Roberson v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge L Scott Coogler on 9/4/12. (KGE, )
2012 Sep-04 PM 03:00
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
MICHAEL J. ASTRUE,
Commissioner of Social Security,
MEMORANDUM OF OPINION
The plaintiff, Angela Roberson, appeals from the decision of the Commissioner
of the Social Security Administration (“Commissioner”) denying her applications for
Supplemental Security Income (“SSI”) and Disability Insurance Benefits (“DIB”).
Ms. Roberson timely pursued and exhausted her administrative remedies and the
decision of the Commissioner is ripe for review pursuant to 42 U.S.C. §§ 405(g),
Plaintiff originally filed applications for a period of disability, DIB and SSI on March 1,
2004. These applications were denied. Thereafter, Plaintiff timely pursued and exhausted her
administrative remedies and filed a civil action in this Court. See Roberson v. Astrue, 3:07-CV-1541VEH. The District Court remanded the case to the Appeals Council, who in turn remanded the case
to the Administrative Law Judge for a new hearing. The Administrative Law Judge held a hearing
on June 9, 2009, and issued a decision on August 5, 2009, finding Plaintiff was not disabled. Said
decision is the subject of the present appeal.
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Ms. Roberson was forty-five years old at the time of the Administrative Law
Judge’s (“ALJ’s”) decision, and she has obtained her GED. (Tr. at 427-52.) Her
past work experiences include employment as a fast food manager, a waitress, a cook,
a cook helper, and a sewing machine operator. (Tr. at 425.) Ms. Roberson claims that
she became disabled on September 6, 2003, due to chronic back pain from her
degenerative disc disease; degenerative joint disease of her left ankle, right knee, and
right shoulder; carpal tunnel syndrome of the right wrist; bipolar disorder; major
depression with psychotic features; personality disorder; and substance abuse,
including alcohol, cocaine, and cannabis. (Doc. 7 at 5.)
When evaluating the disability of individuals over the age of eighteen, the
regulations prescribe a five-step sequential evaluation process. See 20 C.F.R.
§§ 404.1520, 416.920; see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001).
The first step requires a determination of whether the claimant is “doing substantial
gainful activity.” 20 C.F.R. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If he or she is, the
claimant is not disabled and the evaluation stops. Id. If he or she is not, the
Commissioner next considers the effect of all of the physical and mental impairments
combined. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These impairments
must be severe and must meet the durational requirements before a claimant will be
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found to be disabled. Id. The decision depends on the medical evidence in the record.
See Hart v. Finch, 440 F.2d 1340, 1341 (5th Cir. 1971). If the claimant’s impairments
are not severe, the analysis stops. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).
Otherwise, the analysis continues to step three, which is a determination of whether
the claimant’s impairments meet or equal the severity of an impairment listed in 20
C.F.R. pt. 404, Subpart P, Appendix 1. 20 C.F.R. §§ 404.1520(a)(4)(iii),
416.920(a)(4)(iii). If the claimant’s impairments fall within this category, he or she
will be found disabled without further consideration.
If they do not, a
determination of the claimant’s residual functional capacity (“RFC”) will be made
and the analysis proceeds to the fourth step. 20 C.F.R. § 404.1520(e), 416.920(e).
The fourth step requires a determination of whether the claimant’s
impairments prevent him or her from returning to past relevant work. 20 C.F.R.
§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant can still do his or her past
relevant work, the claimant is not disabled and the evaluation stops. Id. If the
claimant cannot do past relevant work, then the analysis proceeds to the fifth step. Id.
Step five requires the court to consider the claimant’s RFC, as well as the claimant’s
age, education, and past work experience in order to determine if he or she can do
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other work. 20 C.F.R. §§ 404.1520(a)(4)(v) 416.920(a)(4)(v). If the claimant can do
other work, the claimant is not disabled. Id.
Applying the sequential evaluation process, the ALJ found that Ms. Roberson
met the insured status requirements of the Social Security Act through September 30,
2008. (Tr. at 417.) He further determined that Ms. Roberson has not engaged in
substantial gainful activity since the alleged onset date. (Id.) According to the ALJ,
Plaintiff’s chronic back pain from her degenerative disc disease; degenerative joint
disease of her left ankle, right knee, and right shoulder; carpal tunnel syndrome of the
right wrist; bipolar disorder; major depression with psychotic features (in partial
remission); personality disorder; and substance abuse are considered “severe” based
on the requirements set forth in the regulations. (Tr. at 418.) However, he found that
these impairments neither meet nor medically equal any of the listed impairments in
Appendix 1, Subpart P. (Tr. at 421.) The ALJ did not find Ms. Roberson’s allegations
to be totally credible, and he determined that she has the residual functional capacity
(“RFC”) to perform light work with the following additional limitation:
The claimant would have difficulty understanding and carrying out
detailed instructions and maintaining concentration, but could
concentrate for two hour periods. She will function better if the job is low
stress and there is flexible scheduling where she is working without coworkers and public contact. She can only have casual contact with the
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(Tr. at 422.)
According to the ALJ, Ms. Roberson is unable to perform any of her past
relevant work, she is a “younger individual,” has at least a high school education, and
is able to communicate in English, as those terms are defined by the regulations. (Tr.
at 425.) The ALJ determined that transferability of job skills is not material to the
determination of disability. (Id.) The ALJ found that there are jobs that exist in
significant numbers in the national economy that the plaintiff can perform considering
her age, education, work experience, and RFC. (Id.) The ALJ concluded his findings
by stating that Plaintiff “has not been under a disability, as defined in the Social
Security Act, from September 6, 2003 through the date of this decision.” (Tr. at
Standard of Review
This Court’s role in reviewing claims brought under the Social Security Act is
a narrow one. The scope of its review is limited to determining (1) whether there is
substantial evidence in the record as a whole to support the findings of the
Commissioner, and (2) whether the correct legal standards were applied. See
Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d
1219, 1221 (11th Cir. 2002). The Court approaches the factual findings of the
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Commissioner with deference, but applies close scrutiny to the legal conclusions. See
Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996). The Court may not decide facts,
weigh evidence, or substitute its judgment for that of the Commissioner. Id. “The
substantial evidence standard permits administrative decision makers to act with
considerable latitude, and ‘the possibility of drawing two inconsistent conclusions
from the evidence does not prevent an administrative agency’s finding from being
supported by substantial evidence.’” Parker v. Bowen, 793 F.2d 1177, 1181 (11th Cir.
1986) (Gibson, J., dissenting) (quoting Consolo v. Fed. Mar. Comm’n, 383 U.S. 607,
620 (1966)). Indeed, even if this Court finds that the evidence preponderates against
the Commissioner’s decision, the Court must affirm if the decision is supported by
substantial evidence. Miles, 84 F.3d at 1400. No decision is automatic, however, for
“despite this deferential standard [for review of claims] it is imperative that the Court
scrutinize the record in its entirety to determine the reasonableness of the decision
reached.” Bridges v. Bowen, 815 F.2d 622, 624 (11th Cir. 1987). Moreover, failure to
supply the correct legal standards is grounds for reversal. See Bowen v. Heckler, 748
F.2d 629, 635 (11th Cir. 1984).
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Ms. Roberson alleges that the ALJ’s decision should be reversed and remanded
because it is not supported by substantial evidence. Specifically, she believes that the
ALJ failed to properly consider the medical evidence of record. (Doc. 7 at 16.)
Plaintiff takes issue with the weight the ALJ gave to the opinions of the medical expert
who testified at her hearing, the consultative psychological examiners, and her treating
Weight Given to Opinion of Medical Expert Regarding GAF Scores
Plaintiff first argues that the ALJ mishandled the GAF2 scores cited in her
medical records. In particular, the plaintiff argues that the ALJ should not have given
any weight to the opinion of Dr. Neil Lewis, a licensed psychologist called to testify
as a medical expert at Plaintiff’s June 2009 hearing. (Doc. 7 at 16.) Plaintiff submits
that the ALJ’s decision should be remanded “for a full and proper consideration of
GAF scores, as originally ordered by this Honorable Court, without the subterfuge of
an inappropriate source.” (Doc. 7 at 17.)
The GAF Scale (Axis V of the Multiaxial Assessment) “is for reporting the clinician’s
judgment of the individual’s overall level of functioning. This information is useful in planning
treatment and measuring its impact, and in predicting outcome . . . the GAF scale is divided into 10
ranges of functioning. Making a GAF rating involves picking a single value that best reflects the
individual’s overall level of functioning . . . In most instances, ratings on the GAF Scale should be
for the current period . . .” American Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental
Disorders, 32-3 (4th ed. Text revision, 2000) (DSM-IV-TR).
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This case was remanded by the District Court so that the ALJ could, among
other things, reconcile the inconsistent GAF scores in the plaintiff’s medical record.
The previous ALJ opinion “neither explained the weight [the ALJ] gave the GAF
scores or why [the ALJ] discredited Dr. Wood’s GAF but still accepted his medical
source statement regarding his examination of Ms. Roberson.” (Tr. at 442.) Pursuant
to the remand, the ALJ heard testimony from Dr. Lewis. (Tr. at 424.) Dr. Lewis
testified that GAF scores are merely an estimation of functioning using a range of
subjective behavioral descriptions. (Tr. at 771.) He further testified that because GAF
scores have a somewhat subjective quality to them, it is difficult to compare scores
given by two different practitioners, and that small differences in GAF scores are not
significant. (Id.) The ALJ gave Dr. Lewis’s testimony significant weight, and, as a
result of Dr. Lewis’s testimony, gave all of the GAF scores in the record very limited
weight. (Tr. at 424.) Plaintiff argues that because Dr. Lewis is an inappropriate source
to give full and proper consideration to Plaintiff’s GAF scores, the ALJ should not
have given his opinion any weight. (Doc. 7 at 16-17.)
In determining disability, the ALJ considers evidence from “acceptable medical
sources,” which include licensed physicians and licensed or certified psychologists.
20 C.F.R. § 416.913(a). The ALJ affords a physician’s testimony “substantial or
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considerable weight unless ‘good cause’ is shown to the contrary.” Crawford v.
Commissioner of Social Security, 363 F.3d 1155, 1159 (11th Cir. 2004) (quoting Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)) (internal quotations omitted). The
weight afforded a medical opinion on the nature and severity of a claimant’s
impairments depends upon, among other things: the examining and treating
relationship the medical source had with the claimant, the evidence the medical
source presents to support the opinion, how consistent the opinion is with the record
as a whole, and the specialty of the medical source. See 20 C.F.R. §§ 404.1527(d),
416.927(d). Reports of physicians who do not examine the claimant, taken alone, do
not constitute substantial evidence on which to base an administrative decision.
Spencer on Behalf of Spencer v. Heckler, 765 F.2d 1090, 1094 (11th Cir. 1985). Here,
however, the ALJ articulated good cause to give Dr. Lewis’s testimony significant
weight, and to therefore give the GAF scores very limited weight, because as is
discussed below, Dr. Lewis’s testimony was consistent with the record as a whole.
Dr. Jon Rogers completed a consultative psychological evaluation of Plaintiff
in May 2004. (Tr. at 271.) He observed that Plaintiff arrived on time for her
appointment, was dressed appropriately and was nicely groomed. (Id.) Dr. Rogers
described Plaintiff’s conversation as normal and her affect as restricted and anxious.
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Dr. Rogers found that Plaintiff “is able to function independently,” and diagnosed her
with depressive disorder, anxiety disorder, alcohol and cocaine abuse (in remission),
and personality disorder. (Tr. at 275.) He also found that the extent of Plaintiff’s
mental impairment is moderate and that she should be able to perform most activities
of daily living. (Tr. at 277.) Dr. Rogers gave the Plaintiff a GAF score of 51.3 (Tr. at
276.) The ALJ gave great weight to Dr. Rogers’ assessment, other than the GAF
score. (Tr. at 424.) He found that the assessment was consistent with the other
medical evidence of record and the plaintiff’s activities of daily living. (Id.)
Dr. Barry Wood completed a consultative psychological evaluation of Plaintiff
in November 2005. (Tr. at 317-24.) Dr. Wood noted depressive syndrome, anxiety
disorder, personality disorder, and partial remission of drug and alcohol abuse. (Id.)
Dr. Wood also found that Plaintiff had moderate restriction of activities of daily living,
difficulties in maintaining social functioning, and difficulties in maintaining
concentration, persistence, or pace, as well as one episode of decompensation of
extended duration. (Id.) He noted that her compliance with treatment for depression
was not particularly good, but that she seemed to respond to medication when
GAF scores between 51 and 60 reflect moderate symptoms, including moderate difficulty
in social, occupational, or school settings. GAF scores between 41 and 50 reflect serious impairment
in social, occupational, or school functioning. See American Psychiatric Ass’n, Diagnostic and
Statistical Manual of Mental Disorders 34 (4th ed.2000).
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abstinent from drug and alcohol abuse. (Id.) Dr. Wood also filled out a medical source
statement form, stating that the plaintiff had moderate difficulty responding
appropriately to supervisors, co-workers, and customers, using judgment in complex
work-related decisions, and dealing with changes in a routine work setting. (Tr. at
323.) He stated that she had mild difficulty using judgment in simple, one and
two-step instructions; understanding, remembering, and carrying out simple one or
two step and detailed or complex instructions; maintaining attention, concentration
or pace for periods of at least two hours; and maintaining social functioning and
activities of daily living. (Tr. at 324.) Dr. Wood gave Plaintiff a GAF score of 50. (Tr.
at 322.) Dr. Lewis noted that the psychological evaluation performed by Dr. Wood in
2005 contained conclusions not supported by medical evidence. (Tr. at 774.) The ALJ
found that Dr. Wood’s assessment on the source statement form was inconsistent
with other medical findings and Dr. Wood’s own examination of Plaintiff. (Tr. at
424.) Therefore, the ALJ gave Dr. Wood’s assessment little weight. (Id.)
On June 13, 2006, Plaintiff underwent a psychiatric evaluation at Riverbend
Medical Center, and was given a GAF score of 45-50. (Tr. at 648.) At that evaluation,
she was diagnosed with major depressive disorder, post traumatic stress disorder,
panic attacks with agoraphoia, and polysubstance dependence in sustained remission.
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(Id.) On June 26, 2006, Plaintiff’s Riverbend progress notes indicated she was
tolerating medication well without adverse effects, and she was given a GAF score of
55. (Tr. at 643.) In August 2006, Plaintiff was tolerating her medications well, was no
longer feeling helpless and hopeless, and denied experiencing any sort of
hallucinations. (Tr. at 639.) At that time, Plaintiff’s GAF score had improved to 60.
(Id.) The ALJ noted that Plaintiff responded well to treatment with medication and
that her GAF score improved while she was at Riverbend. (Tr. at 424.)
As Dr. Lewis opined, many courts have noted that due to their subjective
qualities, reliance upon GAF scores is of questionable value in determining an
individual’s mental functioning capacity. See, e.g., Clarence Bros. v. Astrue, 2012 WL
3243232, at *8 (M.D. Fla. Aug. 8, 2012); DeBoard v. Comm’r of Social Security, 2006
WL 3690637, at *3-4 (6th Cir. 2006). Indeed, the Eleventh Circuit has noted that
“the Commissioner has declined to endorse the GAF scale for ‘use in the Social
Security and SSI disability programs,’ and has indicated that GAF scores have no
‘direct correlation to the severity requirements of the mental disorders listings.’”
Wind v. Barnhart, 133 F. App’x 684, 692 n.5 (11th Cir. 2005). See also 65 Fed.Reg.
50746, 50764-65 (Aug. 21, 2000). In any event, Plaintiff’s most recent GAF score was
60, which reflects moderate as opposed to severe symptoms. (Tr. at 639.)
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Further, Plaintiff’s GAF scores in the lower ranges are not supported by the
plaintiff’s own testimony about her daily activities, the medical evidence, and the
record as a whole. For example, Plaintiff completed an activities questionnaire in
2004 where she indicated that she could take care of her personal needs, she prepared
meals, and she enjoyed music and movies. (Tr. at 115.) Plaintiff indicated that
sometimes she cannot get out of bed, but that she can do yard work. (Tr. at 115, 118.)
At the 2009 hearing, Plaintiff testified that she could wash dishes and sweep floors and
that she had crying spells about once a week. (Tr. at 750.) Plaintiff also underwent
consultative examinations by Drs. Gill, Crouch, Ghandi, and Rogers. (Tr. at 279-81,
309-11, 692-99, 271-78.) Each of these consultative examiners indicated that Plaintiff
had limitations, but each opined that she retained the ability to work and perform daily
functions. (Id.) As such, substantial evidence supported the ALJ’s decision to give
great weight to the opinion of Dr. Lewis, and therefore to give limited weight to
Plaintiff’s GAF scores, because the entire weight of the evidence did not direct a
finding that these GAF scores were entitled to any particular weight.
Weight Given to Opinions of Consultative Examiners
Plaintiff also argues that the ALJ did not give sufficient weight to the opinions
of the consultative examiners, without specifying which ones. (Doc. 7 at 18.) Plaintiff
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takes issue with the ALJ’s determination that the opinions of some of the consultive
examiners were entitled to no weight because they were based solely on the plaintiff’s
“subjective report of her symptoms.” (Tr. at 424-25.)
As an initial matter, the ALJ gave great, considerable, or some weight to each
of the following consultive examiners: Dr. Rogers, Dr. Ghandi, Dr. Gill, and Dr.
Crouch. (Tr. at 427-52.) Each of these consultative examiners indicated that Plaintiff
had limitations, but that she retained the ability to work and perform daily functions.
The only consultative examiner whose opinion the ALJ gave no weight to because it
was based only on the plaintiff’s subjective allegations was Dr. John Haney. (Tr. at
424.) The Eleventh Circuit has stated that one of the factors that an ALJ may
consider in determining that good cause exists not to give a physician’s opinion
substantial weight is if the physician’s opinion was based primarily on the plaintiff’s
subjective complaints. Crawford v. Commissioner of Social Security, 363 F.3d 1155,
1159-60 (11th Cir. 2004).
Dr. Haney performed a consultative psychological
evaluation on Plaintiff in September 2008. (Tr. at 684-89.) He administered an
intelligence test to Plaintiff as part of the evaluation, which demonstrated that Plaintiff
fell in the borderline intellectual functioning capacity. (Tr. at 685.) On examination,
Dr. Haney observed that Plaintiff was fully oriented, her recent and remote memory
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appeared intact and she had no psychotic symptoms. (Tr. at 686.) Dr. Haney
observed that Plaintiff’s mood was depressed, but that her conversation was logical
and goal-directed. (Tr. at 686.) Plaintiff reported to Dr. Haney that she enjoyed
writing, listening to music, and cooking, and that she was obsessed with cleaning. (Tr.
at 686.) Dr. Haney also completed a medical source opinion form, in which he
checked boxes indicating that Plaintiff had marked limitations in her ability to
understand, remember, and carry out detailed or complex instructions, and maintain
attention, concentration or pace for periods of two hours. (Tr. at 688.) The ALJ gave
this opinion form completed by Dr. Haney little weight because it was based in large
part on Plaintiff’s own subjective allegations and not on the objective findings Dr.
Haney included in his report. (Tr. at 424.) Because Dr. Haney’s notation of the
objective findings do not support the severity of limitations he included in the medical
source statement, the ALJ had good cause to give his opinion little weight.
Weight Given to Opinion of Treating Physician
Plaintiff also argues that the ALJ did not give sufficient weight to the opinion
of her treating physician, orthopedic surgeon Dr. Paul Raphael. (Doc. 7 at 18.) The
ALJ determined that Dr. Raphael’s opinion was entitled to no weight because it was
based on the plaintiff’s subjective report of her symptoms and because the doctor’s
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own records did not reveal the type of significant clinical and laboratory abnormalities
one would expect if the plaintiff were in fact disabled. (Tr. at 424-25.) “Good cause”
exists for an ALJ to give substantially less weight to a treating physician’s opinion
when the “(1) treating physician’s opinion was not bolstered by the evidence; (2)
evidence supported a contrary finding; or (3) treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records.” Phillips v.
Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004) (citing Lewis, 125 F.3d at 1440).
Dr. Raphael treated Plaintiff in 2008 and 2009. His treatment notes largely
consist of recitations of Plaintiff’s subjective reports of her symptoms, but do not
indicate actual examination results. (Tr. at 632-34, 702-17.) For example, Plaintiff
reported severe low back pain with radiation to the lower left extremity, numbness in
the left big toe, and right side groin pain. (Tr. at 632-34, 702-17.) Dr. Raphael in turn
diagnosed Plaintiff with “severe chronic low back pain with radiation to the left lower
extremity, and probable osteoarthritis in both hips with chronic subluxation of right
hip . . .” (Tr. at 632, 708, 712, 716.) Dr. Raphael also noted on several occasions that
Plaintiff is “disabled” but provided no basis for that opinion. For example, in
September 2008, Dr. Raphael opined that Plaintiff was disabled but did not even
include an examination during that visit. (Tr. at 632-33.) The Court is aware that
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opinions such as whether a plaintiff is disabled, the plaintiff’s residual functional
capacity, and the application of vocational factors “are not medical opinions, . . . but
are, instead, opinions on issues reserved to the Commissioner because they are
administrative findings that are dispositive of a case; i.e., that would direct the
determination or decision of disability.” 20 C.F.R. §§ 404.1527(e), 416.927(d). The
Court weighs doctors’ evaluations of the plaintiff’s “condition and the medical
consequences thereof, not their opinions of the legal consequences of his condition.”
Lewis, 125 F.3d at 1440. Such physician’s opinions are relevant to the ALJ’s findings,
but they are not determinative, since the ALJ bears the responsibility for assessing a
claimant’s RFC. See e.g., 20 C.F.R. § 404.1546(c). Dr. Raphael recited Plaintiff’s
subjective complaints, but does not provide an opinion on particular limitations
caused by Plaintiff’s impairments. Further, Dr. Raphael’s notes are not bolstered by
the other medical evidence and the record as a whole. As such, the ALJ had good
cause to give no weight to the opinion of Dr. Raphael.
Finally, Plaintiff contends that if the ALJ had doubts about the opinions of some
of the consultative examiners or the opinion of Dr. Raphael, he should have recontacted these sources. It is true that the ALJ has a duty to develop the facts fully
and fairly and to probe conscientiously for all of the relevant information. Ware v.
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Schwieker, 651 F.2d 408, 414 (5th Cir. 1981). However, the regulations indicate that
an ALJ can re-contact a consultative examiner if the report is inadequate or
incomplete, not if the ALJ doubts the findings, as Plaintiff asserts. See 20 C.F.R. §§
404.1519p(b); 416.919p(b). See also Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir.
1999) (finding an ALJ was not obligated to seek additional medical evidence or seek
independent expert medical testimony because the evidence in the record was
sufficient to support a decision). The ALJ was not obligated to re-contact the medical
Upon review of the administrative record, and considering all of Ms.
Roberson’s arguments, the Court finds the Commissioner’s decision is supported by
substantial evidence and in accord with the applicable law. A separate order will be
Done this 4th day of September 2012.
L. SCOTT COOGLER
UNITED STATES DISTRICT JUDGE
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