Smith v. Colvin

Filing 19

MEMORANDUM OPINION AND ORDER that the decision of the Commissioner will be reversed and this case remanded to the Commissioner for further proceedings consistent with this opinion; A separate final judgment will be entered; further ORDERED that, in accordance with Bergen v. Commr of Soc. Sec., 454 F.3d 1273, 17 1278 fn. 2 (11th Cir. 2006), the plaintiff shall have sixty (60) days after he receives notice of any amount of past due benefits awarded to seek attorney's fees under 42 U.S.C. § 406(b).See also Blitch v. Astrue, 261 Fed. Appx. 241, 242 fn.1 (11th Cir. 2008). Signed by Honorable Judge Charles S. Coody on 5/16/16. (djy, )

IN THE DISTRICT COURT OF THE UNITED STATES
FOR THE MIDDLE DISTRICT OF ALABAMA
EASTERN DIVISION
CHRISTOPHER LEE SMITH,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,1
Defendant.

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CIVIL ACTION NO. 3:14cv1169-CSC
(WO)

MEMORANDUM OPINION and ORDER
I. Introduction
Plaintiff Christopher Lee Smith (“Smith”) applied for disability insurance benefits
pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., alleging that he was
unable to work because of a disability.
administrative level.

His application was denied at the initial

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”).2 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). Pursuant

1

2

Carolyn W. Colvin became the Acting Commissioner of Social Security on February 14, 2013.

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.

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. 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 reversed and this case
remanded to the Commissioner for further proceedings.
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.”

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); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). “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). A reviewing court may not look only to those parts of
the record which support 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 (11th Cir. 1986).
[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. Smith was 42 years old on the date of alleged onset of disability
(R. 28), and has tenth grade education. (R. 40). His prior work experience includes work
as a Molding Machine Operator, Security Guard, Material Handler, Hand Finisher, and

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).

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Roofer Helper. (R. 28). Following the administrative hearing, the ALJ concluded that Smith
has severe impairments of “generalized anxiety disorder, not otherwise specified; rule out
benzodiazepine dependence; obesity; L5-S1 disc herniation; T6 herniated disc; hypersomnia;
hypertension; and status post-surgical repair of the left ankle/foot repair.” (R. 15). The ALJ
found that Smith was unable to perform his past relevant work but concluded that he
has the residual functional capacity to perform a sedentary work as defined in
20 CFR 404.1567(a) except he would require an on-demand sit/stand option
to relieve pain and discomfort and he can only ambulate short distances of up
to 75 yards per instance. He can frequently operate foot controls and
frequently reach overhead. He should never climb ladders or scaffolds but he
can occasionally climb ramps and stairs. The claimant should never be
exposed to unprotected heights, dangerous machinery, dangerous tools or
hazardous processes. He should be restricted from hazards such as heights or
dangerous machinery but is able to avoid ordinary hazards in the workplace
such as boxes on the floor, doors ajar and approaching people or vehicles. He
can occasionally operate a motor vehicle and can have frequent exposure to
weather, atmospheric conditions, humidity and wetness. He can never be
exposed to extreme heat or cold or vibration. The claimant can only remember
short simple instructions and would be unable to deal with detailed
instructions. He can do simple routine repetitive tasks but is unable to do
detailed or complex tasks. He is able to accept constructive nonconfrontational criticism, work in small group settings and be able to accept
changes in the work place setting if introduced gradually, but would be unable
to perform assembly line work with production rate pace but could perform
goal-oriented work. He can have frequent interaction with the general public,
coworkers and supervisors and time off task can be accommodated by normal
breaks.
(R. 17).
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, the ALJ concluded that there
were significant number of jobs in the national economy that the plaintiff could perform. (R.
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28-29). Accordingly, the ALJ concluded that the plaintiff was not disabled. (R. 29).
B. Plaintiff’s Claims. Smith presents two issues for the Court’s review. As stated
by Smith, the issues are as follows.
1.

Whether the ALJ failed to properly evaluate the credibility of the Plaintiff’s
complaints of pain consistent with the Eleventh Circuit Pain Standard; and

2.

Whether the ALJ failed to properly articulate good cause for according less
weight to the opinions of the Plaintiff’s treating physician.

(Doc. # 14, Pl’s Br. at 5 & 9).
IV. Discussion
This court’s ultimate inquiry is whether the Commissioner’s disability decision is
supported by the proper legal standards and by substantial evidence. See Bridges v. Bowen,
815 F.2d 622 (11th Cir. 1987). The ALJ is not free to simply ignore medical evidence, nor
may he pick and choose between the records selecting those portions which support his
ultimate conclusion without articulating specific, well supported reasons for crediting some
evidence while discrediting other evidence. Marbury v. Sullivan, 957 F.2d 837, 839-41 (11th
Cir. 1992). When there is a conflict, inconsistency or ambiguity in the record, the ALJ has
an obligation to resolve the conflict, giving specific reasons supported by the evidence as to
why he accepted or rejected one opinion or record over another.
A. The ALJ failed to properly evaluate the credibility of the plaintiff’s complaints
of pain. The law is well-established in this circuit. The Commissioner must consider a
claimant’s subjective testimony of pain if she finds evidence of an underlying medical

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condition, and either (1) objective medical evidence to confirm the severity of the alleged
pain arising from that condition, or (2) that the objectively determined medical condition is
of a severity that can reasonably be expected to give rise to the alleged pain. Mason v.
Bowen, 791 F.2d 1460, 1462 (11th Cir. 1986); Landry v. Heckler, 782 F.2d 1551, 1553 (11th
Cir. 1986). If the Commissioner fails to articulate reasons for refusing to credit a claimant’s
subjective pain testimony, then the Commissioner has, as a matter of law, accepted the
testimony as true. See Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 1991); Holt v.
Sullivan, 921 F.2d 1221 (11th Cir. 1991); Hale v. Bowen, 831 F.2d 1007 (11th Cir. 1987);
MacGregor v. Bowen, 786 F.2d 1050 (11th Cir. 1986).
Moreover, “[p]ain is clearly a non-exertional impairment that limits the range of jobs
the claimant can perform.” Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995); Walker,
826 F.2d at 1003 (“Pain is a nonexertional impairment.”). See also Phillips v. Barnhart, 357
F.3d 1232, 1242 fn 11 (11th Cir. 2004) (“Nonexertional limitations or restrictions affect an
individual’s ability to meet the other demands of jobs and include . . . pain limitations. . .”)
Furthermore, in this circuit, pain itself can be disabling. See Foote, 67 F.3d at 1561;
Marbury, 957 F.2d at 839.
Where an ALJ decides not to credit a claimant’s testimony, the ALJ must articulate
specific and adequate reasons for doing so, or the record must be obvious as to the credibility
finding. Foote, 67 F.3d at 1561-62; Jones v. Dep’t. of Health & Human Servs., 941 F.2d
1529, 1532 (11th Cir. 1991) (articulated reasons must be based on substantial evidence). If

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proof of disability is based on subjective evidence and a credibility determination is,
therefore, critical to the decision, “‘the ALJ must either explicitly discredit such testimony
or the implication must be so clear as to amount to a specific credibility finding.’” Foote, 67
F.3d at 1562, quoting Tieniber v. Heckler, 720 F.2d 1251, 1255 (11th Cir 1983) (although
no explicit finding as to credibility is required, the implication must be obvious to the
reviewing court).
After reciting the law, the ALJ regurgitated some of the medical evidence. The ALJ
found the plaintiff’s testimony “not supported by substantial objective medical evidence . .
. and that the claimant’s testimony is an exaggeration and not credible.” (R. 26). The ALJ
then says this:
Although a MRI indicated disc herniation at L5-S1 and a herniated disc at T6,
multiple examinations indicated no neurological deficits, muscle atrophy, nor
significant weight loss, generally associated with protracted prolonged pain at
a severe level. Examinations also indicated no muscle spasms, bony
abnormalities, or tenderness in the thoracic spine. . . . In this case, the record
reflects excessive symptomotology and not enough pathology, but symptoms
alone do not establish disability unless medical signs and laboratory findings
show that there is a medically determinable impairment that could reasonably
be expected to produce the symptoms alleged (20 CFR 404.1529 and 416.920,
and SSR 96-04p). Here, there is no such medically determinable impairments
that could reasonably be expected to produce the symptoms alleged.
Furthermore, the claimant can ambulate independently and has normal gait and
station. In sum, the totality of the medical evidence reflects excessive
symptomotology and not enough pathology with regard to the claimant’s
alleged lumbar and thoracic pain, specifically considering repeated negative
examination findings. There is no evidence to support any greater limitation
due to these impairments than that set forth above. . .
*

*

*

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The claimant has not generally received the type of medical treatment one
would expect for a totally disabled individual. Although the claimant has
received treatment for the allegedly disabling impairments, that treatment has
been essentially routine and conservative in nature. . . .
(R. 26).
The problem for the court is the ALJ selectively culling the record for evidence to
support his determination that Smith is not disabled, and in doing so, failed to reconcile
inconsistencies and ambiguities in the medical record. For example, on March 30, 2007,
Smith presented to the Wedowee Hospital complaining of pain in shoulders, legs and
tailbone. (R. 350). At that time, radiology reports indicate “broad based central disc
protrusion” at L5-S1 as well as mild effacement of the thecal sac and slight displacement of
nerve roots at S1. (R. 352, 294-95) There was also disc herniation at T10-11. (Id.). The
ALJ does not mention these radiology reports.
The ALJ also does not mention MR scans of the cervical spine, thoracic spine and
lumbar spine taken on July 10, 2008. The cervical spine MRI revealed the following:
Findings: C2-C3: Mild degenerative desiccation without focal bulging or
herniation.
C3-C4: Degenerative desiccation with minimal bulging. Mild right
uncovertebral joint hypertrophy is present causing mild bony stenosis of the
right neural foramen.
C4-C5: Mild degenerative desiccation without focal bulging or herniation.
C5-C6: Mild degenerative desiccation with minimal bulging. There is
asymmetric left posterior bulging, but no definite cord compression.
C6-C7: Degenerative desiccation and mild diffuse bulging. Posterior central
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bulging could represent a tiny protruding herniation. This does not cause
direct cord or root compression.
Overall, there is slight reversal of the cervical lordosis at the C4 level. The
cervical vertebral bodies and the spine cord are normal.
IMPRESSION:
1.
2.
3

Multilevel degenerative disc changes as described without definite cord
or root compression.
Possible small posterior central disc herniation C6-C7 without cord or
root compression. This is not confirmed on sagittal images.
Incidentally noted are small focal areas of increased signal in the
central cord at the C2-C3 and C3 level which probably represent
visualization of the central canal, a normal variant.

(R. 289, 251-52).
The MRI of the thoracic spine also revealed abnormalities:
Findings: T3-T4: Minimal bulging which touches but does not deform the
thoracic cord.
T5-T6: Degenerative desiccation with a posterior central extruded herniation.
This causes moderate anterior central cord compression. There is some
increased signal in the adjacent thoracic cord consisting of mild myelomalacia.
T6-T7: Minimal posterior bulging with subtle anterior central cord
compression.
T7-T8: Degenerative bulging, possibly a small protruding herniation causing
mild anterior central cord compression.
T9-T10: Degenerative desiccation with a small left posterior central disc
herniation causing mild right anterior cord compression.
T10-T11: Degenerative desiccation with a right posterior extruded disc
herniation causing mild left anterior cord compression.
The remainder of the thoracic intervertebral discs, vertebral bodies, and the
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thoracic cord are normal.
IMPRESSION: Multilevel degenerative bulging and/or herniated disc with
cord compression as described. These change are most marked at T5-T6,
where there appears to be some degree of cord myelomalacia associated with
the moderate anterior central cord compression by the herniated disc.
(R. 291, 253-54).
Finally, the lumbar spine MRI revealed a “right posterior central extruded disc
herniation” at L5-S1. (R. 293). The impression from the MRI was “[p]osterior central
extruded disc herniation L5-S1 with slight bilateral S1 root displacement and possible mild
compression.” (Id.)
Although the ALJ references a December 27, 2010 “scoliosis study” which was
“unremarkable,” (R. 20), he ignores a January 17, 2011 MRI that established “mild central
disc protrusions without cord compression at probably T7-8 and T10-11.” (R. 473). The
ALJ also ignores a treatment note that Smith was suffering from “increased thoracic back
pain with lower extremity neuropathy.” (R. 373).
The ALJ considered the plaintiff’s back condition as it related to L5-S1 and T-6.
However, the ALJ ignores many of Smith’s radiology results, and he did not consider
evidence of other herniation, bulging, dessiccation or damage at C6-C7, C3, T7-T8 or T10T11. Thus, the court is unable to determine whether he considered this medical evidence
when he determined that there was insufficient pathology to support Smith’s pain testimony.
The ALJ also discredited Smith’s credibility because of his allegedly conservative
treatment. However, the ALJ ignores medical evidence from the West Georgia Neurology
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and Pain Clinic of Smith’s efforts to treat his pain. For example, on April 2, 2008, Smith
presented to the clinic for pain management of his back, neck and leg pain. (R. 424-25).
Although the ALJ acknowledged that Smith was treated at the clinic in February, March and
May 2010, the ALJ ignores the medical evidence that Smith began treatment on April 3,
2008 for the following conditions:
1. Documented thoracic spine HPN [herniated nucleus pulposus] T10-T11 by
hx and exam Suspect cord involvement here . . . hyperreflexia
2. Documented L5-S1 HPN [herniated nucleus pulposus] . . . Given above
exam/hx - again - more sig. pathology is suspected.
3. LUE [lower upper extremity] C7 (tricep) by hyperreflexia with LUE C6
hyporeflexia would suggest Cspine pathology with possible L C6 root & cord
involvement.
4. . . . migraine headaches - may be related to Cspine pathology . . .
(R. 423).
Smith consistently returned to the clinic to be treated for pain management during
2008. (R. 406-15). On August 27, 2008, Smith reported that he had seen a surgeon who did
not advise surgery because it would be “very complicated.” (R. 410-11). His pain continued
to increase. (R. 414, 409, 406-07). The pain clinic noted that his “baseline pain is not
controlled.” (R. 415).
In 2009, Smith was seen every month at the pain clinic. (R. 391-405). In January
2009, he complained that his lower back was “deteriorating,” but the pain medication was
providing “good control.” (R. 405). The treatment record specifically notes that his “[p]ain

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[is] never completely resolved but can be tolerable.” (R. 396). On September 22, 2009,
Smith complained of more pain in his hips, and “increased spasms left mid back muscles by
palpation” were noted. (R. 395). On November 20, 2009, Smith reported that his
orthopaedic surgeon told him the “pain may be decreased but will not likely be resolved.”
(R. 392-93). On January 20, 2010, Smith presented to the clinic complaining of increased
pain. (R. 390). His pain medications were increased. (Id.). Smith was consistently treated
with numerous pain medications.5
Despite this longitudinal treatment history, the ALJ completely ignores this medical
evidence. More importantly, the ALJ ignores treatment notes that indicate that Smith’s back
pain increased significantly over time, and that his orthopaedic surgeon “felt that surgery may
actually increase” his problems. (R. 385). To say the least, it is odd that the ALJ would fault
the plaintiff for conservative treatment when more aggressive treatment such as surgery was
not recommended.

The ALJ ignores over two years of treatment records for pain

management. The ALJ picked through the medical records and chose those entries that
supported his position. That was erroneous.
A mere statement that the ALJ carefully considered all the testimony and exhibits is

5

There is evidence in the record that Smith takes Oxycontine, Soma, Neurontin, Seroquel and
Methadone to control his pain. (R. 417, 515, 569, 576-77, 596, 624-26). Dr. Peterson indicated that Smith
would have difficulty working because of the effects of his medication. Because the court concludes that
this case must be remanded, the court does not address the ALJ’s failure to properly consider the side effects
of the plaintiff’s medications on his ability to work. However, on remand, the Commissioner should insure
that the ALJ properly considers every side effect of the plaintiff’s medications and determines whether the
side effects constitute an impairment. Thereafter, the Commissioner shall insure that the effects of the
plaintiff’s medications are considered, singly and in combination with his other impairments.

12

not sufficient to comply with his duty to state with particularity the weight given to
difference medical evidence and to provide his reasoning for his decision. Sharfarz v.
Bowen, 825 F.2d 278, 279 (11th Cir. 1987); Cowart v. Schweiker, 662 F.2d 731, 735 (11th
Cir. 1981). “[I]t is the responsibility of the Secretary and not the courts to reconcile
inconsistencies in the medical evidence, . . . .” Seacrist v. Weinberger, 538 F.2d 1054, 105657 (4th Cir. 1976). See also, Gastineau v. Mathews, 577 F.2d 356, 358 (6th Cir. 1978) (“It
is not the function of this Court to resolve conflicts in the medical evidence, but rather it is
the function of the Secretary, whose expertise is given great deference.”). Because the ALJ
ignored numerous medical records, this case must be remanded for further proceedings.
B. The ALJ failed to properly consider the opinion of the treating physicians.
Smith next argues that the ALJ improperly discounted the opinion of his treating physician,
Dr. Russell Peterson. (Doc. # 14, Pl’s Br. at 9). The law in this circuit is also 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.
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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 961-62.
There are, however, 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. 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, 941 F.2d at 1532-33; Edwards v. Sullivan, 937 F.2d 580, 58485 (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 v. Bowen, 816 F.2d 578, 581 (11th Cir. 1987).
On September 8, 2011, Dr. Russell Peterson conducted a physical consultative
examination of Smith at the request of the Commissioner. (R. 515-22). Dr. Peterson
specifically noted that Smith “has significant changes on his MRI compatible with the pain

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he claims.” (R. 516). Dr. Russell’s evaluation of the cervical, thoracic and lumbar spine
revealed the following.
Cervical/Thoracic/Lumbar Spine: Quite tender over the thoracic area, no visual
outward signs, fairly normal range of motion, but states he has pain and
tenderness in the spine with movement. He has tenderness with flexion
extension with the cervical spine and thoracic spine, but overall movement is
pretty good. The lumbar spine is tender in the SI and lower back area but no
radacular (sic) pain and no straight leg raising. He appeared to be
neurologically intact and outwardly a faily (sic) normal physical examination.
*

*

*

This patient will have a lot of difficulty working construction, driving a truck,
etc. The medication he takes will prevent him from working. He will need
pain management, his xrays are much worse than what appears on physical
examination. Even a sedentary job would prove difficulty (sic) with stamina,
difficulty lifting, trouble with even minor duties for any period of time due to
chronic pain.
(R. 517-18).
Dr. Peterson opined that Smith could sit and stand for periods of time, he could not
use his feet for repetitive motion “for any period of time.” (R. 520). Finally, he concluded
that Smith had pain to the extent that it was “[a] [s]ignificant handicap with sustained
attention and concentration; eliminating skilled work tasks.” (R. 522).
On September 12, 2011, Smith presented to Dr. Peterson as a new patient. (R. 530).
On September 26, 2011, Smith complained to Dr. Peterson of chronic back pain and sought
pain management. (R. 529, 596). Dr. Peterson prescribed a TENS unit for Smith.6 Dr.

6

Smith testified at the administrative hearing that he did not receive the unit due to a problem with
insurance. (R. 53).

15

Peterson continued to treat Smith on a monthly basis. (R. 530, 575-96).
The ALJ recited Dr. Peterson’s consultative examination of Smith and his physical
capacity evaluation of Smith. (R. 20).
In assessing residual functional capacity, the ALJ must state with particularity the
weight given to different medical opinions and the reasons therefor. Sharfarz, 825 F.2d at
279. Further, the ALJ is required to accord considerable weight to the opinions of the
claimant’s treating physicians absent good cause for not doing so. Id. at 279-80. The ALJ
may disregard the opinion of a physician, provided that he states with particularity reasons
therefor. The law does not necessarily require the ALJ to accept the validity of Dr.
Peterson’s opinion that Smith’s chronic pain will impact his ability to perform work, but it
does require that, in determining Smith’s residual functional capacity and in evaluating the
credibility of Smith’s allegations of pain, the ALJ must consider all relevant evidence in the
case record, and he must specifically state “good cause” for rejecting the medical opinions
of a treating physician. 20 CFR § 404.1545(a)(1); 20 CFR 416.929(c)(1); Lewis, 125 F.3d
at 1440. While the ALJ parroted portions of the medical evidence, he did not discuss the
weight he assigns to the medical evidence. In particular, he does not accord Dr. Peterson’s
opinion any weight as Smith’s treating physician. The ALJ noted that “[t]he only provider
to recommend more restrictions that are significant was Dr. Peterson. The undersigned
declines to accept his position over the rest of the evidence, as it appears to be inconsistent
with the entire picture and depends heavily on the claimant’s complaints.” (R. 27). The

16

problem with the ALJ’s statement is manifest. Because the ALJ does not discuss Dr.
Peterson’s opinions as a treating physician, the court cannot determine from this conclusory
statement whether the ALJ is discounting Dr. Peterson’s consultative opinion or his opinion
as a treating physician. Moreover, because the ALJ ignored evidence from the pain clinic,
and many of the radiology reports, the ALJ’s rationale for discrediting Dr. Peterson is
compromised.
Rote recitation of the medical evidence is not a substitute for articulating reasons for
discrediting some evidence while accepting other evidence. The ALJ’s conclusory analysis
is simply deficient as a matter of law. It is the responsibility of the ALJ to conduct the
appropriate legal analysis, and his written decision must include sufficient reasoning to
permit the court to determine that he has done so.
V. Conclusion
“Failure to apply correct legal standards or to provide the reviewing court with the
sufficient basis to determine that the correct legal principles have been followed is grounds
for reversal.” Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982). Thus, for the
reasons as stated, the decision of the Commissioner will be reversed and this case remanded
to the Commissioner for further proceedings consistent with this opinion.
A separate final judgment will be entered.
It is further
ORDERED that, in accordance with Bergen v. Comm’r of Soc. Sec., 454 F.3d 1273,

17

1278 fn. 2 (11th Cir. 2006), the plaintiff shall have sixty (60) days after he receives notice
of any amount of past due benefits awarded to seek attorney’s fees under 42 U.S.C. § 406(b).
See also Blitch v. Astrue, 261 Fed. Appx. 241, 242 fn.1 (11th Cir. 2008).
Done this 16th day of May, 2016.

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

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