Denney v. Social Security Administration, Commissioner
MEMORANDUM OPINION Signed by Judge Karon O Bowdre on 9/27/12. (SAC )
2012 Sep-27 PM 03:43
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF ALABAMA
SUSAN M. DENNEY,
MICHAEL J. ASTRUE,
Commissioner of the Social,
CIVIL ACTION NO. 1:11-CV-2099-KOB
On January 14, 2009, the claimant, Susan M. Denney, applied for period of disability,
disability insurance benefits under Title II of the Social Security Act and supplemental security
income under Title XVI of the Social Security Act. The claimant alleges disability commencing
on October 31, 2008, because of migraine headaches. (R. 62-63). The commissioner denied the
claims. (R. 67-77). The claimant filed a timely request for a hearing before an Administrative
Law Judge, and the ALJ held a video hearing on December 2, 2010. (R. 34-61). In a decision
dated December 3, 2010, the ALJ found that the claimant was not disabled as defined in the
Social Security Act. Thus, the claimant had not been under a disability and was ineligible for
disability insurance benefits and supplemental security income. (R. 13-20). The Appeals
Council denied the claimant’s request for review on May 27, 2011. (R. 1). The claimant has
exhausted her administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§
405(g) and 1383(c)(3). For the reasons stated below, this court affirms the decision of the
II. ISSUES PRESENTED
The issue presented is whether the ALJ properly considered the medical evidence of
record by failing to give controlling weight to the treating physician’s opinion in applying the
Eleventh Circuit’s three-part pain standard.
III. STANDARD OF REVIEW
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, 401 U.S. 389, 401
(1971). A reviewing court may not look only to those parts of the record that support the decision
of the ALJ, but instead must view the record in its entirety and take account of evidence that
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.” Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
IV. LEGAL STANDARD
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.” 42
U.S.C. § 423(d)(1)(A).
To make this determination 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.”
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).1
In evaluating pain and other subjective complaints, the Commissioner must consider
whether the claimant demonstrated an underlying medical condition, and either “(1) objective
medical evidence that confirms the severity of the alleged pain arising form that condition or (2)
that the objectively determined medical condition is of such a severity that it can reasonably be
expected to give rise to the alleged pain.” Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991)
(emphasis added); see also Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002); 20 C.F.R.
In considering the medical evidence of record, the Commissioner must give the testimony
of a treating physician “substantial or considerable weight unless ‘good cause’ is shown to the
contrary.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). Good cause is shown
McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986) was 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.
“where the doctor’s opinion is not bolstered by the evidence, . . .where the evidence supported a
contrary finding,” or where “the doctor’s opinions were conclusory or inconsistent with their own
medical records.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
The claimant was twenty-four years old at the time of the administrative hearing and has a
high school education. (R. 20, 121, 172). Her past work experience includes employment as a
cashier, assistant manager of a convenience store, laborer, and sales person. The claimant
testified that she has not engaged in substantial gainful activity since October 31, 2008. (R. 44-6).
The claimant alleged that she is unable to work because of episodic migraine headaches that
cause pain, blurry vision, upset stomach, and sensitivity to light and sound, and because of pain
in the lower back and left hip. (R. 50, 54).
Physical and Mental Limitations
The claimant testified that in October 2008, while working as a cashier at Walmart, she
suffered a possible stroke. The claimant testified that she did not have insurance at the time so it
was not possible for a doctor to perform proper tests to determine the cause of the episode. (R.
On February 11, 2008, the claimant was admitted to the Citizens Baptist Medical Center
Emergency Room after a suicide attempt. The record indicates that the claimant intentionally
overdosed on Cipro and Hydrocodone because of depression and situational problems. (R. 298).
The claimant was released after agreeing to follow up treatment at the Cheaha Mental Health
Center. (R. 302). The record shows no evidence of the claimant seeking follow up treatment at
the mental health center.
On October 29, 2008, the claimant was again admitted to the Citizens Baptist Medical
Center Emergency Room. The claimant complained of a headache, dizziness, lightheadedness,
blurred vision, nausea, and fainting. (R. 288). The doctor performed a brain CT and an EKG,
both of which he interpreted as normal. (R. 277). The doctor diagnosed a urinary tract infection
due to dehydration and prescribed the claimant Cipro. (R. 288, 275).
On November 11, 2008, Dr. Chandra Gehi, a neurologist at Anniston Neurology,
examined the claimant. The claimant explained her history of syncope and complained of
weakness in her left leg. Dr. Gehi performed a neurological exam, and the results of the exam
were normal. The claimant agreed to continue therapy for a few more days to see if it helped her
left leg, and Dr. Gehi gave the claimant a note excusing her from work for the next two weeks.
(R. 288, 275). Dr. Gehi asked the claimant to return for another appointment in two weeks, but
the claimant canceled the appointment and never returned to Dr. Gehi. (R. 265-9).
On February 3, 2009, the claimant was admitted to the Clay County Hospital Emergency
Room. She complained of a left side headache. After a physical examination, the Emergency
Room doctor recorded his impression of an acute, severe, migraine headache. The claimant
received medication in the form of Toradol, Reglan, and Lortab. (R. 234-7).
On February 20, 2009, Dr. Fazal Rahim, a treating physician and neurologist, examined
the claimant on referral from the claimant’s primary care physician, Dr. Charles Hensleigh. The
claimant complained of episodic headaches, insomnia, a fainting spell, and weakness in her
lower extremities. Dr. Rahim performed a neurological examination and concluded that the
claimant had no clear abnormalities other than reduced reflexes on the right side. Dr. Rahim
concluded that the claimant’s headaches were consistent with migraine headaches and prescribed
the claimant Topomax and Elavil. Dr. Rahim ordered an MRI of claimant’s brain to address her
complaints of left side weakness, although he noted that the descriptions of her symptoms and
the way they improved “raise suspicion for conversion type reaction.” (R. 224-6). Dr. Rahim
ordered a MRI that was performed on February 27, 2009, and the results showed no significant
findings within the brain. (R. 231).
On March 18, 2009, Brad Stanley, the state agency adjudicator, performed a physical
RFC assessment on the claimant. Mr. Stanley’s assessment indicated that the claimant could do
the following: occasionally lift fifty pounds; frequently lift twenty five pounds; stand and/or walk
with normal breaks for a total of about six hours in an eight hour work day; push and/or pull with
no limitations; occasionally climb ramps or stairs; never climb ladders, ropes, or scaffolds; and
balance, stoop, kneel, crouch, and crawl with no limitations. (R. 243-250).
Dr. Robert Estock, the state agency psychiatrist, completed a psychiatric review technique
on the claimant on March 23, 2012. Dr. Estock’s assessment indicated that the claimant
suffered from no severe mental impairment. In the “Consultant Notes” in section IV. of the PRT,
Dr. Estock noted that the other than the claimant’s February 2008 overdose, the claimant had no
history of mental health treatment or suicide attempts prior to that time. In addition, Dr. Estock
noted that during subsequent medical evaluations by various doctors, the claimant indicated no
problems with depression. (R. 251-264).
The claimant visited Dr. Rahim again on April, 3, 2009. The claimant indicated that she
thought the medicine was helping to fight her migraines and that she was experiencing fewer
headaches. During this visit, Dr. Rahim found the claimant’s cranial nerves, motor system,
plantar responses, sensory, cerebellar function, gait, speech, and language to all be normal. (R.
At this time, the claimant also complained of pain in her lower back and left hip that
radiates to her left knee. Dr. Rahim increased the claimant’s prescription for Topomax and
continued her prescription for Elavil and Maxalt for her headaches. Dr. Rahim ordered an MRI
of the lumbosacral spine to evaluate the pain in her lower back and left leg. (R. 221-223). The
MRI, performed on April 13, 2009, was negative except for mild lower lumbar degenerative
change. (R. 230).
The record contains headache logs prepared by the claimant from April 2009 through
February 21, 2010. The claimant wrote the logs in her handwriting and indicated the date, time,
severity, duration and symptoms of her headaches. (R. 198-202).
On July 6, 2009, Dr. Rahim completed a residual functional capacity questionnaire about
the claimant and her limitations. Dr. Rahim noted that the claimant could walk ten city blocks
without rest, continuously sit for more than two hours, stand for one hour, lift twenty pounds
occasionally, and would need two fifteen to twenty minute breaks during an eight hour workday.
(R. 215, 217).
On July 31, 2009, Dr. Rahim examined the claimant at a follow up visit. The claimant
complained of another syncopal episode. Dr. Rahim concluded that the claimant’s migraines
were “stable” and continued her on Topomax, Zanaflex, and Maxalt. (R. 211-213). Dr. Rahim
ordered an EEG and scheduled claimant for a sleep study. On July 31, 2009, Dr. Rahim noted
that the claimant was “alert, awake, cooperative, and in no obvious distress.” (R. 212).
The claimant also followed up with her primary care physican during this period on July
30, 2009. The claimant’s primary care physician, Dr. Hensleigh, noted that the claimant’s exam
results were normal. (R. 204-07).
On August 4, 2009, the claimant participated in a sleep study at Clay County Hospital.
Dr. Rohit Patel, a sleep medicine specialist, diagnosed the claimant with obstructive sleep apnea
and recommended the use of a CPAP machine for treatment. (R. 209).
On March 13, 2010, the claimant was admitted to the Clay County Hospital Emergency
Room, complaining of lower back pain. (R. 311). Dr. Warren, the emergency room doctor,
ordered a CT scan of the abdomen and pelvis, and Dr. Todd Brightbill, a radiologist, interpreted
the scan as normal. (R. 316). Dr. Warren prescribed the claimant Flexeril and Lortab and told
her to seek follow up care from her primary care physician if her symptoms persisted for more
than forty-eight hours. (R. 321).
The ALJ Hearing
After the Commissioner denied the claimant’s request for disability insurance and
supplemental security income benefits, the claimant requested a hearing before an ALJ. (R. 27).
On December 2, 2010, an ALJ conducted a hearing on behalf of the claimant. (R. 34-61). At the
hearing, the claimant testified that she takes Topomax, Amitriptyline, and Maxalt for her
headaches. The claimant testified that the medications decrease the amount of migraines she has
and reduce the intensity “a little,” but the medications have not stopped the migraines
completely. The claimant testified that with the medication, she has six or seven headaches a
month. The claimant testified that her headaches last anywhere from four hours to the entire day.
The claimant testified that during 2010, up until the hearing, she had not seen a doctor
other than when she went to the emergency room. The claimant testified that she had not seen Dr.
Rahim, her treating physician and neurologist, in more than a year because she is over the limit
for doctor’s visits that Medicaid allows, and she cannot afford to pay him. The claimant testified
that she still takes the same medications that Dr. Rahim prescribed her. (R. 48).
The claimant testified that she lives at home with her six-year-old son, and she routinely
gets her son ready for school, does laundry and cleans, helps her son with his homework, goes
grocery shopping, and has a valid driver’s license. (R. 49). The claimant testified that when she
experiences a headache while her son is present, she sits on the couch with him until it is over.
The claimant testified that she has “a lot of pain” in her lower back and left hip. She says
that two to three times a month her left leg locks up, and she has to drag her leg. (R. 50-51).
The claimant testified that her current weight, at the time of the hearing, was 337 and a
half pounds. The claimant testified that she has cut back on how much she eats and has tried to
exercise. (R. 51).
The claimant testified that she can sit in one position for about twenty minutes before she
has to change positions. She testified that she spends two hours a day sitting and three and a half
hours a day standing and that she could walk for twenty to twenty-five minutes without stopping.
The claimant stated that she is able to lift and carry household objects and has no limitations in
the use of her hands or feet. The claimant testified that she could climb stairs if she had a rail to
hold onto, although it would take a long time, and she might have to pause. The claimant testified
that she has not had anymore fainting spells since the second documented spell. (R. 51-53).
When the claimant’s attorney questioned her, she claimed that she has severe headaches
even while taking Maxalt. The claimant testified that the headaches feel like “somebody is
stabbing [her] in the head.” The claimant testified that the other symptoms of her headaches
include blurry vision, upset stomach, and sensitivity to light and sound. Additionally, the
claimant claimed that when she has these headaches she cannot see straight, and moving causes
her pain. The claimant testified that she could not go grocery shopping, drive a car, or write bills
while she was having a headache. (R. 54)
The claimant testified that she is no longer taking her medication because she ran out of
money. (R. 55)
A vocational expert, Dr. William Green, testified concerning the type and availability of
jobs that the claimant was able to perform. (R. 56-59). Dr. Green classified the claimant’s
previous work at Walmart as unskilled with a light exertion level. The ALJ asked Dr. Green a
hypothetical based on Dr. Rahim’s residual functional capacity report. The ALJ asked whether a
22 year-old with a high school education, work history as a cashier, and the claimant’s medically
documented impairments could perform the claimant’s past work with the following limitations:
sit continuously at one time for two hours; stand continuously at one time for one hour; sit a total
for four hours in an eight-hour day; stand and walk less than two hours total in an eight-hour day;
have the capacity to sit and stand at will; take one to two unscheduled breaks for every eight-hour
work period; lift and carry up to 20 pounds occasionally; avoid concentrated exposure to extreme
temperatures; and avoid moderate exposure to fumes. Dr. Green testified that such an individual
could not be expected to perform any of the past work, and the individual could also not perform
any other full-time work in the economy. (R. 56-57).
Then, based on the report from Mr. Stanley, the state agency adjudicator, the ALJ asked
Dr. Green whether a 22-year-old with a high school education and a history of light and unskilled
work could perform the claimant’s past work with the following limitations: lift, carry, push and
pull fifty pounds occasionally and twenty-five pounds frequently; stand and/or walk with normal
breaks for six hours total in an eight-hour work day; sit with normal breaks about six hours in an
eight-hour day; occasionally climb ramps and stairs but not climb ladders, ropes, or scaffolds;
and avoid all exposure to unprotected heights, professional traveling, dangerous machinery, or
large bodies of water. Dr. Green testified that such an individual could perform work as a cashier.
However, Dr. Green testified that being absent from work for more than two working days a
month would eliminate available work. (R. 57-58).
Next, the claimant’s attorney questioned Dr. Green. When questioned by the claimant’s
attorney about absenteeism, Dr. Green testified that being absent one day per month is tolerated
in unskilled work. When questioned about the ALJ’s first hypothetical, Dr. Green testified that
being unable to complete an eight-hour work day and requiring two, fifteen to twenty minute
unscheduled work breaks were the primary reasons for his response that past work or full time
work would not be available. (R. 58-59).
The ALJ’s Decision
On December 3, 2010, the ALJ issued a decision finding the claimant was not disabled
within the meaning of the Social Security Act from October 31, 2008 through the date of the
decision. (R. 13). First, the ALJ found that the claimant met the insured status requirements of
the Social Security Act through June 30, 2010. Second, the ALJ found the claimant had not
engaged in substantial gainful activity since October 31, 2008. (R. 15)
Third, the ALJ found the claimant’s migraine headaches and morbid obesity qualified as
severe impairments. The ALJ noted the claimant’s depression; however, he concluded that the
depression did not qualify as a severe impairment because the claimant was not limited in the
four functional areas set out in the disability regulations for evaluating mental disorders. (R. 1516).
Fourth, the ALJ concluded that the severe impairments did not meet or medically equal
one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. To support his
findings, the ALJ noted that although the claimant had been diagnosed with migraine headaches,
all neurological evaluations and reflex, sensory, and motor exams were normal except for slightly
diminished reflexes in the right lower extremity attributed to obesity. The ALJ noted that the
frequency and severity of the migraines were documented only by her headache diaries, and the
claimant told her neurologist that medications reduced the frequency and severity of her
headaches. (R. 17).
Fifth, the ALJ found the claimant had the residual functional capacity to perform light
work except that the claimant must avoid climbing ladders, ropes, and scaffolds; cannot work at
unprotected heights; cannot do commercial driving; cannot be exposed to dangerous machinery
in the workplace; or work on or around large bodies of water. He also concluded the claimant’s
obesity would limit her to no more than light exertion. (R. 17).
To support his conclusion, the ALJ followed a two-step process to evaluate the claimant’s
symptoms. First, the ALJ found that the claimant’s medically determinable physical impairment
could not reasonably be expected to produce the claimant’s pain or other symptoms at the
severity claimed by her. Second, the ALJ decided that the claimant’s statements concerning the
intensity, persistence, and limiting effects of her symptoms were not credible to the extent they
were inconsistent with the residual functional capacity assessment. The ALJ concluded that “the
treatment records, the paucity of ER visits, prescription records, her description of daily
activities, her being the sole care giver for her six year old son, and the lack of treatment or
prescriptions in the last seven months do not support headaches of the frequency and severity
alleged or recorded in the claimant’s headache diaries.” (R. 19).
The ALJ decided that Dr. Rahim’s opinion was not supported by his own treatment
records, the results of objective imaging studies, his own observed clinical signs and symptoms,
or other treatment records. The ALJ noted that Dr. Rahim’s opinion was consistent with the
claimant’s subjective complaints; however, the subjective complaints were not corroborated by
the “signs observed by Dr. Rahim or other physicians or other objective medical evidence
including neurological evaluation, imaging studies, and pharmacy records.” (R. 19).
The ALJ also relied on the opinion evidence of Dr. Estock, the state agency psychiatrist.
Dr. Estock found that the claimant suffered from no severe mental impairment. The ALJ
concluded that the entire medical record supported Dr. Estock’s PRT assessment. (R. 19).
Finally, relying on his evaluation of the claimant’s residual functional capacity, the ALJ
concluded that the claimant was capable of performing past relevant work as a cashier. To
support his conclusion, the ALJ relied on the vocational expert’s testimony. The vocational
expert testified, in response to the ALJ’s hypothetical based on the residual functional capacity
assessment performed by Mr. Stanley, that “none of the non-exertional, impairment caused
limitations would preclude the performance of claimant’s work as a cashier either as she
performed it or as it is generally performed.” (R. 19).
Based on the opinion evidence of Dr. Estock, the finding that Dr. Rahim’s medical
opinion was not supported by his own treatment records or observations, and the testimony from
the vocational expert, the ALJ found that the claimant had not been under a disability, as defined
in the Social Security Act, from October 31, 2008, through the date of the ALJ’s decision. (R.
The claimant contends that the ALJ improperly considered the medical evidence of record
by failing to give controlling weight to the opinion of the claimant’s treating physician, Dr.
Rahim, when applying the Eleventh Circuit’s three-part pain standard. The court finds that the
ALJ sufficiently qualified his evaluation of Dr. Rahim’s opinion in light of the substantial
evidence to the contrary. As such, the court further finds that the ALJ properly applied the threepart pain standard.
The three-part pain standard applies when a claimant attempts to establish disability
through her own testimony of pain or other subjective symptoms. Holt v. Sullivan, 921 F.2d
1219, 1223 (11th Cir. 1991). The pain standard requires “(1) evidence of an underlying medical
condition and either (2) objective medical evidence that confirms the severity of the alleged pain
arising from that condition; or (3) that the objectively determined medical condition is of such a
severity that it can be reasonably expected to give rise to the alleged pain.” Id.
In applying the pain standard and determining whether objective medical evidence
supports the claimant’s otherwise subjective testimony, the ALJ is compelled to give substantial
weight to the opinion of the claimant’s treating physician. Crawford v. Comm’r, 363 F.3d 1155,
1159 (11th Cir. 2004). More specifically, the Commissioner must give the testimony of a
treating physician “substantial or considerable weight unless ‘good cause’ is shown to the
contrary.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (emphasis added). Courts
have identified “good cause” to disregard the opinions of treating physicians when such opinions
were “not bolstered by the evidence, or where the evidence supported a contrary finding.” Id.
Likewise, courts have found “good cause” when the treating physicians’ opinions were
“conclusory or inconsistent with their own medical records.” Id.
In finding that the claimant’s migraines could not reasonably be expected to produce the
claimant’s subjective reports of pain and subsequent limitations, the ALJ relied on the claimant’s
lack of credibility and the objective medical evidence in the record, including Dr. Rahim’s
records. The ALJ, however, chose not to give controlling weight to the opinion of Dr. Rahim,
the claimant’s treating physician. The claimant contends that the ALJ improperly dismissed the
opinion of Dr. Rahim, who found the claimant to have multiple limitations that would prevent
her from sustaining competitive employment. The claimant argues that by dismissing the
opinion of the claimant’s treating physician, the ALJ failed to follow the treating physician rule,
and thus, his decision on the claimant’s disability and RFC was unfounded.
Although Dr. Rahim’s opinion was consistent with the claimant’s subjective complaints,
his opinion was inconsistent with the entirety of the objective medical evidence on record, which
includes Dr. Rahim’s own treatment records, various imagining reports, and evaluations of other
physicians. As a result of this inconsistency, the ALJ relied on the “good cause” exception to the
treating physician rule when he declined to give Dr. Rahim’s controlling weight and determined
that the claimant was not disabled.
First, the ALJ found that Dr. Rahim’s treatment records do not support his opinion on the
claimant’s limitations and her ability to work. Dr. Rahim’s answers to the residual functional
capacity questionnaire on July 6, 2009 indicated that the claimant was only able to stand and
walk for less than two hours and sit for about four hours during an eight hour work day and
would need one to two unscheduled breaks for fifteen or twenty minutes during the work day. In
contrast to Dr. Rahim’s answers to the questionnaire, the ALJ pointed to Dr. Rahim’s own
treatment notes regarding a neurological exam of the claimant on February 20, 2009 that
reflected no clear abnormalities with the claimant’s neurological system. The ALJ additionally
explained that Dr. Rahim determined that the claimant’s complaints of left-side weakness in her
legs might be the result of a conversion type reaction based on the suspicious way her symptoms
Also contrary to the questionnaire responses, Dr. Rahim’s treatment records from April 3,
2009 show that the claimant thought her migraines were improving and that Dr. Rahim found the
headaches had improved with the prescribed medications. Additionally, Dr. Rahim recorded that
the claimant’s cranial nerves, motor system, plantar responses, sensory, cerebellar function, gait,
speech and language were all normal. On July 6, 2009, Dr. Rahim indicated that the claimant’s
headaches were “stable,” and the claimant was “alert, awake, cooperative, and in no obvious
distress.” Therefore, the ALJ correctly determined that Dr. Rahim’s opinion was indeed
inconsistent with his own treatment notes.
In addition to relying on Dr. Rahim’s own treatment notes, the ALJ also relied on
objective MRI and CT findings to show that Dr. Rahim’s RFC assessment is inconsistent with
and unsupported by the evidence in the record. The ALJ explained that Dr. Rahim ordered an
MRI of the claimant in February 2009, and the results showed “no significant findings” within
the brain. Dr. Rahim ordered another MRI in April 2009 that showed only “mild lower lumbar
degenerative change” in the claimant’s spine. The ALJ also noted that while in the emergency
room in October 2008, the claimant underwent a CT scan that revealed no acute intracranial
abnormalities in her brain, and the claimant’s EKG was normal. Further reasoning that Dr.
Rahim’s RFC determination was inconsistent with and unsupported by the substantial evidence
in the record, the ALJ considered a CT scan from the claimant’s March 2010 emergency room
visit. While the claimant complained of low back pain, her CT scan revealed no abnormalities
with her pelvis. (R. 18). The ALJ correctly determined that Dr. Rahim’s opinion was
inconsistent with the objective medical imaging records.
The ALJ also relied on other available treatment records to highlight that Dr. Rahim’s
RFC assessment was unsupported by and inconsistent with the other evidence on record. The
ALJ noted the claimant’s treatment with Dr. Hensleigh, her original primary care physician.
During an exam in 2009, Dr. Hensleigh found the claimant’s exam result to be normal. The ALJ
noted that before the claimant saw Dr. Rahim, Dr. Gehi evaluated her on November 11, 2008.
Although the claimant had subjective complaints of pain and weakness, the neurological exam
results were completely normal. Dr. Gehi excused the claimant from work for two weeks;
however, the claimant never returned to Dr. Gehi for subsequent treatment. (R. 18).
The ALJ also noted that the claimant’s own actions do not support the RFC assessment
made by Dr. Rahim and the alleged severity and intensity of the claimant’s migraines. First, the
ALJ focused on the fact that the claimant testified that she had seen neither Dr. Rahim nor any
other physician for her pain in more than a year. Second, the ALJ noted the claimant’s own
testimony that she is able to get her son ready for school; do laundry and cleaning; go grocery
shopping; help her son with his homework; prepare dinner; and bathe her son. The ALJ correctly
found that the claimant’s ability to perform these daily functions are inconsistent with her alleged
limiting effects of her pain.
This court finds that because Dr. Rahim’s opinion was inconsistent with substantial
evidence in the record and with his own treatment notes, the ALJ had good cause to refuse to
give controlling weight to Dr. Rahim’s opinion. Also, in relying on Dr. Estock’s opinion, the
ALJ correctly found that the claimant did not suffer from a severe mental impairment. The court
also finds that the ALJ properly applied the three-part pain standard, and substantial evidence
supports his decision in this case.
For the reasons as stated, this court concludes that the decision of the Commissioner is
supported by substantial evidence and is to be AFFIRMED.
The court will enter a separate order in accordance with this Memorandum Opinion.
DONE and ORDERED this 27th day of September, 2012.
KARON OWEN BOWDRE
UNITED STATES DISTRICT JUDGE
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?