 225. Worthington reported that she does not leave the
house often except to buy food, pay bills, and go to appointments. Id. Worthington said
she sees her children and other relatives on a regular basis. Id. Dr. George noted that
Worthington’s daily activities “appear to be significantly restricted and her interest and
relationships significantly constricted.” Id.
Dr. George diagnosed Worthington with Axis I: bipolar disorder NOS, with
psychotic features; prolonged post-traumatic stress disorder; anxiety disorder NOS, with
features of generalized anxiety and panic disorder; Axis II: no diagnosis; Axis III:
Page 11 of 22
“displaced kneecap resulting from an injury sustained in an automobile accident; back
pain from degenerative discs; migraine, tension, and cluster headaches; weakness in both
ankles and weakness in both wrists.” Id. Dr. George ultimately found that Worthington
has the ability “to live independently and mange her own funds;” has the “intellectual and
memory ability to understand and remember skilled occupation in a wide range of service
occupations,” but that due to her mood disturbances and anxiety she would “be unable to
relate to coworkers, supervisors and members of the general public and to cope with job
stresses and job changes in the work environment.” Id. Dr. George also recommended
that Worthington be referred for a mental health evaluation and treatment with supportive
psychotherapy/counseling. Id.
On April 4, 2011, Guendalina Ravello, Ph.D. (“Dr. Ravello”), a non-examining
physician, reviewed Worthington’s medical records and completed a Psychiatric Review
Technique form. R. 226-242. Dr. Ravello opined that Worthington has no more than
moderate limitations in her activities of daily living, maintaining social functioning, and
maintaining concentration, persistence, or pace. R. 236. Similarly, Dr. Ravello opined
that Worthington had no more than a moderate limitation in understanding and memory,
sustained concentration and persistence, social interaction, and adaptation. R. 240-241.
Dr. Ravello issued a Functional Capacity Assessment that states that Worthington can:
“understand and remember simple instructions but will have more difficulty with detailed
ones because of symptoms of anxiety, depression, and cognitive deficits;” “can carry out
simple tasks, but not detailed ones;” “should be able to concentrate and attend to simple
tasks for 2 hours and will need all customary rests and breaks;” “tolerate ordinary work
Page 12 of 22
pressures but should avoid: excess workloads, quick decision making, rapid changes and
multiple demands;” have casual contact with the public and co-workers, and feedback
should be supportive, tactful, and non-confrontational; and handle gradual and infrequent
changes in her work setting. R. 242.
After review of the medical records, the ALJ found that Worthington has the
following severe impairments: degenerative disc disease of the lumbar spine; right knee
sprain from motor vehicle accident; history of pseudo-seizures; depression; bi-polar
disorder; and anxiety.
R. 15.
The ALJ found that Worthington Ahas the residual
functional capacity to perform less than the Full Range of medium work@ with the
exception of several limitations.
R. 17.
The ALJ then found that considering
Worthington’s Aage, education, work experience, and residual functional capacity, there
are jobs that exist in significant numbers in the national economy that [she] can perform.@
R. 25.
V. ISSUES
Worthington raises two issues for judicial review:
(1)
Whether the ALJ erred in forming his RFC assessment despite the
record being devoid of any physical RFC assessments completed by a
physician; and
(2)
Whether the ALJ’s finding that Worthington is capable of performing
the mental demands of unskilled level work is supported by substantial
evidence.
See Doc. 12 at 3-4.
Page 13 of 22
VI. DISCUSSION
A.
The ALJ properly formed a RFC assessment without a physician’s physical
RFC assessment in the record.
Worthington argues that “the Commissioner’s decision should be reversed because
the ALJ’s RFC assessment is not supported by substantial evidence as the record is
devoid of any physical RFC assessment from any physicians whatsoever.” See Doc. 12
at 4. The Government responded that the “agency’s regulations and rulings make it clear
that it is the ALJ’s responsibility to assess a claimant’s residual functional capacity.” See
Doc. 15 at 9.
“After careful consideration of the entire record,” the ALJ found that:
[T]he claimant has the residual functional capacity to perform less than the
Full Range of medium work as defined in 20 C.F.R. § 404.1567(c). The
claimant is able to lift and carry 25 pounds frequently and 50 pounds
occasionally; sit, stand and walk for a total of 6 hours each during an 8 hour
workday; frequently use the upper and lower extremities to push and pull;
frequently bend, balance, stoop, kneel, crouch, crawl and climb ramps and
stairs; precluded from climbing ladders, ropes, and scaffolds; frequently
reach overhead; continuously handle, finger and feel; precluded from
exposure to extreme heat and cold; no work around unprotected heights,
dangerous machinery, commercial driving or work around large bodies of
water; able to perform simple routine tasks involving no more than simple,
short instructions and simple work related decisions with few work place
changes; occasionally interact with the general public; and able to sustain
concentration and attention for 2 hours.
R. 17-18. At this point in the five-step, sequential evaluation the burden is on the
claimant to prove that she is disabled. Jones, 190 F.3d at 1228 (citing 20 C.F.R. §
416.912 (1998)); see also Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). “At
the fourth step, the ALJ must assess: (1) the claimant's residual functional capacity
(‘RFC’); and (2) the claimant's ability to return to her past relevant work.” Phillips, 357
Page 14 of 22
F.3d at 1238 (citing 20 C.F.R. § 404.1520(a)(4)(iv)). To determine the claimant’s RFC,
the ALJ “must determine if the claimant is limited to a particular work level.” Id. To be
deemed capable of performing sedentary work, the claimant must have the ability to “lift
no more than 10 pounds at a time and occasionally lifting or carrying articles like docket
files, ledgers, and small tools” and “walking and standing are required occasionally.” 20
C.F.R § 404.1567(a).
“Although a claimant may provide a statement containing a
physician's opinion of her remaining capabilities, the ALJ will evaluate such a statement
in light of the other evidence presented and the ultimate determination of disability is
reserved for the ALJ.” Green v. Soc. Sec. Admin., 223 F. App'x 915, 923 (11th Cir.
2007) (citing 20 C.F.R §§ 404.1513, 404.1527, 404.1545).
In Green, the ALJ discredited the only physician RFC assessment that was in the
record, and the plaintiff argued that the ALJ lacked substantial evidence to base his RFC
assessment without a physician’s RFC. Id. The Eleventh Circuit stated that even without
considering a physician’s RFC assessment, the record indicated that she was managing
her impairments well, and her symptoms were controlled. Id. at 923-24. As a result, the
Eleventh Circuit found that “substantial evidence supports the ALJ's determination that
Green could perform light work.” Id. at 924. Similarly, in Griffin v. Astrue, the plaintiff
argued that a physician’s RFC assessment was required. 2008 WL 4417228, *9 (S.D.
Ala. Sept. 23, 2008). The court found that despite not having a physician’s RFC, the
ALJ’s RFC was “supported by the claimant's treating physicians, as well as the absence
of functional limitations placed on the claimant by any medical source.” Id. at *10. The
court noted that “[w]hile Plaintiff asserts that a physician's RFC assessment was required,
Page 15 of 22
she has not demonstrated that the ALJ did not have enough information to enable him to
make a RFC determination, nor has she pointed to any medical evidence which suggests
that the ALJ's RFC assessment is incorrect.”
Id.
The court ultimately held that
“substantial evidence supports the ALJ’s determination that Plaintiff possesses the RFC
to perform light work” because the medical records demonstrated that despite having
severe impairments, her condition was stable and controlled with medication. Id. The
court also found that the medical records did not reveal any evidence of functional
limitations, and none of the plaintiff’s physicians limited her activities. Id.
After review of the ALJ’s opinion, it is clear to this Court that the ALJ carefully
considered the medical evidence in the record when determining Worthington’s RFC.
The Court recognizes that the record lacks a physical RFC assessment completed by a
physician. A RFC assessment is used to determine the claimant’s capacity to do as much
as they are possibly able to do despite their limitations. See 20 C.F.R. § 404.1545(a)(1)
(2010). An RFC assessment will be made based on all relevant evidence in the case
record. Id.; Lewis, 125 F.3d at 1440.
At a hearing before an ALJ, “the [ALJ] is responsible for assessing [the
claimant’s] residual functional capacity.” 20 C.F.R. § 404.1546(c) (2010). The claimant
is “responsible for providing the evidence [the ALJ] will use to make a finding about [the
claimant’s] residual functional capacity.” 20 C.F.R. § 404.1545(a)(3) (2010). The ALJ
is “responsible for developing [the claimant’s] complete medical history, including
arranging for a consultative examination(s) if necessary, and making every reasonable
effort to help [the claimant] get medical reports from [their] own medical sources. Id.;
Page 16 of 22
Holladay v. Bowen, 848 F.2d 1206, 1209-10 (11th Cir. 1988). “The ALJ is not required
to seek additional independent expert medical testimony before making a disability
determination if the record is sufficient and additional expert testimony is not necessary
for an informed decision.” Nation v. Barnhart, 153 F. App’x 597, 598 (11th Cir. 2005)
(citing Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir. 1999)); see also Griffin, 2008 WL
4417228, at *10 (citing 20 C.F.R. § 416.912(d)) (“The ALJ is bound to make every
reasonable effort to obtain all the medical evidence necessary to make a determination [. .
.]; however, he is not charged with making Plaintiff's case for her”). As previously
stated, Worthington “has the burden of proving that [she] is disabled.” Id. (citing 20
C.F.R. § 416.912(a) and (c); Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987)). The
lack of a physician’s RFC assessment in the record falls upon the claimant; the duty to
obtain sufficient medical records to make a disability determination falls upon the ALJ.
Here, the ALJ found that Worthington suffers from the following severe
impairments: degenerative disc disease of the lumbar spine; right knee sprain from motor
vehicle accident; history of pseudo-seizures; depression; bi-polar disorder; and anxiety.
R. 15. However, the ALJ determined that
[a]fter careful consideration of the evidence, the [ALJ] finds that the
claimant’s medically determinable impairments could reasonably be
expected to cause the alleged symptoms; however, the claimant’s
statements concerning the intensity, persistence and limiting effects of these
symptoms are not credible to the extent that they are inconsistent with the
[RFC] assessment.
R. 20. The ALJ found that he “longitudinal medical evidence does not support the
severity of impairments or the presence of disabling impairments that would preclude
Page 17 of 22
claimant from all work.” Id. The ALJ took particular note of Worthington’s medical
records as recent as 2011 that were inconsistent with Worthington’s allegation of total
disability.
First, the ALJ gave significant weight to Dr. Ellis’ consultative internal medicine
examination conducted on March 8, 2011. Upon examination Dr. Ellis found:
Well-developed, well-nourished, obese white female in no apparent
distress, cooperative, alert and oriented to person, place, and time. The
patient ambulates with a normal gait, which is not unsteady, lurching or
unpredictable. The patient does not require the use of an ambulatory aid.
The patient appears stable at station and comfortable in the supine and
sitting positions. Intellectual functioning appears to be normal during
examination. The patient is able to hear and understand conversational
voices without difficulty. Recent and remote memory for medical events is
good. The patient is able to follow simple commands and instructions
without difficulty.
R. 218. Dr. Ellis also found that Worthington’s range of motion on flexion in her knees
and ankles were normal bilaterally; extremities showed no signs of atrophy, wasting, or
deformity; no clubbing, cyanosis, or edema; her grip strength was 5/5 in each hand; no
muscle spasms; she was able to toe and heel walk, and squat, but with some lower back
pain; no tenderness to palpation and movement of the lumbar spine, and no abnormal
curvature of the spine, no spasms or deformity, and straight leg raise was negative
bilaterally, but she complained of tenderness with palpation and movement of the lumbar
spine. R. 218-19. Dr. Ellis found that Worthington’s neurological findings were within
normal ranges; no gross motor or sensory deficits; she was able to perform a normal
finger to nose; Romberg was normal bilaterally; and she was able to handle, manipulate,
and transfer objects from one hand to another. R. 219.
Page 18 of 22
The ALJ found that Dr. Ellis’ normal findings are consistent with the “very
minimal lumbar degenerative disc disease disclosed by radiology findings in February
2009, and claimant’s own testimony that she merely treats her musculoskeletal pain with
over-the-counter medication.”
R. 21.
Worthington went to the Halifax Health
Emergency Department in February of 2009 after being involved in a motor vehicle
accident.
R. 18, 187-91.
Worthington complained of a headache, nausea, slight
dizziness, one episode of vomiting, and pain in her lower back where she has had chronic
back problems. R. 188. A physical examination revealed no clubbing, cyanosis, edema
or joint tenderness in her extremities. R. 18, 190. Worthington’s back was tender in the
low lumbar paravertebral areas, but without deformity or crepitance, and there was no
flank tenderness.
Id.
X-rays of Worthington’s lumbar spine revealed a slight
degenerative change with no appreciable compression deformity, spondylolisthesis, or
spondylitis. R. 18, 192. Worthington was diagnosed with cervical strain, and paralumbar
strain, and was discharged in stable condition. R. 191.
Next, the ALJ also accorded significant weight to Dr. Ravello’s medical opinion
after she reviewed Worthington’s medical records and completed a Psychiatric Review
Technique form of April 4, 2011. R. 226-242. Of relevance, Dr. Ravello opined that
Worthington has no more than moderate limitations in her activities of daily living,
maintaining social functioning, and maintaining concentration, persistence, or pace. R.
236. Similarly, Worthington requested Dr. Davis to complete a disability form in June of
2011. R. 23. Worthington did not report any physical limitations to Dr. Davis as a
reason that she is disabled. Id. Instead, Worthington reported that she was disabled
Page 19 of 22
because of her “bipolar disorder, concentration deficits, and problems getting along with
others.” Id.
Next, the ALJ reviewed Worthington’s subjective complaints throughout her
medical history and at the hearing. On August 11, 2009, Worthington was treated at Gulf
Coast Mental Health Center. R. 22. The doctor noted that Worthington appears to be in
good physical health. Id. Worthington does not drink or do drugs, but she does smoke
cigarettes. R. 217, 259-260. Worthington said she believes her current medicine regime
is controlling all of her symptoms. R. 256. The doctor also noted that Worthington said
she is an “avid reader, loves to swim [and] lay on the beach, take walks on starry nights,
Native American crafts, crochets[, and is c]urrently ‘writing a novel.’” R. 260.
At the hearing, Worthington testified that she had to stop working in March of
2008, her alleged onset date, “primarily due to concentration problems” and that her
condition has continued to get worse. Id. The ALJ found that “the treatment notes from
Gulf Coast Mental Health in August 2009, over a year after her alleged onset date
indicate that the claimant felt her medications were controlling ‘all’ of her symptoms and
her admitted concentration activities contradict her claims.” Id. The ALJ also noted that
Worthington testified to maintaining her driver’s license and is able to drive, when she
gets stressed she “gets lost in a book,” and her typical day involves Bible study and
morning devotionals, needle work (including sewing, crochet, embroidery, and other
crafts), and watching television. Id. The ALJ held that “[t]hese admitted activities
certainly do not suggest disabling deficits, and indicate that the claimant has no more
than a moderate limitation in her concentration, persistence and pace.” Id.
Page 20 of 22
The ALJ is responsible for determining Worthington’s RFC, not a physician. Had
Worthington received an assessment by a physician, the ALJ would have been required to
consider that assessment in making his determination. “Even though Social Security
courts are inquisitorial, not adversarial, in nature, claimants must establish that they are
eligible for benefits. The [ALJ] has a duty to develop the record where appropriate but is
not required to order [additional evidence] as long as the record contains sufficient
evidence for the [ALJ] to make an informed decision.” Ingram v. Comm’r of Soc. Sec.
Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (citing Doughty v. Apfel, 245 F.3d 1274,
1281 (11th Cir. 2001)). It is clear to this Court that the ALJ carefully considered the
medical evidence in the record in determining Worthington’s physical and mental RFC,
and the record contained sufficient evidence for the ALJ to make his decision. Therefore,
the Court finds that the ALJ’s findings are supported by substantial evidence.
B.
The ALJ’s finding that Worthington is capable of performing the mental
demands of unskilled level work is supported by substantial evidence.
Next, Worthington argues that
[t]he record is devoid of any opinion from a physician regarding Ms.
Worthington’s physical limitations making it unclear how the ALJ
determined Ms. Worthington would be capable of performing work at the
medium level of exertion. The only Physical Residual Functional Capacity
Assessment on file is from the DDS and was completed by M. K. Fendley,
who is a single decision-maker. It is not clear how much weight the ALJ
afforded the single decision-maker’s assessment in Ms. Worthington’s case,
as she failed to mention or make reference to this assessment in her
decision.
See Doc. 12 at 6. On April 5, 2001, M. K. Fendley, a Single Decision-Maker (“SDM”),
completed a Physical RFC Form. R. 57-64. Worthington avers that “the ALJ’s ultimate
Page 21 of 22
residual functional capacity finding was substantially similar to the same one offered by
Ms. Fendley [. . .] [and b]ased on the striking similarity between the ALJ’s RFC and the
assessment completed by Ms. Fendley certainly raises the question of how heavily the
ALJ relied upon Ms. Fendley’s assessment in making her residual functional capacity
finding.” See Doc. 12 at 6-7. As noted by Worthington, SDM forms are “entitled to no
weight or consideration whatsoever.”
See Doc. 12 at 7.
However, Worthington’s
argument fails because, as Worthington admits, there is no evidence that the ALJ
reviewed or considered the SDM form. The ALJ never mentions the SDM form, nor
does she mention Ms. Fendley. The ALJ’s opinion is entirely devoid of any mention or
reference of the SDM form. Worthington argues that the ALJ’s RFC determination is
“substantially similar” to the SDM form; however, there is absolutely no evidence in the
record to support the claim that the ALJ based her findings on the SDM form. Therefore,
this Court finds that Worthington’s argument is completely without merit.
VII. CONCLUSION
Pursuant to the findings and conclusions detailed in this Memorandum Opinion,
the Court concludes that the ALJ’s non-disability determination is supported by
substantial evidence and proper application of the law. It is, therefore, ORDERED that
the decision of the Commissioner is AFFIRMED. A separate judgment is entered
herewith.
DONE this 16th day of July, 2015.
/s/ Terry F. Moorer
TERRY F. MOORER
UNITED STATES MAGISTRATE JUDGE
Page 22 of 22
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?