Johnson v. Colvin

Filing 14

MEMORANDUM OPINION AND ORDER that the decision of the Commissioner is AFFIRMED, as further set out. Signed by Honorable Judge Gray M. Borden on 3/5/18. (djy, )

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF ALABAMA
SOUTHERN DIVISION
JANIE MICHELE JOHNSON,
Plaintiff,
v.
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
Defendant.

)
)
)
)
)
)
)
)
)
)

CASE NO.: 1:16-cv-885-GMB
[WO]

MEMORANDUM OPINION AND ORDER
Plaintiff Janie Michele Johnson filed this action on November 14, 2016 seeking
judicial review of a final adverse decision of the Commissioner of Social Security denying
her application for a period of disability and disability insurance benefits under Title II of
the Social Security Act. Doc. 1. Johnson applied for disability benefits with an alleged
disability onset date of March 1, 2014.
administrative level.

Her application was denied at the initial

Johnson then requested and received a hearing before an

Administrative Law Judge (“ALJ”) on September 22, 2015. Following that hearing, the
ALJ denied Johnson’s claims on November 4, 2015. The Appeals Council rejected a
subsequent request for review making the ALJ’s decision the final decision of the
Commissioner of Social Security (the “Commissioner”).1
With briefing complete, this case is now ripe for review pursuant to 42 U.S.C.

1

Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub. L. No.
103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social
Security matters were transferred to the Commissioner of Social Security.

§ 405(g). The parties have consented to the entry of a final judgment by the undersigned
United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), Rule 73 of the Federal
Rules of Civil Procedure, and Rule 73.1 of the Local Rules for the United States District
Court for the Middle District of Alabama. Docs. 8 & 9. Based upon a review of the
evidentiary record, the parties’ briefs, and the applicable legal authority, the court finds
that the Commissioner’s decision is due to be AFFIRMED.
I. STANDARD OF REVIEW
The court reviews a social security case to determine whether the Commissioner’s
decision “is supported by substantial evidence and based upon proper legal standards.”
Lewis v. Callahan, 125 F.3d 1436, 1439 (11th Cir. 1997). The court “may not decide the
facts anew, reweigh the evidence, or substitute its judgment for that of the Commissioner,”
but rather it “must defer to the Commissioner’s decision if it is supported by substantial
evidence.” Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1997) (internal quotation marks
omitted). Indeed, the court must affirm the Commissioner’s decision “if it is supported by
substantial evidence and the correct legal standards were applied.” Kelly v. Apfel, 185 F.3d
1211, 1213 (11th Cir. 1999) (citing Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir.
1997)).
“Substantial evidence is more than a scintilla—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.” Jones ex rel.
T.J.J. v. Astrue, 2011 WL 1706465, at *1 (M.D. Ala. May 5, 2011) (citing Lewis, 125 F.3d
at 1440). The court must scrutinize the entire record to determine the reasonableness of
2

the decision reached. Hale v. Bowen, 831 F.2d 1007, 1010 (11th Cir. 1987). “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 a finder of fact, and even if the
court finds that the evidence preponderates against the Commissioner’s decision.” Jones,
2011 WL 1706465, at *2 (citing Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir.
1991)). The court will reverse the Commissioner’s decision on plenary review if the
decision applies incorrect law, or if the decision fails to provide the court with sufficient
reasoning to determine that the Commissioner properly applied the law. Cornelius v.
Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991); Jones, 2011 WL 1706465, at *2 (citing
Keeton v. Dep’t of Health & Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994)). There
is no presumption that the Commissioner’s conclusions of law are valid. Id.
II. STATUTORY AND REGULATORY FRAMEWORK
To qualify for disability benefits, a claimant must show the “inability 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.” 42 U.S.C. § 423(d)(1)(A); 42
U.S.C. § 416(i). A physical or mental impairment is “an impairment that results from
anatomical, physiological, or psychological abnormalities which are demonstrated by
medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3).
Johnson bears the burden of proving that she is disabled, and she is responsible for
producing evidence to support her claim. See Ellison v. Barnhart, 355 F.3d 1272, 1276
(11th Cir. 2003).
3

Determination of disability under the Social Security Act requires a five-step
analysis. 20 C.F.R. § 404.1520(a). Specifically, the Commissioner must determine in
sequence:
(1) Is the claimant presently unemployed?
(2) Is the claimant’s impairment severe?
(3) Does the claimant’s impairment meet or equal one of the specific
impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?
(4) Is the claimant unable to perform his or her former occupation?
(5) Is the claimant unable to perform any other work within the economy?
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “An affirmative answer to any
of the above 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 ‘not disabled.’” Id. at 1030 (quoting 20 C.F.R. § 416.920(a)−(f)). “Once
the finding is made that a claimant cannot return to prior work the burden of proof shifts to
the Secretary to show other work the claimant can do.” Foote v. Chater, 67 F.3d 1553,
1559 (11th Cir. 1995) (citing Gibson v. Heckler, 762 F.2d 1516 (11th Cir. 1985)).
III. DISCUSSION
A.

Facts
Johnson was 48 years old on the alleged disability onset date. She has a high school

education and past relevant work experience as an assistant retail manager, a dispatcher,
and a clerical worker.
Johnson filed for disability benefits based on stomach pain and distension, chronic
obstructive pulmonary disease, high blood pressure, high cholesterol, and liver problems.
The ALJ held an administrative hearing on September 22, 2015. Following that hearing,

4

the ALJ found that Johnson suffers from the severe impairments of asthma, chronic
obstructive pulmonary disease, abdominal distention, and obesity, but that none of those
impairments or a combination of those impairments meets or medically equals the severity
of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R.
§§ 404.1520(d), 404.1525 and 404.1526). The ALJ then determined that Johnson has the
residual functional capacity (“RFC”) to perform light work as defined in 20 C.F.R.
§ 404.1567(b) except that she can
never climb ladders, ropes, or scaffolds and occasionally climb stairs, crouch,
crawl, stoop, and kneel. The claimant must avoid work at unprotected
heights and avoid concentrated exposure to fumes, dusts, and gasses [sic].
Due to medication, the claimant is limited to unskilled work, making simple
decisions, with few workplace changes.
Doc. 13-2. Ultimately, the ALJ concluded that Johnson was not disabled within the
meaning of the Social Security Act and denied her claim. Johnson timely appealed that
decision to this court.
B.

Issues Presented
Johnson presents the following issues2 for review:
1.

Whether the ALJ erred by substituting his opinion for the opinion of a

medical professional;
2.

Whether the ALJ’s RFC analysis is supported by substantial evidence;

3.

Whether the ALJ improperly rejected uncontroverted medical evidence; and

2

These are the “issues presented” by Johnson in her brief. Any issue not raised before the court is deemed
to be waived. See Dial v. Berryhill, 2017 WL 459859, at *3 (M.D. Ala. Feb. 2, 2017) (citing Simpson v.
Comm’r of Soc. Sec., 423 F. App’x 882, 885 (11th Cir. 2011) (concluding in a social security case that
issues not raised before the district court are waived)).

5

4.

Whether the ALJ failed to evaluate properly Johnson’s mental impairment.

Doc. 11 at 1. The Commissioner contends that the ALJ’s decision is supported by
substantial evidence and due to be affirmed. Doc. 12. After careful consideration of the
parties’ arguments, the applicable authority, and the record as a whole, the court agrees
with the Commissioner and finds that the Commissioner’s decision is due to be
AFFIRMED, as set forth below.
C.

Analysis
1.

Evaluation of Johnson’s Mental Impairment

Both the first and last issues raised by Johnson in her brief challenge the ALJ’s
evaluation of her alleged mental impairment. Because resolution of those issues is
intertwined, the court will discuss them collectively below.
Johnson first contends that the ALJ improperly substituted his opinion for the
opinion of a medical professional when he rejected the diagnosis of non-severe anxiety
made by Dr. Robert Estock, a state-agency non-examining physician.3 The record shows
that, after reviewing Johnson’s medical records, Dr. Estock concluded that she had the
non-severe impairment of anxiety with mild restrictions in activities of daily living;
maintaining social function; and maintaining concentration, persistence, or pace.
However, when asked to provide “additional explanation,” Dr. Estock clarified that
Johnson “alleges only physical limitations” and “has a [prior medical history] of anxiety”
but “takes no mental meds,” has had no psychiatric treatment, and her activities of daily

3

Neither the record nor the parties specify Dr. Estock’s specialty, if any.

6

living “note no problems w/ mental limitations.” Doc. 13-3.
In formulating Johnson’s RFC, the ALJ rejected Dr. Estock’s diagnosis, instead
finding that Johnson had no mental impairment whatsoever.

Specifically, the ALJ

explained:
Dr. Estock, the state agency consulting physician who reviewed the medical
records available on May 2, 2014, found the claimant to have nonsevere
mental impairment. The undersigned finds the claimant to have no mental
impairment, and that the claimant did not testify to any mental impairment.
The claimant’s only allegations of a mental impairment are regarding side
effects of her medication causing her to be unable to concentrate. The
undersigned has found the claimant to be generally not credible, including
statements as to the severity of her medication side effects.
Doc. 13-2. From this conclusion, Johnson contends that the ALJ committed reversible
error by impermissibly substituting his own opinion for that of Dr. Estock, a medical
professional, on the issue of whether she has a mental impairment.
When assessing medical opinions, the ALJ must consider several factors to
determine how much weight to give the opinion, “including whether the physician has
examined the claimant; the length, nature, and extent of a treating physician’s relationship
with the claimant; the medical evidence and explanation supporting the physician’s
opinion; how consistent the physician’s opinion is with the ‘record as a whole’; and the
physician’s specialty.” Huntley v. Soc. Sec. Admin., Comm’r, 683 F. App’x 830, 832 (11th
Cir. 2017) (citing 20 C.F.R. §§ 404.15267(c) & 416.927(c)). “These factors apply to both
examining and non-examining physicians.” Id. The ALJ “must state with particularity the
weight given to different medical opinions and his supporting reasons.” Id. “The opinion
of a non-examining physician ‘taken alone’ does not constitute substantial evidence to

7

support” an ALJ’s decision. Id. (quoting Swindle v. Sullivan, 914 F.2d 222, 226 n.3 (11th
Cir. 1990)). Ultimately, however, the ALJ is “free to reject the opinion of any physician
when the evidence supports a contrary conclusion.” Id. (citing Sryock v. Heckler, 764 F.2d
834, 835 (11th Cir. 1985)).
The court finds that the ALJ did not err by impermissibly substituting his own
opinion for Dr. Estock’s on the issue of whether Johnson has a mental impairment.
Although the ALJ did not specifically articulate the weight he assigned to Dr. Estock’s
opinion on that issue, the fact that he reached an entirely different conclusion than Dr.
Estock—that Johnson has no mental impairment at all, rather than a non-severe mental
impairment—implies that he assigned no weight to Dr. Estock’s opinion. And the ALJ’s
reasons for doing this are adequately explained in his decision. Indeed, the hearing
transcript does not reflect that Johnson complained of a mental impairment or anxiety
specifically. To the contrary, she testified only about the cognitive limitations caused by
the side effects of her medications, and the ALJ reasonably discounted the credibility of
that testimony as not borne out by her medical and treatment records.
Johnson contends that the ALJ should not have rejected Dr. Estock’s opinion
because her mental impairment is supported by other medical evidence in the record.
Johnson specifically points to medical records from the Mayo Clinic Jacksonville from
2012 noting that she was depressed because of her abdominal symptoms, and a note from
her treating physician, Dr. Michael Williams, assessing a cognitive disorder due to her
medications. Doc. 13-7.

The undersigned does not find this evidence sufficient to

demonstrate that the ALJ’s conclusion that Johnson has no mental impairment was
8

erroneous or unsupported by substantial evidence. The evidence does not show that Dr.
Williams and the physicians who examined Johnson at the Mayo Clinic Jacksonville are
mental-health specialists, and their medical records do not reflect that she was ever
specifically treated for a mental condition or illness. At most, this evidence reflects that
Johnson experienced intermittent depression and frustration as a result of her abdominal
pain and lack of diagnosis or effective treatment for those symptoms, but it does not
evidence treatment of any mental impairment.

Indeed, Dr. Williams attributed any

cognitive issues solely to Johnson’s medication, and even Dr. Estock’s anxiety diagnosis
expresses equivocation in that he qualified that diagnosis with additional explanation that
Johnson complained only of physical impairments, that his finding was based solely on her
past medical history, and that his finding is not supported by any evidence that she takes
medications for mental illness, that she has had any psychiatric treatment, or that her
activities of daily living otherwise note problems with mental limitations.
In fact, Johnson never listed a mental condition as a basis for her disability in her
initial application or on reconsideration, and she has never amended her disability
application to include a mental impairment or testified that her disability is based on a
mental impairment. Even when Johnson updated her disability report to include new
complaints of disabling back pain, she did not mention or claim that her ability to work
was limited because of a mental illness or impairment. Likewise, in a function report,
Johnson did not complain of limitations in her social functioning, including understanding,
following instructions, paying attention, and getting along with others, and she further
reported no problems with changes in stress or routine and no unusual behaviors or fears.
9

Johnson relies on Carril v. Barnhart, 201 F. Supp. 2d 1190 (N.D. Ala. 2002), to
support her argument that the ALJ improperly substituted his opinion on her mental
impairment for Dr. Estock’s opinion. In Carril, the district court found that the ALJ had
erred in rejecting the only medical evidence of a mental impairment to find that the
claimant had no mental impairment. Id. at 1191. The circumstances in Carril, however,
are different from those presented here. Carril involved the rejection of a consultative
examination performed by a psychologist which specifically diagnosed the claimant with
the severe impairment of major depressive disorder. Id. Here, the medical records illustrate
prior medical history positive for anxiety and intermittent mentions of depression, but
unlike in Carril, there is no evidence in Johnson’s treatment history of an examination and
corresponding findings of a severe mental impairment by a mental-health specialist.
In fact, in providing a comparative citation, the Carril court points to another case
with circumstances akin to those presented here. In Stanton v. Apfel, 2000 WL 1005817,
at *1 (S.D. Ala. July 5, 2000), the ALJ found that the claimant had no mental impairment
when the administrative records contained no evidence of treatment for mental impairment
or illness; the only mental health records consisted of consultative examinations from two
psychologists, neither of whom had a treating relationship with the claimant or had
diagnosed a specific mental disease, illness, or impairment that would significantly affect
the claimant’s ability to perform basic work activities; and the claimant had never alleged
a mental impairment in his initial disability application or on reconsideration. Id. at *3-6.
Finding this evidence sufficient to support the ALJ’s decision, the district court rejected
the claimant’s argument that the ALJ had improperly substituted his opinion for that of the
10

psychologists and affirmed the ALJ’s finding on the claimant’s mental impairment as
supported by substantial evidence. Id. at *6.
The court finds Stanton persuasive. As in Stanton, Johnson never alleged a mental
impairment in her initial disability application or on reconsideration. The medical records
also reflect no treatment for a mental condition, and the opinion at issue—Dr. Estock’s—
comes from a state-agency reviewing physician who never examined or treated Johnson.
What is more, there is no diagnosis in the medical records of a specific mental disease,
illness, or impairment that would significantly affect Johnson’s ability to perform basic
work activities. At most, the record evidence demonstrates that Johnson’s cognitive
abilities are affected by side effects from her medications, and the ALJ accounted for those
side effects in his RFC determination by limiting her to “unskilled work, making simple
decisions, with few workplace changes.” Doc. 13-2. For these reasons, the court finds that
the ALJ did not err by improperly substituting his opinion for Dr. Estock’s when
determining that Johnson has no mental impairment.
Johnson also challenges the ALJ’s failure to evaluate her mental impairment
pursuant to the Psychiatric Review Technique Form (“PRTF”) set out by the Eleventh
Circuit in Moore v. Barnhart, 405 F.3d 1208 (11th Cir. 2005). What this argument
overlooks, however, is the fact that an ALJ is not required to apply the PRTF unless a
claimant presents a “colorable claim of mental impairment.” Johnson has failed to do, as
she did not allege a mental impairment in her initial disability application, on
reconsideration, through amendment of her application, or via testimony at her hearing
before the ALJ.
11

“The Eleventh Circuit has found, and Defendant correctly points out, that ‘an
administrative law judge is under no obligation to investigate a claim not presented at the
time of the application for benefits and not offered at the hearing as a basis for disability.’”
Pierce v. Astrue, 2012 WL 1231876, at *3 (M.D. Ala. Apr. 12, 2012) (quoting Street v.
Barnhart, 133 F. App’x 621, 627 (11th Cir. 2005)). In Pierce, the district court held that
a claimant had not presented a colorable claim of mental impairment sufficient to trigger
the ALJ’s duty to apply the PRTF when she had not listed a mental impairment in her initial
application, had not testified to a mental impairment at her hearing before the ALJ, and the
record contained no diagnosis of a mental illness. Id. Although the district court noted that
two physicians had referenced a mental condition or impairment in their treatment notes,
the court did not find this evidence indicative of a colorable claim of mental impairment
because the physicians were not “qualified mental examiners nor do their brief statements
in the treatment notes qualify as objective medical evidence of a mental impairment.” Id.
The same can be said here. Johnson did not list a mental impairment in her initial
application or on reconsideration, and she did not testify to a mental impairment at her
hearing before the ALJ. In fact, it is unclear from Johnson’s brief precisely how she claims
to be mentally impaired or how the impairment would limit her ability to work. While
there are a handful of brief references to depression and anxiety in Johnson’s treatment
records, there is no evidence that the physicians who made these references were qualified
mental examiners or, even if they were, that these references, which are buried within
detailed notes about Johnson’s gastrointestinal and pulmonary issues, qualify as objective
medical evidence of a colorable claim of mental impairment such that the ALJ should have
12

engaged in the PRTF analysis. For these reasons, the court concludes that the ALJ did not
err in evaluating Johnson’s mental impairment.
2.

The ALJ’s RFC Finding

Johnson argues that the ALJ erred in his finding that she has the RFC to perform
light work with certain limitations because he “does not provide analysis as to how the
limitations he found are actually supported by the medical evidence.” Doc. 11. Put
differently, Johnson argues that because the ALJ did not provide “rationale” or
“specifically point to any evidence” demonstrating that she can perform light work, his
RFC finding is not supported by substantial evidence. Doc. 11.
At step four of the sequential evaluation process, the ALJ summarized Johnson’s
medical records and ultimately concluded that she has the RFC to perform light work
except that she
can never climb ladders, ropes, or scaffolds and occasionally climb stairs,
crouch, crawl, stoop, and kneel. The claimant must avoid work at
unprotected heights and avoid concentrated exposure to fumes, dusts, and
gasses [sic]. Due to medication, the claimant is limited to unskilled work,
making simple decisions, with few workplace changes.
Doc. 13-2. Light work is defined as work that 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).
Johnson contends that the ALJ did not sufficiently articulate in his RFC finding how
her medical records show that she can lift 20 pounds occasionally and 10 pounds
frequently. To support this argument, Johnson points to a medical source statement from
Dr. Williams, her treating physician, on August 4, 2014, which severely limits her ability
13

to do work-related physical activities in a work setting. Specifically, Dr. Williams restricts
Johnson to lifting and carrying only five pounds occasionally to one pound frequently;
sitting, standing, and walking a total of one hour in an eight-hour workday; never bending,
stooping, operating motor vehicles, or working with or around hazardous machinery; rarely
reaching (including overhead); occasionally pushing, pulling, climbing, balancing, and
using gross manipulation; and frequently using fine manipulation and exposure to
“environmental problems” like allergies and dust.4 Doc. 13-7. Dr. Williams also states that
Johnson will likely be absent from work due to her impairments more than four days per
month (when she only works two days a week) and that these limitations are due to her
“chronic abdominal pain and distension” and “also cognitive impairments from the
medication she is on” for her abdominal problems. Doc. 13-7. Johnson also points to her
own testimony that she cannot lift a gallon of milk (weighing approximately 8.6 pounds).
Ultimately, Johnson argues that Dr. Williams’ medical source statement and her testimony
about her limitations prove that she cannot perform light work, and since the ALJ failed to
articulate how the medical records show otherwise his RFC finding cannot be supported
by substantial evidence.
The court finds that Johnson’s argument lacks merit for several reasons. First,
Johnson has not persuaded the court that an ALJ must accept a claimant’s limitations as
provided in a medical source statement when those limitations are not supported by the

4

Dr. Williams’ recommendation that Johnson can have frequent exposure to environmental problems is
perplexing given her COPD and Dr. Williams’ own treatment record from February 12, 2014, wherein he
notes that Johnson’s shortness of breath is aggravated by smoke and dust. Doc. 13-7.

14

medical evidence. Nor has Johnson persuaded the court that the ALJ failed to show how
his light-work RFC finding is supported by the medical evidence. To the contrary, the ALJ
considered Dr. Williams’ medical source statement but ultimately gave the limitations
contained therein little weight—and rightfully so since the extreme nature of those
limitations is not borne out by the medical evidence, as explained in the ALJ’s decision
and below.
Johnson’s medical records show that she was treated at the Mayo Clinic
Jacksonville in 2012 for abdominal pain and distension. Those records indicate that she
had been experiencing abdominal pain and distension since 2006, that she had a repeat
laparoscopic lysis of adhesions in 2008, but that she had not seen a doctor since then. A
CT of her abdomen and pelvic area was negative. Johnson was diagnosed with abdominal
pain and referred for rehabilitation with no work limitations.
The next medical record is from January 2014, when Johnson began treatment with
Dr. Williams at PrimeCare. On her first visit, she reported symptoms of a cough, sinus
congestion, and headache. At that visit, she did not complain of abdominal pain, was not
in acute distress, and had normal range of motion. On February 12, 2014, Dr. Williams
saw Johnson for a routine blood pressure check and noted that she “has done fairly well
with no interim problems,” that she “is without any complaints or problems at this time,”
and that she specifically denies abdominal pain. Doc. 13-7. Upon exam, she was noted to
have normal gait, normal tone, and the ability to stand without difficulty. Johnson was
treated by Dr. Williams again on February 28, 2014 for complaints of a non-productive
cough, fever, and wheezing; she denied any additional symptoms. Dr. Williams treated
15

Johnson for another non-productive cough and upper respiratory tract symptoms on March
10, 2014, but she again denied any additional symptoms. In April 2014, Johnson was
treated by Dr. Emily Jones at PrimeCare for a rash. She did not complain of abdominal
pain and was not in acute distress at that time.
In fact, it was not until May 2014 that Johnson first complained to Dr. Williams of
abdominal distension, which she claimed to be causing lower back pain that radiated into
her leg. Dr. Williams noted that Johnson had diffuse abdominal tenderness to palpation,
abdominal distension, and moderate lumbar spine tenderness to palpation. However, she
otherwise was noted to have normal range of motion, normal gait, normal tone, normal
reflexes, normal sensation, and the ability to participate in an exercise program.
Dr. Williams treated Johnson again on August 4, 2014 for abdominal pain, fullness,
and bloating. Johnson reported to Dr. Williams that her pain was severe and that eating,
exercise, standing, and sitting exacerbated it. She also reported to Dr. Williams that her
employer would not allow her to continue working due to the side effects of her pain
medications. Upon exam, Dr. Williams noted mild epigastric region lower abdominal
tenderness to palpation and abdominal protuberance, and stated that Johnson could not
work because of her chronic abdominal pain and distension “as well as cognitive problems
secondary to medication.” Dr. Williams completed his medical source statement on the
same day.
There are no further treatment records until June 23, 2015, almost a year after
Johnson’s August 2014 visit with Dr. Williams, when she was seen for a regularly
scheduled blood pressure check. Dr. Williams noted that Johnson has “done fairly well
16

with no interim problems” since her August 2014 visit and that she “states she is doing
well and is without any complaints or problems at this time.” Doc. 13-7. Johnson
specifically denied abdominal pain and, upon exam, was noted to have a non-tender
abdomen to palpation. She was also noted to have normal range of motion, normal gait,
normal reflexes, normal tone, and the ability to stand without difficulty.
From this evidence, it was reasonable for the ALJ to assign Dr. Williams’ severe
physical limitations little weight, as the medical evidence demonstrates that those
limitations are not supported by Dr. Williams’ own medical records or the other medical
evidence. To the contrary, the record evidence indicates that, while Johnson may have
abdominal pain and distension, those issues did not limit her ability to perform workrelated activities in a significant way because Dr. Williams noted on multiple occasions
that Johnson still retained a normal gait, normal tone, normal reflexes, the ability to stand
without difficulty, and even the ability to participate in an exercise program.
The ALJ also reasonably discounted the credibility of Johnson’s testimony
regarding the severity of her medical conditions and the physical limitations they cause.
Although Johnson testified she could not lift even a gallon of milk or sit for more than 30
minutes before having to stand, her function report shows that her medical conditions do
not cause her problems with personal care, such as dressing, bathing, feeding herself, and
using the toilet; she cooks daily for around 30 minutes; she does laundry, cleans, and rides
the lawn mower; she goes outside daily; she rides in and drives a car; she goes out alone;
she shops and handles money; she reads, makes crafts, and watches television; she spends
time with others; she goes to the ballpark, shopping, and to her families’ homes regularly;
17

and she has no problems with understanding or following instructions. In fact, in her
function report, Johnson writes that she can lift up to 20 pounds before it causes her pain.
Based on this evidence, along with Johnson’s infrequent medical treatment,5 it was
reasonable for the ALJ to discount her testimony of a severely disabling medical
condition.6 Accordingly, the court finds that the ALJ’s RFC finding is supported by
substantial evidence.
3.

Improper Rejection of Uncontroverted Medical Opinion

Finally, Johnson argues that the ALJ erred by rejecting Dr. Williams’
uncontroverted medical opinion as to her physical limitations because “no medical opinion
in the file contradicts the physical limitations placed” on Johnson by Dr. Williams. “An
ALJ may not discount a treating physician’s opinion without articulating good cause for
doing so.” Ybarra v. Comm’r of Soc. Sec., 658 F. App’x 538, 541 (11th Cir. 2016).
“Acceptable reasons for discounting the opinion of a treating physician are that it is
conclusory; it is unsupported by medical evidence; it is inconsistent with the record as a
whole; or other evidence supports a contrary finding.” Id. (citing Crawford v. Comm’r of
Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004) (holding that treating physician’s

5

Although Johnson does not specifically argue that the ALJ improperly relied upon her infrequent medical
treatment as a reason to discount the credibility of her testimony, she does point out that she testified she
could not afford health insurance. While Johnson did testify that she could no longer afford health insurance
after she began working part-time in March 2014, she did testify that she had health insurance through
March 1, 2014, but still had infrequent medical treatment up until that point. Moreover, while Johnson
testified that she could not afford health insurance after she began working part-time in March 2014, she
did not testify that she could no longer afford medical care whatsoever, and she continued seeing Dr.
Williams after her positon became part-time.
6
To the extent Johnson challenges the ALJ’s decision to assign the opinion of her employer little weight,
that decision was reasonable, as Johnson’s employer is not a trained medical professional and his opinion
was based on the claimant’s subjective complaints, which the ALJ reasonably found lacking credibility.

18

testimony was properly discounted when it was inconsistent with physician’s own
treatment reports and the record as a whole and appeared to be based on the claimant’s
subjective complaints). For the reasons explained in Part III.C.2 above, Dr. Williams’ own
medical records, and the other medical evidence in the file, contradict the severe limitations
he imposed on Johnson in the August 4 medical source statement. Thus, it was reasonable
for the ALJ to discount the opinions contained in Dr. Williams’ medical source statements.
Accordingly, the court concludes that the ALJ did not err by improperly rejecting an
uncontroverted medical opinion.
IV. CONCLUSION
The court has carefully and independently reviewed the record and concludes that,
for the reasons stated above, the decision of the Commissioner is AFFIRMED. A final
judgment consistent with this opinion will be entered separately.
DONE this 5th day of March, 2018.

19