Hayes v. Colvin

Filing 15

MEMORANDUM OPINION. Signed by Honorable Judge Charles S. Coody on 9/23/14. (scn, )

IN THE DISTRICT COURT OF THE UNITED STATES
FOR THE MIDDLE DISTRICT OF ALABAMA
NORTHERN DIVISION
MARGARET HAYES,
Plaintiff,
v.
CAROLYN W. COLVIN,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.

)
)
)
)
)
)
)
)
)
)
)

CIVIL ACTION NO. 2:13-cv-343-CSC
(WO)

MEMORANDUM OPINION
I. Introduction.
On July 1, 2010, Margaret Hayes protectively filed an application for a period of
disability and disability insurance benefits under Title II of the Social Security Act, 42 U.S.C.
§§ 401, et seq. Hayes also protectively filed an application for supplemental security income
on July 1, 2010, pursuant to Title XVI of the Social Security Act, 42 U.S.C. § 1381, et seq.
In both applications, Hayes alleged disability beginning May 1, 2008. These claims were
denied at the administrative level. Thereafter, Hayes filed a written request for hearing, and,
on November 18, 2011, a hearing was held before Administrative Law Judge (“ALJ”) Frank
M. Klinger. 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,

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

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).2 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 determination3 the Commissioner employs a five step, sequential
evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.
(1) Is the person presently unemployed?
(2) Is the person’s impairment severe?
(3) 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?
(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 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
Security matters were transferred to the Commissioner of Social Security.
2

Pursuant to 28 U.S.C. § 636(c), the parties have consented to entry of final judgment by the United
States Magistrate Judge.
3

A “physical or mental impairment” is one resulting from anatomical, physiological, or psychological
abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.

2

disabled.
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).4
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); Ingram v. Comm. of Soc. Sec. Admin., 496 F.3d 1253, 1260 (11th Cir.
2007). “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.” Richardson v. Perales, 402 U.S. 389, 401 (1971); Crawford v. Comm’r of Soc.
Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004). A reviewing court may not look only to
those parts of the record which supports the decision of the ALJ but instead must view the
record in its entirety and take account of evidence which detracts from the evidence relied
on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986). 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, however,] . . . 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
claims.

4

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).

3

Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
III. The Issues
A. Introduction.
Hayes was 55 years old at the time of the hearing before the ALJ and has completed
four years of college. (R. 41). Her prior work experience includes work as a nurse’s aide,
phlebotomist, cashier, and laboratory assistant. (R. 47-48). Following the administrative
hearing, the ALJ concluded that Hayes has severe impairments of “noninsulin dependent
diabetes mellitus; hypertension; mild degenerative joint disease of the lumbar spine; mild
osteoarthritis of the knees; obesity; and, ‘pancreatitis’ diagnosed on one occasion.” (R. 24).
The ALJ concluded that Hayes was able to perform her past relevant work as a phlebotomist
and lab assistant. (R. 31).
B. The Plaintiff’s Claims. Hayes presents the following two issues for review:
1. Whether the ALJ erred by relying on the residual functional capacity
assessment of a single decision-maker; and
2. Whether the ALJ’s finding that Hayes had no manipulative limitations is
supported by substantial evidence.
IV. Discussion
A disability claimant bears the initial burden of demonstrating the existence of a
disability. 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 his 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 his 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.
A.

The ALJ did not improperly rely on the opinion of the single decision-maker.
Hayes argues that the ALJ erred by considering the residual functional capacity

determination (R. 55-62) made by a Single Decision Maker (“SDM”)5 at the level of the
initial disability determination. Because an SDM has no medical credentials, but instead
makes the initial disability determination after consulting with appropriate medical sources,
SDM-completed forms are not opinion evidence at the appeals level, and the ALJ should not
give any evidentiary weight to the residual functional capacity determination of an SDM.

5

“SDMs are part of a test program of the Social Security Administration for making initial disability
determinations by non-medical experts. 20 C.F.R. § 404.906(a).” Chaverst v. Astrue, 2012 WL 5379063 at
*8 (N.D. Ala. 2012); see also 20 CFR § 416.1406 (setting forth information about the test program with
respect to SSI benefits). Alabama is one of the states in which the use of SDMs is being tested. 71 Fed. Reg.
45,890 (August 10, 2006).

5

Cooper v. Comm’r of Soc. Sec., 521 Fed. Appx. 803, 807 (11th Cir. 2013); Siverio v.
Comm’r of Soc’ Sec., 461 Fed. Appx. 869, 871 (11th Cir. 2012).
The ALJ stated in his opinion:
In this case, a Single Decision-Maker completed the Physical Residual
Functional Capacity Form, and therefore, it has been evaluated as an
adjudicatory document only, and not accorded any evidentiary weight in
deciding this case at the hearing level by reason of its source. However, it
appears to be fully correct and does coincide with my assessment of functional
capacity, again as noted that is giving the claimant the benefit of every possible
reasonable doubt on this medical record (Exhibit 3A).
(R. 30).
Thus, the ALJ made clear in his opinion that he did not assign any evidentiary weight
to the SDM’s report. Further, it is clear from the ALJ’s remarkably detailed discussion of
the record in its entirety, including the medical evidence and his own personal observation
of Hayes’s lack of credibility at the hearing, that he did thoroughly and independently
consider the record as a whole and independently assess Hayes’s residual functional capacity.
See 20 CFR § 404.1545(a)(1) & 416.945(a)(1) (“We will assess your residual functional
capacity based on all the relevant evidence in your case record.”); 20 C.F.R. § 404.1546(c)
( “Responsibility for assessing residual functional capacity at the administrative law judge
hearing . . . level. If your case is at the administrative law judge hearing level . . ., the
administrative law judge ... is responsible for assessing your residual functional capacity.”).
Then, after carefully considering the entire record, the ALJ simply noted that the SDM’s
report coincided with his own independent findings. (R. 30).

6

Accordingly, the ALJ did not commit legal error by mentioning that the SDM’s
opinion happened to coincide with his own independent assessment of Hayes’s residual
functional capacity. See Castel v. Comm'r of Soc. Sec., 355 F. App’x 260, 266 (11th Cir.
2009) (finding no error caused by “the ALJ’s reference to th[e] DDS report,” which “merely
confirmed [the] objective medical evidence”); Black v. Colvin, No. 3:11 cv--1008–CSC,
2013 WL 1278938, * 3 (M.D. Ala. 2013) (finding no error where the ALJ noted the opinion
of the SDM but nevertheless independently assessed the claimant’s residual functional
capacity based on all of the evidence in the record).
B.

Substantial evidence supports the ALJ’s finding the Hayes did not have
manipulative limitations.
On September 20, 2010, Dr. Stuart May may performed a comprehensive consultative

medical examination of Hayes. During that examination, he noted the following regarding
Hayes’s range of motion in her hands and wrist:
WRIST JOINTS: Extension 0- 60 degrees, flexion 0- 60 degrees, radial
deviation 0-20 degrees, and ulnar deviation 0-30 degrees bilaterally.
FINGER/THUMB JOINTS: Flexion/extension of the proximal phalanx 70
degrees and distal phalanx 90 degrees bilaterally.
(R. 225).
Dr. May summarized his medical conclusions from the examination as follows:
GENERAL FINDINGS: The claimant is hypertensive. She has a scarcity of
other findings on physical examination. There was [sic] slight paravertebral
muscle spasms but no crepitus, deformities, or trigger points.
....
7

DIAGNOSES :
1 . Mild degenerative joint disease lumbar spine.
2 . Mild osteoarthritis knees.
3 . Noninsulin dependent diabetes mellitus.
4 . Hypertension.
(R. 225).
Thus, Dr. May clearly did not assign any medical significance to his findings
regarding Hayes’s range of motion in her hands and wrist. Nevertheless, Hayes argues that
the ALJ should have disregarded Dr. Mays’s medical assessment of his own objective
clinical findings, and instead the ALJ should have substituted an independent diagnosis that
Hayes had a medical impairment resulting in manipulative limitations in her hands. Hayes
argues that the ALJ should have formed this independent diagnosis based on Dr. Mays’s
observations that Hayes’s “flexion/extension of the proximal phalanx was seventy (70)
degrees and distal phalanx was ninety (90) degrees bilaterally,” and the “range of motion in
her wrists was limited to extension zero (0) to sixty (60) degrees, radial deviation zero (0) to
twenty (20) degrees, and ulnar deviation zero (0) to thirty (30) degrees bilaterally.” (Doc.
12 p. 11). However, Hayes has not presented any evidence from the record or otherwise that
these raw observations regarding Hayes’s wrists and hands indicated manipulative
impairments. To a non-medical professional, there is nothing inherent in Dr. Mays’s
recorded observations about the range of motion in Hayes’s hand and wrist that undermine
Dr. Mays’s ultimate conclusions and diagnosis, particularly when Dr. Mays himself did not
consider those particular observations to be clinically significant.

8

“Medical opinions are statements from physicians . . . that reflect judgments about the
nature and severity of [a claimant’s] impairment(s), including [the claimant’s] symptoms,
diagnosis and prognosis, what [the claimant] can still do despite impairment(s), [the
claimant’s] physical or mental restrictions.” 20 CFR § 416.927(a)(2). An ALJ is not a
physician and he may not arbitrarily substitute his own medical opinion for that of a medical
professional. Williams v. Barnhart, 140 Fed. Appx. 932, 934 (11th Cir. 2005); see also
Graham v. Bowen 786 F.2d 1113, 1115 (11th Cir. 1986) (finding that “the ALJ improperly
substituted his conclusion that appellant ‘appeared moderately handicapped in her gait’ for
the medical evidence presented); Freeman v. Schweiker, 681 F.2d 727, 731 (11th Cir.1982)
(“[A]n ALJ . . . is not a medical expert.”). Dr. Mays’s medical opinion was that, aside from
hypertension, the findings of the clinical examination (including those pertaining to range
of motion in Hayes’s hands) were not significant, and he did not diagnose any condition that
could limit the range of motion in her hands.
The ALJ specifically emphasized Dr. Mays’s finding that, other than hypertension,
Hays had “a scarcity of findings on physical examination.” (R. 28). The ALJ also relied on
Dr. Mays’s diagnosis, which did not include any medical impairment related to Hayes’s
hands. (R. 28). An ALJ is entitled to rely on the medical opinion of a consulting examining
physician, particularly where, as here, that opinion is not inconsistent with the opinion of a
treating physician or other evidence in the record. 20 CFR § 404.1527(b)-(c); 20 CFR §
416.927(b)-(c). Accordingly, substantial evidence supports the ALJ’s opinion, and reversal

9

is not warranted. Ingram v. Comm’r of Soc. Sec. Admin., 496 F.3d 1253, 1260 (11th Cir.
2007) (holding that a reviewing court must affirm if the decision reached by the ALJ is
supported by substantial evidence).
Moreover, 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), and Hayes has
made no showing how Dr. Mays’s raw observations regarding her wrists and hands
demonstrate that she is unable to return to her past work as a phlebotomist and lab assistant.
V. Conclusion
For the reasons stated, the court concludes that the decision of the Commissioner
denying benefits to Hayes should be affirmed.
The Court will enter a separate final judgment.
Done this 23rd day of September, 2014.
/s/Charles S. Coody
CHARLES S. COODY
UNITED STATES MAGISTRATE JUDGE

10