Thomas v. Social Security Administration, Commissioner
MEMORANDUM OF OPINION. Signed by Judge L Scott Coogler on 8/4/2015. (PSM)
2015 Aug-04 AM 09:00
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CAROLYN W. COLVIN,
Commissioner of Social Security,
Case No. 2:14-CV-00897-LSC
MEMORANDUM OF OPINION
The plaintiff, Stevie Thomas, appeals from the decision of the
Commissioner of the Social Security Administration (“Commissioner”) denying
his application for a period of disability, Disability Insurance Benefits (“DIB”), and
Supplemental Security Income (“SSI”). Mr. Thomas timely pursued and
exhausted his administrative remedies and the decision of the Commissioner is ripe
for review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).
Mr. Thomas was forty-four years old at the time of the Administrative Law
Judge’s (“ALJ’s”) decision, and he has a high school education. (Tr. at 52, 129.)
His past work experiences include employment as a clamp truck driver and a
double back operator. (Id. at 47.) Mr. Thomas claims that he became disabled on
July 16, 2010 due to diabetes mellitus, cervical degenerative disc disease, hydrocele,
status post rotator cuff repair of the left shoulder, and chronic pain. (Id. at 128.)
The Social Security Administration has established a five-step sequential
evaluation process for determining whether an individual is disabled and thus
eligible for DIB or SSI. See 20 C.F.R. §§ 404.1520, 416.920; see also Doughty v.
Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). The evaluator will follow the steps in
order until making a finding of either disabled or not disabled; if no finding is made,
the analysis will proceed to the next step. See 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). The first step requires the evaluator to determine whether the
plaintiff is engaged in substantial gainful activity (“SGA”).
See id. §§
404.1520(a)(4)(i), 416.920(a)(4)(i). If the plaintiff is not engaged in SGA, the
evaluator moves on to the next step.
The second step requires the evaluator to consider the combined severity of
the plaintiff’s medically determinable physical and mental impairments. See id. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). An individual impairment or combination of
impairments that is not classified as “severe” and does not satisfy the durational
requirements set forth in 20 C.F.R. §§ 404.1509 and 416.909 will result in a finding
of not disabled. See 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). The
decision depends on the medical evidence contained in the record. See Hart v.
Finch, 440 F.2d 1340, 1341 (5th Cir. 1971) (concluding that “substantial medical
evidence in the record” adequately supported the finding that plaintiff was not
Similarly, the third step requires the evaluator to consider whether the
plaintiff’s impairment or combination of impairments meets or is medically equal
to the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix
1. See 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the criteria of a listed
impairment and the durational requirements set forth in 20 C.F.R. §§ 404.1509
and 416.909 are satisfied, the evaluator will make a finding of disabled. 20 C.F.R.
§§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).
If the plaintiff’s impairment or combination of impairments does not meet or
medically equal a listed impairment, the evaluator must determine the plaintiff’s
residual functional capacity (“RFC”) before proceeding to the fourth step. See id.
§§ 404.1520(e), 416.920(e). The fourth step requires the evaluator to determine
whether the plaintiff has the RFC to perform the requirements of his past relevant
See id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv).
If the plaintiff’s
impairment or combination of impairments does not prevent him from performing
his past relevant work, the evaluator will make a finding of not disabled. See id.
The fifth and final step requires the evaluator to consider the plaintiff’s
RFC, age, education, and work experience in order to determine whether the
plaintiff can make an adjustment to other work. See id. §§ 404.1520(a)(4)(v),
416.920(a)(4)(v). If the plaintiff can perform other work, the evaluator will find
him not disabled. Id.; see also 20 C.F.R. §§ 404.1520(g), 416.920(g). If the plaintiff
cannot perform other work, the evaluator will find him disabled. 20 C.F.R. §§
404.1520(a)(4)(v), 404.1520(g), 416.920(a)(4)(v), 416.920(g).
Applying the sequential evaluation process, the ALJ found that Mr. Thomas
meets the nondisability requirements for a period of disability and DIB and was
insured through the date of her decision. (Tr. at 22.) She further determined that
Mr. Thomas has not engaged in SGA since the alleged onset of his disability. (Id.)
According to the ALJ, Plaintiff’s diabetes mellitus, mild cervical degenerative disc
disease, and status post rotator cuff repair of the left shoulder are considered
“severe” based on the requirements set forth in the regulations. (Id.) However, she
found that these impairments neither meet nor medically equal any of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 23.) The ALJ
did not find Mr. Thomas’s allegations to be totally credible, and she determined
that he has the following RFC: to lift and carry up to 20 pounds occasionally and
10 pounds frequently; to sit for six hours in an eight hour day and walk six hours in
an eight hour day; he should never climb ladders, ropes, or scaffolds and should
avoid all exposure to workplace hazards; he can frequently climb ramps and stairs
and can frequently balance, stoop, crouch, kneel, and crawl; he can occasionally
push and pull with the left upper extremity and can occasionally reach in all
directions with the left upper extremity; he should avoid concentrated exposure to
temperature extremes, wetness, and humidity; and he can maintain attention and
concentration for two-hour periods at a time. (Id. at 26-27.)
According to the ALJ, Mr. Thomas is unable to perform any of his past
relevant work, he is a “younger individual age 18-49,” and he has at least a high
school education, as those terms are defined by the regulations. (Id.) She
determined that the transferability of skills is not an issue in this case. (Id.) Because
Plaintiff cannot perform the full range of light work, the ALJ used MedicalVocation Rule 201.25 as a guideline and sought the testimony of a Vocational
Expert (“VE”) to find that there are a significant number of jobs in the national
economy that he is capable of performing, such as gate guard, security system
monitor, and appointment clerk. (Id.) The ALJ concluded her findings by stating
that Plaintiff “was not under a ‘disability,’ as defined in the Social Security Act, at
any time through the date of this decision.” (Id.)
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 Stone
v. Comm’r of Soc. Sec., 544 F. App’x 839, 841 (11th Cir. 2013) (citing Crawford v.
Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004)). This Court gives
deference to the factual findings of the Commissioner, provided those findings are
supported by substantial evidence, but applies close scrutiny to the legal
conclusions. See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996).
Nonetheless, this Court may not decide facts, weigh evidence, or substitute
its judgment for that of the Commissioner. Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005) (quoting Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir.
“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
proof preponderates against the Commissioner’s decision, it must affirm if the
decision is supported by substantial evidence. Miles, 84 F.3d at 1400 (citing Martin
v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).
However, no decision is automatic, for “despite th[e] deferential standard
[for review of claims], it is imperative that th[is] 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) (citing Arnold v. Heckler, 732 F.2d 881,
883 (11th Cir. 1984)). Moreover, failure to apply the correct legal standards is
grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
Mr. Thomas alleges that the ALJ’s decision should be reversed and
remanded for two reasons. First, Plaintiff argues that the ALJ should have at least
granted him a closed period of disability from his onset date of July 16, 2010, until
July 19, 2011, the date that his treating physician released him to work with no
limitations. Second, he believes that the ALJ’s RFC findings are not based on
substantial evidence, primarily because of the ALJ’s alleged failure to obtain a
medical source opinion from a consultative examiner.
Twelve Month Disability Period
The Social Security Act defines disability as the “inability to engage in any
substantial gainful activity by reason of any medically determinable physical or
mental impairment 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); see also 42 U.S.C. §
1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). Both the impairment or
impairments and the inability to work must last for at least twelve consecutive
months. See 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a),
404.1509, 416.905(a), 416.909; Social Security Ruling (“SSR”) 82-52; Barnhart v.
Walton, 535 U.S. 212, 217-20 (2002). In addition, a claimant cannot meet the
twelve-month duration requirement by combining two or more unrelated severe
impairments. See 20 C.F.R. §§ 404.1522, 416.922; SSR 82-52. Thus,
the duration requirement to establish disability will not be met and a
disability claim will be denied based on evidence that, within 12
months of the onset of an impairment which prevented substantial
gainful activity and before [the Commissioner has] issued any notice
of determination or decision finding disability, the impairment no
longer prevents substantial gainful activity.
Determining Disability and Blindness; Substantial Gainful Activity Guides, 65 Fed.
Reg. 42,772, 42,774 (Jul. 11, 2000), quoted in Walton, 535 U.S. at 217.
Here, Plaintiff asserts that the ALJ should at least have found a closed period
of disability from his alleged onset date of July 16, 2010, until the date Dr. Buggay,
his treating physician, released him to work with “no limitations” on July 19, 2011.
According to Plaintiff, this date range satisfies the durational requirement for
disability. However, as explained herein, the record establishes that Mr. Thomas’s
limitations did not prevent him from engaging in SGA for a consistent twelve
month period. This is because both Dr. Buggay and Plaintiff’s examining physical
therapist opined that Plaintiff was capable of returning to at least medium work
before July 2011, and their treatment records do not indicate he was unable to
engage in SGA for any continuous twelve month period.
Plaintiff underwent arthroscopic surgery to his left shoulder in order to
repair his rotator cuff on July 30, 2010. (Tr. at 257). Due to continuing problems
with his shoulder, Plaintiff underwent a second procedure on January 26, 2011. (Tr.
at 248). Only six months passed between these two procedures, so even assuming
arguendo that Plaintiff was unable to perform SGA between the first procedure and
the second, he did not meet the requirement that the condition last for twelve
continuous months. See 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A); 20
C.F.R. §§ 404.1505(a), 416.905(a). After his second procedure, Dr. Buggay noted
in February 2011 that Plaintiff was “doing well,” and while his shoulder remained
tight in external rotation, he was “not having much pain.” (Tr. at 284). In March,
Dr. Buggay limited Plaintiff to not lifting any weight greater than five pounds and
restricted him from driving due to “some activity and exercise related pain.” (Tr.
at 283). In May 2011, Plaintiff reported “just some soreness.” (Tr. at 281). Dr.
Buggay found Plaintiff had “markedly improved,” and allowed him to begin
driving again. (Id.) Importantly, on June 9, 2011, Dr. Buggay released Plaintiff to
perform medium work with a limitation to occasional overhead reaching. (Tr. at
280). Dr. Buggay opined that he “really [did] not think [Plaintiff’s condition] is
going to need any kind of ongoing treatment.” (Tr. at 280). He showed Plaintiff
how to do some “gentle stretches” and advised him that he could take over-thecounter anti-inflammatory medication. (Tr. at 280).
Like Dr. Buggay, Plaintiff’s physical therapist also noted Plaintiff’s
improving condition and his ability to work in some capacity before July 19, 2011. In
late February 2011, about a month after the procedure, the physical therapist
advised Plaintiff to slowly wean himself off the sling. (Tr. at 318). In March 2011
Plaintiff reported his pain was a one out of ten, and “only hurts in weather.” (Tr. at
315). At his last appointment in April, he reported his pain was a zero out of ten.
(Tr. at 311). On May 27, 2011, Plaintiff participated in a physical therapy
examination that lasted more than two hours. (Tr. at 270-76). The examination,
which involved extensive physical testing, concluded that Plaintiff was capable of
heavy work as defined by the Dictionary of Occupational Titles. (Tr. at 270).
Plaintiff has not challenged these doctors’ findings. These opinions were
given before July 16, 2011, which would be twelve months after the alleged onset
date of July 16, 2011. Plaintiff argues that he remained disabled until at least July 19,
2011, when Dr. Buggay released him to work with “no limitations.” (Tr. at 299).
However, the Social Security Act defines disability as “inability to engage in any
substantial gainful activity,” meaning that a person capable of medium work, even
with some postural limitations, is not unable to engage in any SGA. See 42 U.S.C. §
423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a).
Because there was substantial evidence in the record to find that Plaintiff did not
have a limited period of disability for at least twelve months, this Court finds that
Plaintiff’s first argument lacks merit.
The ALJ’s RFC Finding
Plaintiff also contends that the RFC assessment is erroneous for several
reasons. First, he contends that the ALJ erred in failing to obtain a medical source
opinion from a consultative examiner. A medical source opinion may be obtained
“to try to resolve an inconsistency in the evidence, or when the evidence as a whole
is insufficient to allow [the Commission] to make a determination or decision on [a]
claim.” 20 C.F.R. § 404.1519a(b). However, an ALJ is not required to obtain an
additional medical source opinion if the record already contains sufficient evidence
for the ALJ to make an informed decision. See Doughty v. Apfel, 245 F.3d 1274,
1281 (11th Cir. 1999). Furthermore, the Plaintiff must show prejudice in the ALJ’s
decision before the case may be remanded for further record development. See
Graham v. Apfel, 129 F.3d 1420, 1422-23 (11th Cir. 1997).
In this case, there was already sufficient evidence for the ALJ to make an
informed decision as to whether Plaintiff could work without needing to order a
consultative examination. The ALJ based her decision on several medical opinions
already in the record. First, she gave substantial weight to treating physician Dr.
Buggay’s opinions and treatment notes. (Tr. at 27.) As discussed in the preceding
section, Dr. Buggay approved Plaintiff for medium work in the months following
Plaintiff’s second shoulder operation. (Id. at 283, 270.) Dr. Buggay also noted
improvement on February 22, 2011, less than a month after the second surgery.
(Id. at 284.) Indeed, the average pain Plaintiff reported decreased steadily through
February and March 2011, until in April 2011 he stated he experienced no pain.
(Tr. at 311, 315, 316, 317, 322). Second, the ALJ considered the examining physical
therapist’s opinion on May 27, 2011, written after a two-hour examination of the
plaintiff, which opined that he was capable of heavy work. (Id. at 270.) The twohour examination involved observing Plaintiff perform numerous physical tasks.
(Tr. at 269-276). He saw Plaintiff sit for sixty minutes and sit/stand for over two
hours. (Tr. at 275, 276). He also saw Plaintiff lift and carry up to fifty-five pounds,
and watched him climb fifty-two stairs up and down in under two minutes with no
increase in pain. (Tr. at 274, 275). Finally, the ALJ gave great weight to the State
Agency medical consultant’s opinion that Plaintiff could perform light work as of
January 2012, stating that it was supported by the evidence on record and fully took
into account Plaintiff’s complaints of pain. (Tr. at 27.) State agency consultants
are highly-qualified specialists who are also experts in the Social Security disability
programs, and their opinions may be entitled to great weight if the evidence
supports their opinions. See 20 C.F.R. §§ 404.1527(e)(2)(i); 416.927(e)(2)(i), SSR
Mr. Thomas claims that the ALJ should have ordered the consultative
examination because the RFC assessment did not take into account his medical
records from the following year, 2012, after the treating physician, physical
therapist, and state agency consultant had already issued their opinions in 2011.
The specific information from 2012 that Plaintiff refers to is limited to one hospital
visit where Plaintiff complained of shoulder pain and groin pain, four occupational
therapy sessions, and an ultrasound of Plaintiff’s groin. (Tr. at 360-62, 367-69,
370-73.) Regarding Plaintiff’s shoulder pain, during the hospital visit in February
2012, the doctor made the observation that Plaintiff’s back was normal, although
his shoulders had a limited range of motion, and recommended that he seek
physical therapy. (Tr. at 372.) The treatment record also notes that Plaintiff has an
inguinal hernia for which he had previously sought treatment but had not followed
up on the recommended surgery. (Tr. at 370). These mild findings are consistent
with Dr. Buggay’s opinion in June 2011 that Plaintiff had some limitation in his
upper extremity range of motion, and degenerative disc disease in his cervical
spine. (Tr. at 280, 371). The hospital visit does not demonstrate that Plaintiff’s
condition worsened in 2012. Then, in April and May 2012, Plaintiff received four
physical-therapy treatment sessions. (Tr. at 360-62). At the final session on May
30, 2012, the therapist noted that Plaintiff was “within functional limits for
strength” and range of motion and that no further physical therapy was indicated,
although Plaintiff should continue to practice his exercises at home. (Tr. at 360).
This finding is also consistent with Dr. Buggay’s June 2011 opinion that Plaintiff’s
back and shoulder conditions could be treated with over-the-counter medication
and “gentle stretches.” (Tr. at 280). Finally, in March 2012, an ultrasound found
small calcifications in Plaintiff’s scrotum but did not indicate that they would cause
the pain that Plaintiff reported. (Tr. at 367-69). These treatment notes do not
assess any limitations with regard to Plaintiff’s groin pain. Indeed, as the ALJ
discussed, treatment records from April 2012 indicated as follows: “urology stated
that they found no clear reason for pt’s [groin] tenderness and that he had a [sic]
normal physical findings” (Tr. at 23, 364). The only evidence of Plaintiff’s groin
pain was his own testimony, and the ALJ found him less than fully credible, a
finding that Plaintiff does not challenge on appeal. See Hamilton v. Southland
Christian School, Inc., 680 F.3d 1316, 1318-19 (11th Cir. 2012) (holding that issues
that are not clearly designated in the appellant’s brief are normally deemed
abandoned). Although Plaintiff now argues that his groin pain “would affect
push/pulling at least with the lower extremities,” (doc. 8 at 10), his opinion as to
the limitations that could possibly arise from groin pain does not constitute
sufficient evidence to call the medical record or the ALJ’s findings into question.
As such, the ALJ’s conclusion that the groin pain was not a severe impairment is
not due to be disturbed on appeal.
In sum, since the treating physician’s notes, physical therapist’s notes, and
the medical examiner’s assessment in the RFC provide sufficient evidence for the
ALJ’s determination that Plaintiff was not disabled, and the records from 2012 do
not show any worsening conditions not addressed by those physicians, there was no
need for the ALJ to obtain a medical source opinion from a consultative examiner.
See Doughty, 245 F.3d at 1281.
Plaintiff also argues that, pursuant to Ingram v. Commissioner of Social
Security, 496 F.3d 1253 (11th Cir. 2007), the additional medical record he submitted
to the Appeals Council renders the ALJ’s decision as to his RFC erroneous.
Generally, a claimant may present new evidence at each stage of the administrative
process. Ingram, 496 F.3d at 1261 (citing 20 C.F.R. § 404.900(b)). The Appeals
Council has discretion not to review the ALJ’s denial of benefits. See C.F.R. §§
404.970(b), 416.1470(b). However, the Appeals Council “must consider new,
material, and chronologically relevant evidence and must review the case if the
administrative law judge’s action, findings, or conclusion is contrary to the weight
of the evidence currently of record.” Ingram, 496 F.3d at 1261; see also 20 C.F.R. §
404.970 (“The Appeals Council shall evaluate the entire record including the new
and material evidence submitted if it relates to the period on or before the date of
the administrative law judge hearing decision.”). When reviewing the Appeals
Council’s denial of review, the Court must “look at the pertinent evidence to
determine if the evidence is new and material, the kind of evidence the [Appeals
Council] must consider in making its decision whether to review an ALJ’s
decision.” Falge v. Apfel, 150 F.3d 1320, 1324 (11th Cir. 1998).
In this case, the Appeals Council stated that it considered both the reasons
Plaintiff disagreed with the ALJ’s decision and the additional evidence submitted,
but found that none of this information provided a basis for changing the ALJ’s
decision. (Tr. at 2.) The Appeals Council did not err in refusing to remand to the
ALJ based on the new evidence Plaintiff submitted. (Tr. at 379-87). The new
evidence is a treatment note from July 2012 that reiterates Plaintiff’s subjective
complaints of groin pain, provides a tentative diagnosis that the pain is
“neuropathic in origin,” and notes Plaintiff has been experiencing burning upon
urination. (Tr. at 381-84). The treatment note is cumulative of the note regarding
groin pain that the ALJ had before her, and like the other note, it does not assess
any particular limitations with regard to this groin pain. The diagnosis of a
neuropathic origin appears to be the new information on which Plaintiff relies, but
the diagnosis in itself does not show that Plaintiff’s groin pain had become more
limiting than it was at the time the ALJ determined it was not a severe impairment.
See Wind v. Barnhart, 133 F. App’x 684, 690 (11th Cir. 2005) (“a diagnosis or a
mere showing of ‘a deviation from purely medical standards of bodily perfection or
normality’ is insufficient; instead, the claimant must show the effect of the
impairment on [his] ability to work” (quoting McCruter v. Bowen, 791 F.2d 1544,
1547 (11th Cir. 1986)). As a result, the Appeals Council did not err in denying
remand to Plaintiff, even in light of the new evidence that he submitted.
Upon review of the administrative record, and considering all of Mr.
Thomas’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 and ORDERED on August 4, 2015.
L. Scott Coogler
United States District Judge
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