Haynes v. Astrue (CONSENT)

Filing 17

MEMORANDUM OPINION. Signed by Honorable Judge Charles S. Coody on 7/10/2012. (jg, )

IN THE DISTRICT COURT OF THE UNITED STATES
FOR THE MIDDLE DISTRICT OF ALABAMA
EASTERN DIVISION
CYNTHIA DEAN HAYNES,
Plaintiff,
v.
MICHAEL J. ASTRUE,
Commissioner of Social Security,
Defendant.

)
)
)
)
)
)
)
)
)
)

CIVIL ACTION NO. 3:11cv693-CSC
(WO)

MEMORANDUM OPINION
I. Introduction
The plaintiff, Cynthia Dean Haynes (“Haynes”), applied for disability insurance
benefits pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and
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). Based on

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.

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 affirmed.2
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,3 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
disabled.”

2

Pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1, the parties have consented to the United
States Magistrate Judge conducting all proceedings in this case and ordering the entry of final judgment.
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

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); 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
claims.
Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
III. The Issues
A. Introduction. Haynes was 42 years old at the time of the administrative hearing.
(R. 49). She has completed high school and has some vocational technical training in
computer programming. (R. 44). The ALJ concluded that Haynes has severe impairments

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

of “psychotic disorder and obesity,” but concluded that Haynes’ migraine headaches did not
constitute a severe impairment because this condition did not “manifest with the degree of
severity that suggest they should be included as severe.”5 (R. 21). The ALJ concluded that
the plaintiff was unable to perform her past relevant work, but, using the Medical-Vocational
Guidelines, 20 C.F.R. Pt. 404, Subpt. P., App. 2, as a framework and relying on the testimony
of a vocational expert, she also concluded that there were significant number of jobs in the
national economy that the plaintiff could perform. (R. 33-35). Thus, the ALJ concluded that
the plaintiff was not disabled. (R. 35).
B. Plaintiff’s Claims. Haynes presents two issues for the Court’s review. As stated
by Haynes, they are as follows:
1.

The Commissioner’s decision should be reversed, because the ALJ
erred in failing to find Ms. Haynes’ migraine headaches to be a severe
impairment.

2.

The Commissioner’s decision should be reversed, because the ALJ
erred in failing to accord adequate weight to Ms. Haynes’s treating
physician, Dr. David Willis.

(Doc. # 12, Pl’s Br. at 6).
IV. Discussion
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

5

The ALJ also concluded that Haynes’ hypertension was not severe because this condition did not
adversely impact her. (R. 21). The ALJ concluded that Haynes’ carpal tunnel syndrome and fibromyalgia
were undocumented, not medically determinable, and thus, not severe. (Id.) Haynes does not challenge these
findings.

4

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 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).
A. Severe Impairment. The plaintiff argues that the ALJ failed to properly consider
that her migraine headaches were a severe impairment at step 2 of the sequential analysis.
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
5

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 Haynes’ 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 migraine headaches were not a severe impairment, 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 migraine headaches do not constitute a “severe impairment” within the meaning
of the Social Security Act. Haynes applied for disability benefits alleging a disability onset
date of July 14, 2009. (R. 45, 127 & 157). In her disability report, Haynes asserted that she
cannot work because she is in “[i]ntense pain.” (R. 157). She reported that she had to reduce
her hours as a secretary due to fibromyalgia, and that she had to quit her job as a home health
nurse because she could no longer perform the work.
6

(Id.)

However, during the

administrative hearing, Haynes testified that she continues to work part time as a church
secretary three days a week and she still works at Signature as a companion for an elderly
woman once a week, even though she has migraines twice to four times a week. (R. 46, 50).
In her functions report, Haynes reported that she could no longer drive, (R. 198), yet she also
stated that she goes out daily and when she does, she drives. (R. 200).
Her medical records reveal that while she has migraine headaches, they are now
controlled with medication. On December 30, 2005, Haynes presented at the Wedowee
Hospital complaining of a migraine headache. (R. 310). She was given Demerol and
Phenergan6, and prescribed bed rest. (R. 311). In 2006, Haynes complained of a migraine
headache six times and was prescribed Nubain7 and Phenergan. (R. 245-51). Between
February and July 2007, Haynes complained of migraine headaches four times and was
prescribed Nubain and Phenergan. (R. 240-43). On August 23, 2007, Haynes requested a
prophylactic prescription because she was going camping, and was afraid she might get a
migraine. (R. 239). She was prescribed Oxycondone.8 (Id.) She again complained of
migraines on October 4 and December 18, 2007. (R. 236-37).
On April 1, 2008, Haynes presented to Dr. David R. Willis at Wadley Cornerstone
Clinic complaining of anxiety, migraines, and abdominal pain. (R. 313-14). On May 1,

6

Phenergan is an anti-nausea medication.

7

Nubain is a pain medication prescribed for moderate to severe pain.

8

Oxycondone is the generic brand of OxyContin which is an opioid used to control moderate to
severe pain.

7

2008, Dr. Willis diagnosed Haynes with bipolar disorder, migraines, caffeine rebound
headaches and a sleep disorder. (R. 315). He prescribed Trazodone,9 Klonopin,10 and
OxyIR.11 (Id.) Haynes complained twice more in 2008 of migraines and received refills on
her prescriptions. (R. 318, 323).
On February19, 2009, Haynes complained of a severe headache with photophobia.
(R. 323). Haynes complained on June 8, 2009, July 27, 2009, and August 25, 2009 of
migraines and requested refills of her medication. (R. 338, 336). Thereafter, however,
Haynes saw Dr. Willis seven more times between September 2009 and August 2010, but she
did not complain about migraine headaches. (R. 438-64). In fact, Dr. Willis’ treatment
records indicate that Haynes’ migraines are not intractable but rather are controlled. (R. 439,
448, 451, 458). His treatment notes also have a section entitled chronic problems. The only
condition listed in that section is hypertension. (R. 438, 440, 445, 447, 466, 468, 471, 474)
Moreover, in August 2010, December 2010, and January 2011, there is no mention of
migraine headaches in Dr. Willis’ treatment notes. (R. 440, 471-73, 476). The frequency
with which Haynes sought medical treatment for her migraines and the timing of her
complaints militates against her credibility. See Dyer, 395 F.3d at 1211-12.
While the record indicates that the plaintiff has been diagnosed with migraine
headaches, the medical evidence in the record indicates that her headaches are controlled by
9

Trazodone is used to treat depression.

10

Klonopin is used to treat anxiety.

11

OxyIR is another name for Oxycodone.

8

medication and do not have more than a minimal effect on her ability to perform basic work
activity. “[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). Haynes has failed to
demonstrate that her migraine headaches “significantly limit” 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). The consultative physician opined that Haynes
could perform work. (R. 350) (“The patient, medically, appears to be able to work sedentary
type jobs . . . I see no reason she could not work a standard job, cashier, checker, secretary,
etc.”). 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 Haynes points to that suggests that her
migraine headaches compromise her ability to work is her own testimony, which the ALJ
discounted. Consequently, the court concludes that Haynes has failed to meet her burden of
establishing that the ALJ’s decision regarding the severity of that impairment was not
supported by substantial evidence.12

12

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).

9

B. Treating Physician’s Opinion. Haynes argues that the ALJ failed to give her
treating physician’s opinion adequate weight about the severity of her limitations. (Doc. #
13, Pl’s Br. at 10). In essence, the plaintiff argues that if the ALJ accepted Dr. Willis’
assessment about her impairments, she would be disabled. On September 23, 2010, Dr.
Willis completed an evaluation form describing Haynes’ limitations.

(R. 433-37).

According to Dr. Willis, Haynes has marked or extreme limitations in eleven areas dealing
with her ability to function in a work environment. (Id.) She has moderate restrictions in
three areas, and mild restrictions in four areas. (Id.) According to Dr. Willis, Haynes’
impairments would be expected to last more than 12 months. (R. 435). Dr. Willis also
completed a “clinical assessment of pain” form. (R. 436). Dr. Willis opined that Haynes has
pain that is incapacitating “at times,” causes her distraction or to totally abandon tasks, and
she suffers from severe side effects of medication. (Id.).
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 his 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,
10

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.
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 gave the opinion of Dr. Willis “little
weight” because
11

[h]e apparently relied quite heavily on the subjective report of symptoms and
limitations provided by the claimant, and seemed to uncritically accept as true
most, if not all, of what the claimant reported. His own treatment notes do not
corroborate a debilitating condition based on migraine headaches. Although
the claimant has been treated for migraine headaches since 2003, she has been
treated conservatively with pain medications. She has also been able to
maintain gainful employment. The claimant’s continued work as a church
secretary at least 3 days per week as well as performing duties as a sitter for
an elderly person on a weekly basis are inconsistent with the marked and
extreme limitations noted by Dr. Willis. Although I give his diagnoses some
weight, I do note that at least part of his assessment of a mental impairment(s)
appears to be outside his area of expertise. It is unclear how he arrived at a
diagnosis of bipolar disorder, since the single mental health assessment does
not state bipolar disorder. Further, the other limitations suggested in the
records such as carpal tunnel syndrome, depression, and sciatic neuralgia do
not contain diagnostic testing or additional evaluations by a specialist in those
fields to confirm the preliminary diagnoses.
(R. 29-30).
The ALJ further discounts Dr. Willis’ opinion because his assessment does not
identify the “nexus between the migraines” and some of his restrictions “remain[]
unexplained.” (R. 29). Finally, the ALJ noted the inconsistencies between Dr. Willis’
treatment notes regarding whether Haynes’ headaches were refractory or “not intractable.”
(Id.)
The ALJ may disregard the opinion of a physician, provided that he states with
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. Willis’ assessment
of the severity of Haynes’ pain from her migraine headaches, and discounted his assessment.
The ALJ’s determination is supported by substantial evidence. A review of Dr. Willis’
treatment notes demonstrate that Haynes’ migraines were controlled with medication. (R.
12

438-39, 448, 451, 458, 467). On several occasions, headaches are not mentioned in Dr.
Willis’ notes. (R. 440, 473, 476). Finally, although Dr. Willis’ records provide space to note
chronic conditions, none of Haynes’ records indicate that Dr. Willis considered her migraine
headaches to be a chronic condition. 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.
Willis’ opinion that Haynes’ migraine headaches cause render her disabled.
V. Conclusion
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 supported by substantial evidence
and is due to be affirmed.
A separate order will be entered.
Done this 10th day of July 2012.

/s/Charles S. Coody
CHARLES S. COODY
UNITED STATES MAGISTRATE JUDGE

13