Briers v. Astrue (CONSENT)
MEMORANDUM OPINION. Signed by Honorable Judge Charles S. Coody on 12/16/2013. (wcl, )
IN THE DISTRICT COURT OF THE UNITED STATES
FOR THE MIDDLE DISTRICT OF ALABAMA
MESHETTE JAWANTAY BRIERS,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
CIVIL ACTION NO. 2:13cv73-CSC
The plaintiff applied for disability insurance benefits pursuant to Title II of the Social
Security Act, 42 U.S.C. §§ 401, et seq., and for supplemental security income benefits under
Title XVI of the Social Security Act, 42 U.S.C. § 1381, et seq., alleging that she was unable
to work because of a disability. Her application was denied at the initial administrative level.
The plaintiff then requested and received a hearing before an Administrative Law Judge
(“ALJ”). Following the hearing, the ALJ also denied the claim. The Appeals Council
rejected a subsequent request for review. The ALJ’s decision consequently became the final
decision of the Commissioner of Social Security (Commissioner).1 See Chester v. Bowen,
792 F.2d 129, 131 (11th Cir. 1986). The case is now before the court for review pursuant
to 42 U.S.C. §§ 405(g) and 1383(c)(3). The parties have consented to the United States
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.
Magistrate Judge conducting all proceedings in this case and ordering the entry of final
judgment, pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1. Based on the court’s
review of the record in this case and the briefs of the parties, the court concludes that the
decision of the Commissioner should be affirmed.
II. Standard of Review
Under 42 U.S.C. § 423(d)(1)(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 . . .
To make this determination,2 the Commissioner employs a five-step, sequential
evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.
Is the person presently unemployed?
Is the person’s impairment severe?
Does the person’s impairment meet or equal one of the specific
impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?
Is the person unable to perform his or her former occupation?
Is the person unable to perform any other work within the economy?
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
A “physical or mental impairment” is one resulting from anatomical, physiological, or
psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).3
The standard of review of the Commissioner’s decision is a limited one. This court
must find the Commissioner’s decision conclusive if it is supported by substantial evidence.
42 U.S.C. § 405(g); Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Substantial
evidence is “more than a scintilla,” but less than a preponderance; it “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, 1158-59 (11th Cir. 2004) (quotation marks
omitted). The court “may not decide the facts anew, reweigh the evidence, or substitute . .
. [its] judgment for that of the [Commissioner].” Phillips v. Barnhart, 357 F.3d 1232, 1240
n. 8 (11th Cir. 2004) (alteration in original) (quotation marks omitted).
[The court must] . . . scrutinize the record in its entirety to determine the
reasonableness of the [Commissioner’s] . . . factual findings . . . No similar
presumption of validity attaches to the [Commissioner’s] . . . legal conclusions,
including determination of the proper standards to be applied in evaluating
Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
III. The Issues
A. Introduction. The plaintiff was 29 years old on the alleged date of onset of
disability, April 1, 2010.4 (R. 131). She has her general equivalency diploma (GED). (R.
McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986) is a supplemental security income case (SSI).
The same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately
cited as authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5th Cir. 1981) (Unit A).
When she applied for benefits, Briers alleged an onset date of March 1, 2010. (R. 42). At the
administrative hearing, she amended her onset date to April 1, 2010. (R. 57).
174). Her past work experience includes work as a hospital cleaner, security guard,
housekeeper/cleaner in a hotel, cashier checker, production assembler, and laborer. (R. 63).
Following the hearing, the ALJ concluded that the plaintiff has severe impairments of
“obesity, migraine headaches, and atypical chest pain.” (R. 23). The ALJ concluded that
Briers’ hypertension and left leg pain and swelling were not severe impairments. (R. 30-31).
The ALJ concluded that the plaintiff could perform her past relevant work as a production
assembler, and thus, she was not disabled. (R. 32).
B. Plaintiff’s Claims. As stated by Briers, she presents two issues for the Court’s
The Commissioner’s decision should be reversed because the ALJ erred
in failing to assign weight to any medical opinion in support of her
residual functional capacity finding.
The Commissioner’s decision should be reversed because the ALJ erred
in finding Ms. Briers’ fibromyalgia and leg pain and leg swelling to not
be severe impairments.
(Doc. # 12, Pl’s Br. at 3).
A disability claimant bears the initial burden of demonstrating an inability to return
to her past work. Lucas v. Sullivan, 918 F.2d 1567 (11th Cir. 1990). In determining whether
the claimant has satisfied this burden, the Commissioner is guided by four factors: (1)
objective medical facts or clinical findings, (2) diagnoses of examining physicians, (3)
subjective evidence of pain and disability, e.g., the testimony of the claimant and her family
or friends, and (4) the claimant’s age, education, and work history. Tieniber v. Heckler, 720
F.2d 1251 (11th Cir. 1983). The ALJ must conscientiously probe into, inquire of and explore
all relevant facts to elicit both favorable and unfavorable facts for review. Cowart v.
Schweiker, 662 F.2d 731, 735-36 (11th Cir. 1981). The ALJ must also state, with sufficient
specificity, the reasons for her decision referencing the plaintiff’s impairments.
Any such decision by the Commissioner of Social Security which involves a
determination of disability and which is in whole or in part unfavorable to such
individual shall contain a statement of the case, in understandable language,
setting forth a discussion of the evidence, and stating the Commissioner’s
determination and the reason or reasons upon which it is based.
42 U.S.C. § 405(b)(1) (emphases added). Within this analytical framework, the court will
address the plaintiff’s claims.
Treating Physician’s Opinion.
Briers argues that the ALJ’s residual
functional capacity assessment is erroneous because the ALJ failed to give any weight to the
opinion of her treating physician, Dr. Mamath Siricilla. (Doc. # 12 at 3). In essence, the
plaintiff argues that if the ALJ accepted Dr. Siricilla’s assessment about her physical
impairments, she would be disabled. On July 15, 2010, Dr. Siricilla completed a physical
capacities evaluation form describing Briers’s physical limitations. (R. 496). According to
Dr. Siricilla, Briers could sit and stand or walk for one hour during the work day; could lift
10 pounds occasionally and 5 pounds frequently; and she would miss more than four days
per month due to her impairments. (R. 496).
Dr. Siricilla added that her assessment was
based on Briers’ fibromyalgia, chronic back pain, history of myocarditis, migraine headaches,
obesity and hypertension. (Id.). Dr. Siricilla also completed a medical statement regarding
Briers’ migraine headaches in which she opined that Briers suffered from migraines several
times a week and that she could not work while suffering from a headache. (R. 497).
Of course, the law in this circuit is well-settled that the ALJ must accord “substantial
weight” or “considerable weight” to the opinion, diagnosis, and medical evidence of the
claimant’s treating physician unless good cause exists for not doing so. Jones v. Bowen, 810
F.2d 1001, 1005 (11th Cir. 1986); Broughton v. Heckler, 776 F.2d 960, 961 (11th Cir. 1985).
The Commissioner, as reflected in her regulations, also demonstrates a similar preference for
the opinion of treating physicians.
Generally, we give more weight to opinions from your treating sources, since
these sources are likely to be the medical professionals most able to provide
a detailed, longitudinal picture of your medical impairment(s) and may bring
a unique perspective to the medical evidence that cannot be obtained from the
objective medical findings alone or from reports of individual examinations,
such as consultive examinations or brief hospitalizations.
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (citing 20 CFR § 404.1527 (d)(2)).
The ALJ’s failure to give considerable weight to the treating physician’s opinion is reversible
error. Broughton, 776 F.2d at 961-2; Wiggins v. Schweiker, 679 F.2d 1387 (11th Cir. 1982).
However, there are limited circumstances when the ALJ can disregard the treating
physician’s opinion. The requisite “good cause” for discounting a treating physician’s
opinion may exist where the opinion is not supported by the evidence, or where the evidence
supports a contrary finding. See Schnorr v. Bowen, 816 F.2d 578, 582 (11th Cir. 1987).
Good cause may also exist where a doctor’s opinions are merely conclusory; inconsistent
with the doctor’s medical records; or unsupported by objective medical evidence. See Jones
v. Dep’t. of Health & Human Servs., 941 F.2d 1529, 1532-33 (11th Cir. 1991); Edwards v.
Sullivan, 937 F.2d 580, 584-85 (11th Cir. 1991); Johns v. Bowen, 821 F.2d 551, 555 (11th
Cir. 1987). The weight afforded to a physician’s conclusory statements depends upon the
extent to which they are supported by clinical or laboratory findings and are consistent with
other evidence of the claimant’s impairment. Wheeler v. Heckler, 784 F.2d 1073, 1075 (11th
Cir. 1986). The ALJ “may reject the opinion of any physician when the evidence supports
a contrary conclusion.” Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11th Cir. 1983). The
ALJ must articulate the weight given to a treating physician’s opinion and must articulate any
reasons for discounting the opinion. Schnorr, 816 F.2d at 581.
After reviewing all the medical records, the ALJ rejected the assessments of Dr.
As for the opinion evidence, Dr. Siricilla’s assessments dated July 15, 2011,
are given no weight, as they are totally inconsistent with all records of
evidence. Dr. Siricilla reported the claimant to have pain to the extent that it
prevented her from working and assessed her capable of sitting, standing, and
walking a total of two hours in an eight-hour day due to fibromyalgia, chronic
back pain, obesity, history of myocarditis, migraine headaches, and
Fibromyalgia was diagnosed and treated by Dr. Jakes from May 2009 through
May 2010. However, he noted all laboratory findings to be normal with the
exception of low vitamin D levels. His examinations consistently revealed the
claimant to have full range of motion of all joints without pain, swelling,
stiffness, or instability. Chronic back pain was not diagnosed or treated by Dr.
Siricilla or any other facility according to the records. The claimant is obese
and has been recommended diet and exercise repeatedly by Dr. Siricilla’s
facility as well as the claimant’s cardiologist and has been noncompliant.
However, as of July 2, 2011, she reported that she had begun walking and was
feeling well. Myocarditis was diagnosed in April 2009 and the claimant has
complained of chest pain since that time. She has undergone full cardiac
workup with no findings. The acute myocarditis found in April 2009 remains
a history of myocarditis and not an impairment at any time since her alleged
onset date. The claimant’s migraine headaches were treated by a neurologist
in 2009. She had negative computed tomography scans and magnetic
resonance imaging of the head and brain. She has ceased to take medication
for her migraines according to her report to Dr. May in July 2010. Last of all,
Dr. Siricilla recited hypertension as one of the reasons for the claimant’s
restrictions. However, her records consistently reveal controlled hypertension,
even when she was not on medication. Thus, Dr. Siricilla’s assessments are
totally without basis and rejected.
The ALJ’s determination is supported by substantial evidence. On February 25, 2009,
Briers presented to the University of Alabama Birmingham (“UAB”) School of Medicine
complaining of headaches. (R. 419). She had no nausea, vomiting, aura, or blurred vision.
(Id.). CT scans of her brain and cervical spine were negative. (Id.) At that time, she reported
no other complaints other than headaches. (Id.)
On March 13, 2009, Briers presented to Alabama Neurological Clinic complaining
of headaches. (R. 246). At that time, she complained of photophobia, phonophobia, nausea
and occasional vomiting. (Id.). She could tandem walk well; she had no ataxia on her gait.
She was started on medication to interrupt the headache cycle. (Id.) An MRI of her brain
on April 6, 2009 was “normal.” (R. 251). On April 14, 2009, Briers returned to the clinic
complaining of headaches but she moved her extremities and there was no evidence of ataxia.
On April 27, 2009, Briers presented to the emergency room complaining of a
headache for two (2) days. She had a rash on her thigh. (R. 311-316). She was admitted to
the hospital on April 28, 2009 after complaining of headaches, left lower extremity erythema
and itching. (R. 324). She was also diagnosed with cellulitis. (Id.) While Briers’
extremities did not show any edema, she had some non-tender erythema which was treated
with antibiotics. (R. 325). A mass on Briers’ left thigh appeared to be subcutaneous fat and
an MRI confirmed a fatty area.5 (R. 332-33). During her hospitalization, Briers was
“ambulating in halls without difficulty.” (R. 249).
Once admitted, Briers began to experience chest discomfort. (R. 324) She underwent
a cardiac consultation and assessment. (R. 346-48). An April 29, 2009, echocardiogram
indicated no abnormalities and normal ventricles. (R. 359-60, 384, 386, 389). On May 3,
2009, Briers was diagnosed with myocarditis. (R. 349).
When she was discharged on May 5, 3009, her diagnoses on discharge were “[a]cute
myocarditis (possibly viral versus rheumatologic), [c]ellulitis/dermatitis left buttock, thigh
responded to antibiotics, left thigh mass referred to oncologist orthopedist, [m]ild anemia,
and headaches.” (R. 248).
On May 13, 2009, Briers presented to Montgomery Rheumatology Associates for an
“evaluation of hurting all over.” (R. 423). At that time, she had “full range of motion of all
joints without pain, stiffness, swelling or instability.” (Id.) Leg raises were negative. (Id.)
Briers was sent for an orthopedic evaluation to rule out liposarcoma. (R. 342-43). The left mass
was ultimately determined to be benign. (R. 417-18).
Dr. Jakes diagnosed Briers with fibromyalgia, and prescribed Flexeril. He also indicated that
he would conduct “a complete laboratory evaluation for fibromyalgia and see her back in a
On May 28, 2009, Briers was seen by cardiologist Dr. Wool. (R. 407-11). Although
she continued to complain of chest pain, an echocardiogram was unremarkable. (R. 404).
Briers did not complain of chest pain during a stress test on June 3, 2009. However, the test
was terminated due to her complaints of fatigue. (R. 401). Further testing revealed a mild
fixed defect in the heart but was unremarkable in any other aspect. (R. 402).
On June 19, 2009, Briers complained to Dr. Jakes of loss of balance, joint pain and
leg cramps. (R. 425). Although Dr. Jakes noted trigger points in Briers’ back, he also noted
“full range of motion of all joints without synovitis.” (Id.) Dr. Jakes opined that “[b]asically
everything was normal except for a low vitamin D level.” (R. 426). Dr. Jakes continued to
diagnose fibromyalgia but prescribed trazadone instead of Flexeril. (Id.). On June 25, 2009,
Briers complained of headaches. (R. 240-41). Maxalt alleviated her pain. (Id.) On that
date, Briers was diagnosed with intractible migraine headaches, sleep apnea and
hypertension. (R. 241). There is no diagnosis of leg pain or fibromyalgia. (Id.)
On June 28, 2009, Briers presented to the emergency room complaining of headaches,
chest pain, shortness of breath and nausea. (R. 286). No pulmonary disease was noted. (R.
300). On June 29, 2009, Briers complained of difficulty sleeping, and waking with a
headache. (R. 238-39). It was recommended that she undergo a polysomnography.6 (Id.)
On July 21, 2009, Briers presented to UAB for her second visit. At that time, she
reported “doing fine today.” (R. 416). “Today, she does not have any active complaints.
She states that she cannot work and is fighting for disability.” (Id.) Dr. Sarvepalli references
Dr. Jakes’ diagnosis of arthritis. (Id.)
On July 23, 2009, Dr. Jakes evaluated Briers for fibromyalgia. She was taking Elavil
and was “generally feeling better.” (R. 436). Dr. Jakes noted that Briers “has full range of
motion of all joints without pain, stiffness, swelling or instability. She has no trigger points
in her back.” (Id.) Although Dr. Jakes diagnosed Briers with fibromyalgia, he also noted
that “[t]his problem is doing well.” (R. 437).
On October 22, 2009, Briers presented to the emergency room complaining of a
severe headache and lower left extremity pain. (R. 271, 583). On November 15, 2009,
Briers complained again of headaches, (R. 260), but a CT scan of her brain was normal. (R.
On March 10, 2010, Dr. McCormick, a cardiologist, examined Briers for chest pain.
Briers denied “muscle cramps, joint pain, joint swelling, . . . back pain, stiffness, muscle
weakness. . .” (R. 397-98, 468-69). A treatment note indicates that Briers continued to walk
but she was not losing any weight. (R. 396, 399, 467, 470). An examination revealed full
range of motion of all joints. (R. 398, 469). A full cardiac work up was negative, and Dr.
There is no evidence in the record to suggest that Briers was diagnosed with sleep apnea after a
McCormick noted that it was atypical to have angina at Briers’ age. (R. 399, 470).
Dr. Jakes saw Briers again on May 28, 2010. At that time, he noted that she can “walk
without difficulty. She stopped taking Elavil because it wasn’t helping. She still has
occasional headaches.” (R. 438-39, 457-58). Dr. Jakes diagnosed Briers with fibromyalgia
but also noted that she was “stable and doing well.” (R. 439, 458).
Briers presented to her cardiologist on July 7, 2010. At that time, she reported that
she was “very sedentary with no regular exercise. She does not follow a regular diet.” (R.
462-65). She complained of pain in her left leg related to the mass. (Id.) An EKG was
normal. (R. 464).
Dr. Stuart May conducted a consultative physical examination of Briers on July 10,
2010. Briers complained of leg pain caused by the mass, migraine headaches, and chest pain.
(R. 441-444). Dr. May noted that Briers “walked to the exam room without assistance. [She]
sat comfortably. She got on and off the exam table. She took her shoes off and put them
back on. I noted no inconsistencies.” (R. 442). At this examination, Dr. May noted that no
assistive device was necessary or used. (R. 443). Dr. May opined
There is a scarcity of findings in this claimant. . . . No muscle spasms,
tenderness, effusion or deformities are noted. Motor strength bulk and tone;
lower extremity bilaterally 5/5 no atrophy. Upper extremity bilaterally 5/5 no
On November 22, 2010, Briers underwent a transthoracic echocardiogram which was
normal with no significant abnormalities noted. (R. 460-61, 490-91).
On April 19, 2011, Briers complained to her cardiologist of sharp chest pain. (R. 48689). She was not exercising regularly. (Id.) She was diagnosed with atypical chest pain.
(Id.) On April 28, 2011, a CTA heart scan was normal. (R. 483-85).
Dr. McCormick saw Briers on June 2, 2011. Briers had since undergone a coronary
CTA but she was still experiencing episodes of “atypical pain.” (R. 478). Briers reported
that she “started to walk daily and feels well.” (Id.) Dr. McCormick noted that Briers’
complaints of chest pain were atypical, “[h]er coronary CTA is within normal limits,” and
her hypertension was well-controlled. (R.479-80).
On June 19, 2011, Briers presented to the emergency room complaining of a
headache. (R. 519). She reported no sensitivity to light and no nausea. She also indicated
that Lortab usually alleviated her pain. (Id.) In addition, Briers complained of thigh pain.
Her thigh was non-tender and she could ambulate without difficulty or assistance. (R. 520).
Briers presented to Dr. Siricilla at UAB on June 22, 2011. At that time, she
complained of knee pain. (R. 508). Dr. Siricilla diagnosed Briers with arthritis of the knees,
“most likely secondary to obesity.” (Id.) Briers requested a cane for walking. (R. 509). A
x-ray of Briers’ right knee on July 5, 2011, indicated “premature medial DJD.” (R. 510,
507). A x-ray of her left knee indicated no abnormalities. (R. 513, 507).
Briers presented to UAB on July 11, 2011 complaining of chronic headaches,
myocarditis, left leg pain, hypertension and fibromyalgia. (R. 506-07). On July 15, 2011,
Briers presented to UAB complaining of back pain. (R. 505).
Dr. Siricilla completed the physical capacities evaluation, a clinical assessment of pain
form and a medical statement regarding migraine headaches on July 15, 2011. (R. 495-967).
Between July 21, 2009, and July 15, 2011, Briers was seen at UAB six times.7 (R. 416-18,
419, 508-09, 506-07, 505). Three of those visits occurred between June 22, 2011 and July
15, 2011. (R. 508-510). Dr. Siricilla saw Briers at most three (3) times.8 It is clear that Dr.
Siricilla’s notes reflect complaints as told to her by Briers. At the administrative hearing,
Briers testified that Dr. Harris told her to not return to work and he prescribed the cane for
her because she fell when her left leg collapsed on her. (R. 43). She also testified that the
pain in her left leg and her heart condition are the impairments that interfere with her ability
to work. (R. 44). The medical records contradict Briers’s testimony regarding these two
impairments. There is no indication in the medical records that Dr. Harris opined that Briers
could not return to work. In addition, while an x-ray indicated early degenerative changes
in Briers’ right knee, an x-ray of her left knee was unremarkable. Multiple medical records
indicate no tenderness of Briers’ left leg, and no interference with her ability to ambulate.
The cardiology records indicate no abnormal cardiac condition. Notwithstanding the medical
records, Dr. Siricilla opined that Briers experienced significant pain that would interfere with
her ability to work. (R. 495).
The ALJ may disregard the opinion of a physician, provided that she state with
The medical records indicate that Dr. Sarvepelli saw Briers on February 25, 2009, May 19, 2009,
and July 21, 2009. (R. 416-419).
The first medical record that indicates Dr. Siricilla saw Briers is dated June 22, 2011. (R.508-09)
particularity reasons therefor. Sharfarz v. Bowen, 825 F.2d 278 (11th Cir. 1987). The ALJ
examined and evaluated the medical records for evidence supporting Dr. Siricilla’s
assessment of the severity of Briers’s physical impairments. While it is clear that Briers
suffers from some pain, the record contains only minimal evidence, other than the plaintiff’s
own self-reports, of the severity of her impairments ascribed to her by Dr. Siricilla in her
assessment of Briers. Dr. Siricilla rarely saw Briers. The medical records do not support Dr.
Siricilla’s assessments. Based upon its review of the ALJ’s decision and the objective
medical evidence of record, the court concludes that the ALJ properly rejected Dr. Siricilla’s
opinion regarding the severity of Briers’s physical impairments.
Severe impairments of fibromyalgia and leg pain and swelling. Briers next
argues that the ALJ committed reversible error by failing to find her fibromyalgia and leg
pain and swelling severe impairments at step 2 of the sequential analysis. (Doc. # 12 at 6).
The severity step is a threshold inquiry which allows only “claims based on the most trivial
impairment to be rejected.” McDaniel, 800 F.2d at 1031. A physical impairment is defined
as “an impairment that results from anatomical, physiological or psychological abnormalities
which are demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.” 42 U.S.C. § 1382c(a)(3)(c). A severe impairment is one that is more than “a
slight abnormality or combination of slight abnormalities which would have no more than
a minimal effect on an individual’s ability to work.” Bowen v. Yuckert, 482 U.S. 137, 154
fn. 12 (1987) citing with approval Social Security Ruling 85-28 at 37a. The plaintiff has the
“burden of showing her impairment is “severe” within the meaning of the Act.” McDaniel,
800 F.2d at 1030.
It is Briers’ obligation, in the first instance, to demonstrate that she can no longer
perform her past relevant work, and she is entitled to benefits. See Lucas, 918 F.2d at 1571
(the claimant bears the burden of establishing the existence of a disability). “Unless the
claimant can prove, as early as step two, that she is suffering from a severe impairment, she
will be denied disability benefits.” McDaniel, 800 F.2d at 1031. “Even though Social
Security courts are inquisitorial, not adversarial, in nature, claimants must establish that they
are eligible for benefits.” 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)). See also
Holladay v. Bowen, 848 F.2d 1206, 1209 (11th Cir. 1988).
In finding that the plaintiff’s fibromyalgia and leg pain and swelling were not severe
impairments, the ALJ reviewed the plaintiff’s medical records. After carefully reviewing the
medical records, the court concludes that substantial evidence supports the ALJ’s conclusion
that the plaintiff’s fibromyalgia and leg pain and swelling do not constitute “severe
impairments” within the meaning of the Social Security Act. Briers applied for disability
benefits alleging a disability onset date of March 1, 2010. (R. 131, 135). In her disability
report, Briers asserted that she cannot work because of “[m]ass in leg, hbp, heart problems,
migraines, arthritis.” (R. 174).
Her medical records reveal that while Briers was diagnosed with fibromyalgia, she no
longer has trigger points, and her condition has improved. Furthermore, although Briers
complains of leg pain, the mass in her leg has repeatedly been noted as non-tender. Her
medical records demonstrate that Briers has no difficulty ambulating. In addition, Briers
requested a cane from Dr. Siricilla, shortly before Dr. Siricilla completed her functional
“[T]he severity of a medically ascertained disability must be measured in terms of its
effect upon ability to work, and not simply in terms of deviation from purely medical
standards of bodily perfection or normality.” McCruter v. Bowen, 791 F.2d 1544, 1547 (11th
Cir. 1986); Gray v. Comm’r of Soc. Sec., 426 Fed. Appx. 751, 753 (11th Cir. 2011); Manzo
v. Comm’r of Soc. Sec., 408 Fed. Appx. 265, 269 (11th Cir. 2011). While the record
indicates that the plaintiff has been diagnosed with fibromyalgia, the medical evidence in the
record indicates that this condition is well controlled and does not have more than a minimal
effect on her ability to perform basic work activity. Briers has failed to demonstrate that her
fibromyalgia “significantly limits” her ability to work. Crayton v. Callahan, 120 F.3d 1217,
1219 (11th Cir. 1997). See also Reynolds v. Comm’r of Soc. Sec., 457 Fed. Appx. 850, 852
(11th Cir. 2012).
With respect to her leg pain and swelling, the consultative physician opined that
“[t]here was a scarcity of findings in this claimant.” (R. 443). He noted that no assistive
device was needed or used, (id.) and that Briers “walked to the exam room without
assistance.” (R. 442). Briers sat comfortably and was able to get on and off the examination
table. (Id.) Her coordination was normal as was her station and gait. (Id.) This court must
accept the factual findings of the Commissioner if they are supported by substantial evidence
and based upon the proper legal standards. Bridges v. Bowen, 815 F.2d 622 (11th Cir. 1987).
The only evidence that Briers points to that suggests that her fibromyalgia and leg pain and
swelling9 compromise her ability to work is her own testimony, which the ALJ discounted.
Consequently, the court concludes that Briers has failed to meet her burden of establishing
that the ALJ’s decision regarding the severity of these impairments was not supported by
The court has carefully and independently reviewed the record and concludes that
substantial evidence supports the ALJ’s conclusion that plaintiff is not disabled. Thus, the
court concludes that the decision of the Commissioner is due to be affirmed.
A separate order will be entered.
Done this 16th day of December, 2013.
/s/Charles S. Coody
CHARLES S. COODY
UNITED STATES MAGISTRATE JUDGE
The court scoured the medical records and has not found a single incident where a medical
professional noted that Briers suffered from swelling in her leg.
Even if the court were to conclude that the ALJ’s determination at step two was erroneous, any
error was harmless because the ALJ fully considered and analyzed all the medical evidence including
evidence of headaches. See Delia v. Comm’r of Soc. Sec., 433 Fed. Appx. 885, 887 (11th Cir. 2011); Burgin
v. Comm’r of Soc. Sec., 420 Fed. Appx. 901, 903 (11th Cir. 2011).
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