Adams v. Social Security Administration, Commissioner

Filing 12

MEMORANDUM OPINION. Signed by Judge Madeline Hughes Haikala on 1/13/2015. (KEK)

FILED
2015 Jan-13 PM 04:05
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
NORTHEASTERN DIVISION
DWIGHT G. ADAMS,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner, Social Security
Administration,
Defendant.

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Case No.: 2:13-cv-02265-MHH

MEMORANDUM OPINION
Plaintiff Dwight G. Adams filed this action on December 17, 2013, pursuant
to Title XVI of Section 1631(c)(3) of the Social Security Act. Mr. Adams seeks
judicial review of the decision by the Commissioner of the Social Security
Administration1 denying his claims for a period of disability and supplemental
security income (SSI). See 42 U.S.C. § 1383(c). After careful review, the Court
remands the Commissioner’s decision.

1

Carolyn W. Colvin became the Acting Commissioner of Social Security on February 14, 2013.
Therefore, she should be substituted for Commissioner Michael J. Astrue as Defendant in this
suit. See Fed. R. Civ. P. 25(d) (“An action does not abate when a public officer who is a party in
an official capacity dies, resigns, or otherwise ceases to hold office while the action is pending.
Later opinions should be in the substituted party’s name, but any misnomer not affecting the
parties’ substantial rights must be disregarded.”).

I.

STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the

ALJ denies benefits and the Appeals Council denies review,” the Court “review[s]
the ALJ’s ‘factual findings with deference’ and his ‘legal conclusions with close
scrutiny.’” Riggs v. Soc. Sec. Admin., Comm’r, 522 Fed. Appx. 509, 510–11 (11th
Cir. 2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the findings of the Commissioner. “Substantial evidence is more than a
scintilla and 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 (11th Cir. 2004).

In making this evaluation, the Court may not

“reweigh the evidence or decide the facts anew,” and the Court must “defer to the
ALJ’s decision if it is supported by substantial evidence even if the evidence may
preponderate against it.” Gaskin v. Comm’r of Soc. Sec., 533 Fed. Appx. 929, 930
(11th Cir. 2013) (quoting Dyer v. Barnhart, 395 F.2d 1206, 1210 (11th Cir. 2005)).
With respect to the ALJ’s legal conclusions, the Court must determine whether the
ALJ applied the correct legal standards. If the Court finds an error in the ALJ’s
application of the law, or if the Court finds that the ALJ failed to provide sufficient
reasoning to demonstrate that the ALJ conducted a proper legal analysis, then the

2

Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 1143,
1145–46 (11th Cir. 1991).
II.

PROCEDURAL AND FACTUAL BACKGROUND
Mr. Adams alleges that his disability began on June 8, 2010. (Doc. 7-6, p.

2). Mr. Adams first applied for social security income benefits under Title XVI in
August 2010. (Doc. 7-6, p. 2). The Social Security Administration denied Mr.
Adams’s application on November 12, 2010. (Doc. 7-4, pp. 2–3). At Mr. Adams’s
request, an Administrative Law Judge (ALJ) held a hearing on May 31, 2012.
(Doc. 7-3, pp. 69–92). At the time of the hearing, Mr. Adams was 51 years old.
(Doc. 7-6, p. 2). Mr. Adams has a high school education and past relevant work
experience as a corrections officer, a security guard, and a van driver. (Doc. 7-7,
pp. 4, 12).
On June 13, 2012 the ALJ denied Mr. Adams’s request for disability
benefits. The ALJ found that Mr. Adams is not disabled under sections 216(i) and
223(d) of the Social Security Act. (Doc. 7-3, p. 34). In his 14-page opinion, the
ALJ described the “five-step sequential evaluation process for determining whether
an individual is disabled.” (Doc. 7-3, pp. 21–23). The ALJ explained that “[i]f it
is determined that the claimant is or is not disabled at a step of the evaluation
process, the evaluation will not go on to the next step.” (Doc. 7-3, pp. 21–22).

3

The ALJ found that Mr. Adams “has not engaged in substantial gainful
activity since June 8, 2010, the alleged onset date.” (Doc. 7-3, p. 23). Although
Mr. Adams had worked since his alleged disability onset date, his earnings did not
rise to substantial gainful activity levels. (Doc. 7-3, p. 24; Doc. 7-6, p. 10). The
ALJ noted that Mr. Adams continued to work in spite of his alleged impairments
and concluded that Mr. Adams was not unable to engage in any substantial gainful
activity. (Doc. 7-3, p. 24). Still, because Mr. Adams’s work was not performed
above substantial gainful activity levels, the ALJ continued the analysis of Mr.
Adams’s impairments. (Doc. 7-3, p. 24).
The ALJ determined that Mr. Adams has “the following severe impairments:
anxiety disorder, coronary artery disease post heart attack and degenerative joint
disease of the knees.” (Doc. 7-3, p. 24). He found these impairments to be severe
because they have more than a minimal impact on Mr. Adams’s ability to perform
work on a regular and continuous basis at competitive levels of employment.
(Doc. 7-3, p. 24). The ALJ considered Mr. Adams’s diagnosed hypertension and
his obesity but did not find them to be severe impairments. (Doc. 7-3, pp. 24, 25).
The ALJ concluded that none of Mr. Adams’s impairments meets or medically
equals the severity of one of the listed impairments. (Doc. 7-3, p. 25).
The ALJ also determined that Mr. Adams’s mental impairment did not meet
or medically equal the criteria of listing 12.06. (Doc. 7-3, p. 25). The ALJ found
4

that Mr. Adams had mild restriction in activities of daily living; moderate
difficulties in social functioning; moderate difficulties with concentration,
persistence, or pace; and no episodes of decompensation. (Doc. 7-3, pp. 25–26).
Next, the ALJ calculated Mr. Adams’s residual functional capacity (RFC).
(Doc. 7-3, p. 27). The ALJ determined that Mr. Adams has the RFC to perform
light work except that he “can perform occasional push and pull operations with
the lower extremities, should never climb ladders, ropes or scaffolds, should never
work around hazards, would require a sit/stand option[], would require to [sic]
simple, routine tasks, infrequent contact with the public and only occasional
changes in work setting. (Doc. 7-4, p. 27). In making this finding, the ALJ
examined Mr. Adams’s history of cardiac issues. (Doc. 7-3, p. 27). The ALJ
indicated that Mr. Adams first suffered myocardial infarction in 2000, resulting in
surgery. (Doc. 7-3, p. 27; Doc. 7-10, p. 46). Mr. Adams suffered another cardiac
incident on June 8, 2010, which resulted in cardiac catheterization. (Doc. 7-3, p.
27; Doc. 7-14, p. 45). The ALJ noted Mr. Adams’s testimony that this incident has
resulted in ongoing physical issues such as shortness of breath, dizziness, and
episodes of severe chest pain 2-3 times per week. (Doc. 7-3, p. 27). The ALJ
determined that this evidence is consistent with Mr. Adams’s ongoing cardiac
issues. (Doc. 7-3, p. 27).

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The ALJ stated that Mr. Adams received a CT scan in June 2010 after Mr.
Adams’s cardiac incident. (Doc. 3-7, p. 27; Doc. 7-9, p. 2). The scan showed that
Mr. Adams’s heart and vascular structures were unremarkable. (Doc. 3-7, p. 28;
Doc. 7-9, p. 2). The ALJ also noted that Mr. Adams had a chest X-ray, which
showed his heart and mediastinum were unremarkable and that Mr. Adams’s heart
exhibited no significant abnormality or interval change. (Doc. 3-7, p. 28; Doc. 7-9,
p. 5). The ALJ concluded from these findings that Mr. Adams’s heart issues were
not as severe as alleged. (Doc. 3-7, p. 28).
The ALJ noted that Mr. Adams returned for a follow-up appointment two
months after his myocardial infarction. (Doc. 3-7, p. 28; Doc. 7-9, p. 38). During
this visit, Mr. Adams acknowledged that he had some dizziness and dyspnea on
exertion along with chest pains and palpitations, (Doc. 3-7, p. 28; Doc. 7-9, p. 38);
however, the ALJ indicated that Mr. Adams had not increased his medications as
instructed by his physician, and he only rated his pain at 1 out of 10. (Doc. 3-7, p.
28; Doc. 7-9, p. 38). The ALJ found that this “eroded the claimant’s credibility.”
(Doc. 7-3, p. 28).
The ALJ also considered Mr. Adams’s chest X-ray in February of 2011,
which showed clear lungs, moderate cardiomegaly, and no significant osseous
abnormalities. (Doc. 7-3, p. 28; Doc. 7-11, p. 5). In March 2012, Mr. Adams
complained of chest pain similar to the pain he had in June 2010 when he
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underwent cardiac catheterization. (Doc. 7-3, p. 28; Doc. 7-14, p. 45). The ALJ
pointed out that Mr. Adams had sought minimal treatment for cardiac conditions
between 2010 and 2012. (Doc. 7-3, p. 28). Although Mr. Adams stated that he
was taking his medication with little relief, the examining physician did not find
Mr. Adams’s issues to warrant a cardiac catheterization. (Doc. 7-14, p. 47). The
ALJ stated that this appeared to be an isolated incident, as Mr. Adams had not
complained of chest pains or cardiac complications for some time prior to this
event and had not sought ongoing care or management of the impairment. (Doc. 73, p. 28).
In regards to Mr. Adams’s alleged myocardial infarction, the ALJ found that
at a recent consultative treatment exam, Mr. Adams’s heart exhibited a normal rate
and rhythm, no murmurs and normal heart sounds. (Doc. 7-3, p. 29; Doc. 7-10, p.
70). The ALJ found that this indicates that Mr. Adams’s cardiac issues have not
impacted his apparent heart function. (Doc. 7-3, p. 29). The ALJ also noted that
even though Mr. Adams has not been consistent in seeking treatment for his
alleged myocardial infarction, Mr. Adams appears to have retained the ability to
function in most respects in his day-to-day life. (Doc. 7-3, p. 29). Based on all the
physicians’ findings concerning Mr. Adams’s heart, the ALJ concluded that while
Mr. Adams’s coronary artery disease status post heart attack was severe, it was not
so severe as to be disabling. (Doc. 7-3, p. 29).
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The ALJ then examined treatment notes concerning Mr. Adams’s alleged
degenerative joint disease. (Doc. 7-3, p. 29). An X-ray of Mr. Adams’s knees
taken in March of 2012 indicated “mild to moderate degenerative narrowing at the
medial femorotibial joint space bilaterally with marginal osteophytes.” (Doc. 7-3,
p. 29; Doc. 7-14, p. 35). This, in addition to some minor patellar enthesopathy and
slight varus angulation, indicated to the ALJ that Mr. Adams did exhibit some knee
issues consistent with his allegations of pain. (Doc. 7-3, p. 29; Doc. 7-14, p. 35).
A consultative physical examination of Mr. Adams concerning gait and posture
indicated that while he did have limitations, those limitations did not bar him from
work. (Doc. 7-3, p. 29; Doc. 7-10, pp. 70, 71).
The ALJ acknowledged that Mr. Adams stated a need for a cane and braces
to manage his knee pain. (Doc. 7-3, p. 29). The ALJ noted that Mr. Adams did
not exhibit severe difficulty with ambulation and that Mr. Adams had recently
stated that he was able to walk 3 miles and feel “pretty good.” (Doc. 7-3, p. 29;
Doc. 7-13, p. 15). The ALJ found this impairment to have some impact on Mr.
Adams’s ability to function in a work setting, and he accounted for the impairment
in his RFC findings. (Doc. 7-3, p. 30). Nevertheless, the ALJ concluded that Mr.
Adams’s knee issues did not bar him from returning to full-time, gainful
employment. (Doc. 7-3, p. 30).

8

The ALJ then assessed treatment notes regarding Mr. Adams’s alleged
anxiety. (Doc. 7-3, p. 30). Mr. Adams states that he has vivid nightmares 4-5
times a week and that his anxiety affects his ability to concentrate and spend time
in public. (Doc. 7-3, p. 30; Doc. 7-10, p. 46). The ALJ noted that despite Mr.
Adams’s mental health issues, treatment notes indicated that Mr. Adams was alert
and oriented and had spontaneous and fluent speech. (Doc. 7-3, p. 30; Doc. 7-13,
p. 13). Furthermore, treatment notes state that Mr. Adams had logical and goaldirected thought process with fair insight and judgment. (Doc. 7-3, p. 30; Doc. 713, p. 13). The ALJ considered that Mr. Adams’s anxiety issues were controlled
when he took his prescribed medication and that Mr. Adams admitted he felt better
after his dosage increased and he took his medication consistently. (Doc. 7-3, p.
30; Doc. 7-13, pp. 25, 26, 79). The ALJ determined that although Mr. Adams’s
anxiety was severe, it was not disabling. (Doc. 7-3, p. 31).
The ALJ considered Mr. Adams’s history of marijuana abuse. (Doc. 7-3, p.
31). The ALJ noted that Mr. Adams used marijuana sporadically as a coping tool
to address anxiety and stress and that Mr. Adams had lost a job in the past due to
marijuana use. (Doc. 7-3, p. 31; Doc. 7-13, pp. 32, 74). Because the use was
sporadic and because Mr. Adams continued to suffer mental and physical issues
regardless of whether he was using marijuana, the ALJ determined that marijuana
abuse was immaterial to the disability determination. (Doc. 7-3, p. 31).
9

In making his disability determination, the ALJ consulted the treatment
notes of Disability Determination Services (DDS) physician Dr. Robert Heilpern.
(Doc. 7-3, p. 31). Dr. Heilpern opined that Mr. Adams could perform the full
range of light exertional activity, could perform unlimited push and pull, could
occasionally climb ramps and stairs, balance, stoop, kneel, crouch and crawl, and
should avoid moderate exposure to hazards. (Doc. 7-3, p. 31; Doc. 7-10, pp. 104–
111). The ALJ did not give controlling weight to Dr. Heilpern’s opinion because
Dr. Heilpern was not an examining physician, but the ALJ did find Dr. Heilpern’s
opinion to be consistent with the medical evidence of record. Consequently, the
ALJ gave great weight to Dr. Heilpern’s opinion. (Doc. 7-3, p. 31).
In regard to Mr. Adams’s mental capacity to perform work, the ALJ
consulted the assessment of DDS non-examining psychologist, Dr. Megan Sherod.
(Doc. 7-3, p. 31). Dr. Sherod noted some moderate limitations concerning Mr.
Adams’s functional capacity that the ALJ considered in making his RFC findings.
(Doc. 7-3, p. 31; Doc. 7-10, pp. 100–102). The ALJ did not give controlling
weight to Dr. Sherod’s opinion because Dr. Sherod was not an examining
psychologist; however, the ALJ found that Dr. Sherod’s opinion is consistent with
the medical evidence of record, so the ALJ gave Dr. Sherod’s opinion substantial
weight. (Doc. 7-3, p. 31).

10

In addition, the ALJ assessed treatment notes from examining physician Dr.
Ashley Thomas, who completed a physical consultative examination of Mr. Adams
at the request of the SSA. (Doc. 7-3, p. 32). Dr. Thomas opined that Mr. Adams
could stand or walk for 6 hours in an 8-hour workday with frequent breaks and that
Mr. Adams could sit for 8 hours in an 8-hour workday with frequent breaks. (Doc.
7-3, p. 32; Doc. 7-10, p. 71). The ALJ gave Dr. Thomas’s opinion significant
weight because she had the opportunity to examine Mr. Adams and because Dr.
Thomas is familiar with the regulations and practices of the SSA. (Doc. 7-3, p.
32).
Finally, the ALJ considered a third-party function report that Dwight G.
Adams, Jr., Mr. Adams’s son, completed. (Doc. 7-3, p. 32). Mr. Adams, Jr. stated
that Mr. Adams was limited in his ability to lift, stand, reach, walk, talk, climb
stairs, and complete tasks. (Doc. 7-3, p. 32; Doc. 7-7, pp. 45–52). The ALJ
commended Mr. Adams, Jr. for his sincere and caring attitude toward his father,
but gave the report very little weight because it was inconsistent with the medical
evidence and because Mr. Adams, Jr. is not an approved medical source. (Doc. 73, p. 32).
Based on the vocational expert’s testimony, the ALJ determined that Mr.
Adams would not be able to perform his past relevant work. (Doc. 7-3, p. 33).
The ALJ then considered Mr. Adams’s age, education, work experience, and RFC
11

and determined that there are jobs that exist in significant numbers in the national
economy that Mr. Adams can perform. (Doc. 7-3, p. 33). The ALJ relied on the
testimony of vocational expert William Green, who stated that a person with Mr.
Adams’s age, education, work experience, and RFC could perform the following
representative occupations: assembler, of which there are 1,200 jobs statewide and
60,000 nationwide; marker, of which there are 800 positions statewide and 65,000
nationwide; and production worker, of which there are 700 jobs statewide and
65,000 nationwide. (Doc. 7-3, p. 34). The ALJ concluded that Mr. Adams “has
not been under a disability, as defined in the Social Security Act, from June 8,
2010, through the date of this decision.” (Doc. 7-3, p. 34).
This became the final decision of the Commissioner on October 17, 2013,
when the Appeals Council refused to review the ALJ’s decision. (Doc. 7-3, p. 2).
Having exhausted all administrative remedies, Mr. Adams filed this action for
judicial review pursuant to §205(g) and §1631(c)(3) of the Social Security Act, 42
U.S.C. §405(g) and §1383(c)(3). (Doc. 1, p. 1).
III.

ANALYSIS
To be eligible for disability insurance benefits, a claimant must be disabled.

Gaskin v. Comm’r of Soc. Sec., 533 Fed. Appx. 929, 930 (11th Cir. 2013). “A
claimant is disabled if he is unable to engage in substantial gainful activity by
reason of a medically-determinable impairment that can be expected to result in
12

death or which has lasted or can be expected to last for a continuous period of at
least 12 months.” Id. (citing 42 U.S.C. § 423(d)(1)(A)).
A claimant must prove that he is disabled. Id. (citing Ellison v. Barnhart,
355 F.3d 1272, 1276 (11th Cir. 2003).

To determine whether a claimant is

disabled, the Social Security Administration applies a five-step sequential analysis.
Gaskin, 533 Fed. Appx. at 930.
This process includes a determination of whether the claimant (1) is
unable to engage in substantial gainful activity; (2) has a severe and
medically-determinable physical or mental impairment; (3) has such
an impairment that meets or equals a Listing and meets the duration
requirements; (4) can perform his past relevant work, in the light of
his residual functional capacity; and (5) can make an adjustment to
other work, in the light of his residual functional capacity, age,
education, and work experience.
Id. (citation omitted).

“The claimant’s residual functional capacity is an

assessment, based upon all relevant evidence, of the claimant’s ability to do work
despite his impairments.” Id. (citing Lewis v. Callahan, 125 F.3d 1436, 1440 (11th
Cir. 1997); 20 C.F.R. § 404.1545(a)(1)).
Mr. Adams contends that he is entitled to relief from the ALJ’s decision
because the ALJ’s RFC findings were not based on substantial evidence. (Doc. 10,
p. 6). Specifically, Mr. Adams states that the ALJ erred in not addressing the
consultative physician’s testimony regarding Mr. Adams’s need for frequent
breaks. (Doc. 10, p. 6). The Court agrees.
13

In making his RFC determination, the ALJ considered the assessment of
consultative physician Dr. Ashley Thomas, who stated that Mr. Adams could stand
or walk for 6 hours in an 8-hour workday with frequent breaks and could sit for 8
hours in an 8-hour workday with frequent breaks. (Doc. 7-3, p. 32; Doc. 7-10, p.
71). The ALJ stated that Dr. Thomas’s opinion was “very credible” and that he
gave it “significant weight” because Dr. Thomas had the opportunity to examine
Mr. Adams. (Doc. 7-3, p. 32). The ALJ also stated that Dr. Thomas’s opinion was
consistent with the other substantial evidence in the record. (Doc. 7-3, p. 32).
The ALJ did not take into account Dr. Thomas’s opinion that Mr. Adams
would need frequent breaks when he posed hypothetical questions to the VE at the
hearing. (Doc. 7-3, p. 89). Upon examination by Mr. Adams’s counsel, the VE
stated that frequent breaks would not be tolerated in the jobs he proposed in
response to the ALJ’s hypothetical. (Doc. 7-3, p. 92).
Q:

. . . What tolerances are there for breaks above and beyond
standard A.M. and P.M. and lunchtime breaks in those jobs, and
the jobs you outlined?

A:

Yeah. I think more than two five-minute breaks in addition
would not be tolerated. But people can usually get away with
two brief breaks.

(Doc. 7-3, p. 92).
The ALJ “may reject the opinion of any physician when the evidence
supports a contrary conclusion.” McCloud v. Barnhart, 166 Fed. Appx. 410, 418
14

(11th Cir. 2006) (citing Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11th Cir.
1983)). However, the ALJ is required “to state with particularity the weight he
gives to different medical opinions and the reasons why.” Id. at 418–19 (citing
Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987)). Here, the ALJ did not
explain why he discredited Dr. Thomas’s findings regarding Mr. Adams’s need for
frequent breaks.
In Barnes v. Astrue, 494 F. Supp.2d 1275, 1277 (N.D. Ala. 2007), the
consultative physician determined that the claimant needed “frequent breaks” in an
8-hour workday.

The ALJ gave the consultative physician’s opinion “great

weight” and found it to be consistent with and supported by the evidence in the
record. Id. at 1277–78. The VE testified that frequent breaks would preclude the
plaintiff from any level of work activity. Id. Nevertheless, the ALJ determined
that the claimant had the RFC to perform light work. Id. The Court remanded the
case, holding that the ALJ failed to properly demonstrate that the plaintiff could
perform other work. Id.
Similarly, in this case, the ALJ generally gave significant weight to the
consultative physician’s opinion, but the ALJ did not explain why he discounted
Dr. Thomas’s finding that Mr. Adams would need frequent breaks during a
workday. In addition, the ALJ did not explain or account for the impact that those
breaks would have on the jobs available to Mr. Adams. Given the VE’s testimony
15

that frequent breaks would not be tolerated in the jobs that were responsive to the
ALJ’s hypothetical, the Court needs more information before it may complete its
review of the ALJ’s decision that Mr. Adams has the RFC to perform light work.
The Court remands this case to the ALJ so that he may either address his
rationale for disregarding Dr. Thomas’s finding that Mr. Adams needs frequent
breaks during a work day or reconcile his RFC findings with the VE testimony that
frequent breaks would not be tolerated in the jobs available to Mr. Adams.
IV.

CONCLUSION
For the reasons outlined above, the Court REMANDS the decision of the

Commissioner for further administrative proceedings consistent with the Court’s
memorandum opinion.
DONE and ORDERED this January 13, 2015.

_________________________________
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE

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