Coleman v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Virginia Emerson Hopkins on 11/12/2015. (JLC)
2015 Nov-12 AM 11:43
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
VERONICA G. COLEMAN,
CAROLYN W. COLVIN, ACTING
) Case No.: 2:14-CV-1897-VEH
Plaintiff Veronica G. Coleman (“Ms. Coleman”) brings this action under 42
U.S.C. § 405(g), Section 205(g) of the Social Security Act. She seeks review of a
final adverse decision of the Commissioner of the Social Security Administration
(“Commissioner”), who denied her application for Disability Insurance Benefits
(“DIB”). Ms. Coleman timely pursued and exhausted her administrative remedies
available before the Commissioner. The case is thus ripe for review under 42 U.S.C.
FACTUAL AND PROCEDURAL HISTORY
Ms. Coleman was 50 years old at the time of her hearing before the
Administrative Law Judge (“ALJ”). (Tr. 45). She has completed the twelfth grade.
(Tr. 45). Her past work experience includes employment as a nurse assistant. (Tr. 70).
She claims she became disabled on April 16, 2010 due to status post rotator cuff
repair of the left shoulder, rotator cuff tear of the right shoulder, degenerative disc
disease of the cervical spine, type II diabetes mellitus, and arterial hypertension. (Tr.
23). Her last period of work ended on April 15, 2010. (Tr. 195).
On July 10, 2011, Ms. Coleman protectively filed a Title II application for a
period of disability and DIB. (Tr. 20). On September 13, 2011, the Commissioner
initially denied these claims. Id. Ms. Coleman timely filed a written request for a
hearing on September 21, 2011. Id. The ALJ conducted a hearing on the matter on
January 23, 2013. Id. On April 24, 2013, he issued his opinion concluding Ms.
Coleman was not disabled and denying her benefits. (Tr. 17). She timely petitioned
the Appeals Council to review the decision on May 14, 2013. (Tr. 14-16). On August
5, 2014, the Appeals Council issued a denial of review on her claim. (Tr. 1-5).
Ms. Coleman filed a Complaint with this court on October 6, 2014, seeking
review of the Commissioner’s determination. (Doc. 1). The Commissioner answered
on January 14, 2015. (Doc. 8). Ms. Coleman filed a supporting brief (Doc. 10) on
February 27, 2015, and the Commissioner responded with her own (Doc. 11) on
March 12, 2015. With the parties having fully briefed the matter, the court has
carefully considered the record and affirms the decision of the Commissioner.
STANDARD OF REVIEW
The court’s review of the Commissioner’s decision is narrowly circumscribed.
The function of this court is to determine whether the decision of the Commissioner
is supported by substantial evidence and whether proper legal standards were applied.
Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219,
1221 (11th Cir. 2002). This court must “scrutinize the record as a whole to determine
if the decision reached is reasonable and supported by substantial evidence.”
Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). Substantial evidence
is “such relevant evidence as a reasonable person would accept as adequate to support
a conclusion.” Id. It is “more than a scintilla, but less than a preponderance.” Id.
This court must uphold factual findings that are supported by substantial
evidence. However, it reviews the ALJ’s legal conclusions de novo because no
presumption of validity attaches to the ALJ’s determination of the proper legal
standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). If the
court finds an error in the ALJ’s application of the law, or if the ALJ fails to provide
the court with sufficient reasoning for determining that the proper legal analysis has
been conducted, it must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d
1143, 1145-46 (11th Cir. 1991).
STATUTORY AND REGULATORY FRAMEWORK
To qualify for disability benefits and establish his or her entitlement for a
period of disability, a claimant must be disabled as defined by the Social Security Act
and the Regulations promulgated thereunder.1 The Regulations define “disabled” as
“the inability to do 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
twelve (12) months.” 20 C.F.R. § 404.1505(a). To establish an entitlement to
disability benefits, a claimant must provide evidence about a “physical or mental
impairment” that “must result from anatomical, physiological, or psychological
abnormalities which can be shown by medically acceptable clinical and laboratory
diagnostic techniques.” 20 C.F.R. § 404.1508.
The Regulations provide a five-step process for determining whether a claimant
is disabled. 20 C.F.R. § 404.1520(a)(4)(i-v). The Commissioner must determine in
whether the claimant is currently employed;
whether the claimant has a severe impairment;
The “Regulations” promulgated under the Social Security Act are listed in 20 C.F.R. Parts
400 to 499, revised as of June 26, 2014.
whether the claimant’s impairment meets or equals an impairment listed
by the [Commissioner];
whether the claimant can perform his or her past work; and
whether the claimant is capable of performing any work in the national
Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to formerly applicable
C.F.R. section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 56263 (7th Cir. 1999); accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).
The sequential analysis goes as follows:
Once the claimant has satisfied steps One and Two, she will
automatically be found disabled if she suffers from a listed impairment.
If the claimant does not have a listed impairment but cannot perform her
work, the burden shifts to the [Commissioner] to show that the claimant
can perform some other job.
Pope, 998 F.2d at 477; accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995).
The Commissioner must further show that such work exists in the national economy
in significant numbers. Id.
FINDINGS OF THE ADMINISTRATIVE LAW JUDGE
After consideration of the entire record, the ALJ made the following findings:
Ms. Coleman met the insured status requirements of the Social Security
Act through December 31, 2015.
She had not engaged in substantial gainful activity since April 16, 2010,
the alleged disability onset date.
She had the following severe impairments: status post rotator cuff repair
of the left shoulder, rotator cuff tear of the right shoulder, degenerative
disc disease of the cervical spine, type II diabetes mellitus, and arterial
She did not have an impairment or combination of impairments that met
or medically equaled one of the listed impairments in 20 C.F.R. Part
404, Subpart P, Appendix 1.
She had the residual functioning capacity (“RFC”) to perform light work
which allows her to occasionally perform pushing and pulling
movements with arm and/or leg controls. She could occasionally climb,
balance, bend and stoop. She could frequently perform gross and fine
manipulation. She should never reach with the left upper extremity. She
could operate motor vehicles and work around dust, allergens, and
She was unable to perform any past relevant work.
She was 50 years old, which is defined as closely approaching advanced
She has at least a high school education and was able to communicate
Transferability of job skills was not material to the determination of
disability because using the Medical-Vocational Rules as a framework
supported a finding that she was “not disabled,” whether or not she had
transferable job skills.
Considering her age, education, work experience, and residual
functioning capacity, there were jobs that existed in significant numbers
in the national economy that she could perform.
Ms. Coleman had not been under a disability, as defined in the Social
Security Act, from April 16, 2010, through the date of this decision.
The court may only reverse a finding of the Commissioner if it is not supported
by substantial evidence. 42 U.S.C. § 405(g). “This does not relieve the court of its
responsibility to scrutinize the record in its entirety to ascertain whether substantial
evidence supports each essential administrative finding.” Walden v. Schweiker, 672
F.2d 835, 838 (11th Cir. 1982) (citing Strickland v. Harris, 615 F.2d 1103, 1106 (5th
Cir. 1980)).2 However, the court “abstains from reweighing the evidence or
substituting its own judgment for that of the [Commissioner].” Id. (citation omitted).
Ms. Coleman objects to the ALJ’s conclusion that she retains the residual
functional capacity (“RFC”) to perform work-related activities at the light level of
exertion. She urges this court to reverse the Commissioner’s decision to deny her
benefits on the grounds that the ALJ’s decision is not supported by substantial
evidence because he did not properly evaluate the medical source opinions of Dr.
Jeffrey Davis and Dr. Richard Rex Harris. (Doc. 10 at 8, 10). In the alternative, she
requests that “her case be remanded for a full and proper consideration of the medical
Strickland is binding precedent in this Circuit. See Bonner v. City of Prichard, 661 F.2d
1206, 1209 (11th Cir. 1981) (en banc) (adopting as binding precedent all decisions of the former
Fifth Circuit handed down prior to October 1, 1981).
evidence of record, including the opinions of [her] treating physician, Dr. Davis, and
the consultative physician, Dr. Harris.” (Doc. 10 at 15).
Ms. Coleman argues that the evidence of record supports a more limited RFC
based upon the severity of her pain and other subjective limitations, and that she
would have been found disabled had the ALJ evaluated the examining physicians’
opinions correctly. Id. at 9, 11. She also asserts that the ALJ had a duty to recontact
the examining physicians. (Doc. 10 at 15). In its review, this court finds that the ALJ
applied the correct legal standard and afforded the appropriate weight to the medical
source opinions of Ms. Coleman’s examining physicians. Substantial evidence
supports the ALJ’s conclusion that Ms. Coleman has a RFC to perform light work
activity, and that she is not disabled given this RFC finding.
THE ALJ APPROPRIATELY EVALUATED AND ASSIGNED
WEIGHT TO DR. DAVIS’S OPINION, AND HIS DISABILITY
DECISION IS SUPPORTED BY SUBSTANTIAL EVIDENCE.
Ms. Coleman contends that the ALJ’s decision is not based on substantial
evidence because he failed to accord adequate weight to the opinion of treating
physician, Dr. Jeffrey Davis. (Doc. 10 at 10). Ms. Coleman’s argument triggers the
treating physician’s rule, requiring the opinions of Dr. Davis to “be given substantial
or considerable weight unless ‘good cause’ is shown to the contrary.” Phillips v.
Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2003). Against this backdrop, the court sees
no reversible error committed by the ALJ and finds the ALJ’s RFC finding is
consistent with the work-related limitations that Dr. Davis imposed taken as a whole.
Dr. Davis treated Ms. Coleman for a period between October 2010 and
December 2011, during which he would assess Ms. Coleman’s complaints, conduct
physical examinations, and make recommendations about her functional capacity
based upon his observations and objective medical evidence. On January 25, 2011,
Dr. Davis placed Ms. Coleman at maximum medical improvement (“MMI”) with a
permanent partial impairment of “12% of the upper extremity, [and] 7% of the whole
person.” (Tr. 282). He then released Ms. Coleman to work “as per functional capacity
evaluation done,” referring to the limitations of her December 2010 functional
capacity evaluation (“FCE”).3 Id. On October 10, 2011, Dr. Davis performed a
physical capacity evaluation (“PCE”) of Ms. Coleman and a clinical assessment of
her pain (“CAP”).4 In December of 2011, Dr. Davis recommended “no change in date
In December 2010, Ms. Coleman demonstrated she could perform activities at the “medium
work classification level.” (Tr. 294). Her FCE placed the following work restrictions on her:
constantly grip/grasp and reach at the waist level; frequently stand, walk, lift 8 lbs. from floor to
waist, lift 13 lbs. from waist to overhead, and carry 15 lbs.; and occasionally reach overhead, stoop
and reach low, climb a ladder, crawl, push with 45 lbs. of force, pull with 35 lbs. of force, lift from
floor to waist 15 lbs. unilaterally to the left and 20 lbs. unilaterally to the right, lift 20 lbs. from waist
to overhead, lift from waist to head 10 lbs. unilaterally to the left and 15 lbs. unilaterally to the right,
and carry 35 lbs. (Tr. at 297). The FCE noted that her performance of these tasks were “[l]imited by
complaints of right hip pain.” Id.
In the PCE, Dr. Davis found that Ms. Coleman could lift or carry 20 lbs. occasionally and
10 lbs. frequently, and that in an eight hour workday she could sit for eight hours and stand or walk
for five hours. (Tr. 348). Dr. Davis noted Ms. Coleman did not need a device to ambulate. Id. Dr.
Davis opined Ms. Coleman must never reach with her left upper extremity, but she could
of [her] maximum medical improvement or permanent partial impairment,” and he
recommended “no change in her permanent restrictions as per [her] FCE.” (Tr. 377).
Almost a year passed before Ms. Coleman returned to Dr. Davis’s office on
November 27, 2012. (Tr. 455-57). During that visit, he noted she experienced “left
shoulder pain” and “cervical pain referred to [her] left shoulder.” (Tr.455). He
recommended “no change in date of [Ms. Coleman’s] maximum medical
improvement and permanent partial impairment.” Id. Dr. Davis also recommended
“no change in her work restrictions for her functional capacity evaluation,” which was
last assessed in October 2012 and reflected the ability to perform work at the light
activity level.5 Id.
The ALJ assigned “great weight” to Dr. Davis’s opinion concerning Ms.
Coleman’s physical capacity, “given the nature and extent of his treating
occasionally pull or push using arm and leg controls, climb and balance, bend and stoop, and
frequently perform gross and fine manipulation with her hands. Id. In his assessment of Ms.
Coleman’s pain, Dr. Davis noted that “[p]ain is present to such an extent as to be distracting to
adequate performance of daily activities or work,” and that physical activities “[g]realty increased
pain, and to such a degree as to cause distraction from tasks or total abandonment of tasks.”(Tr. 349).
However, he noted that her pain medication had only some side effects, “but not to such a degree as
to create serious problems in most instances.” (Tr. 350).
Her latest FCE was conducted in October 2012, and reported her “current work capacity”
as “light based on FCE Performance.” (Tr. 481). The FCE placed the following work restrictions on
Ms. Coleman: occasionally lift 20 lbs. from floor to waist, lift 15 lbs. from waist to overhead, carry
25 lbs., push with 25 lbs. of force, pull with 35 lbs. of force, and reach overhead. (Tr. 482). Her
unrestricted activities were reaching horizontal at desk level, reaching low below the waist, standing,
walking, stair climbing, sitting, kneeling, crouching, and stooping. Id. She was reported as having
“no apparent impairments in hand dexterity and hand coordination.” Id.
relationship.” (Tr. 32). The ALJ reasoned that Dr. Davis’s “opinions are well
supported by, and not inconsistent with, the evidence of record as a whole.” Id.
However, the ALJ had “not given any weight” to Dr. Davis’s assessment of Ms.
Coleman’s pain because he determined Dr. Davis’s “opinions are based on a very
intermittent treatment history, not a longitudinal history of ongoing pain problems
sufficient to establish a disabling medical condition.” Id. Ms. Coleman argues that the
ALJ did not adequately weigh Dr. Davis’s medical opinions because his treatment of
Dr. Davis’s assessment of her physical capacity was inconsistent with his treatment
of Dr. Davis’s assessment of her pain.6 (Doc. 10 at 9). Ms. Coleman argues that, “if
given proper weight, the ALJ should have found [her] disabled based upon the
severity of pain indicated by Dr. Davis.” Id.
The court finds that any alleged error in the ALJ’s assignment of weight to Dr.
Davis’s individual assessments constitutes harmless error, because it is evident from
the ALJ’s decision that he adopted Dr. Davis’s opinion of Ms. Coleman’s functional
capacity in determining her RFC.7 Further, Dr. Davis did not somehow limit the scope
Ms. Coleman notes, “in reference to one single exhibit, the ALJ concludes that it is to be
given great weight due to Dr. Davis’[s] long treatment relationship with Plaintiff, but then
determines in the same paragraph that the opinion is not to be given any weight due to the
relationship not being long enough.” (Doc. 10 at 9). She argues that “[t]his inconsistency in the
ALJ’s decision would demand remand so that the ALJ can properly clarify this statement.” Id.
In a non-binding opinion, the Eleventh Circuit found that the ALJ’s failure to discuss the
weight given to a physician’s findings was harmless error because the physician’s findings did not
contradict the ALJ’s opinions. Caldwell v. Barnhart, 261 F. App’x 188, 191 (11th Cir. 2008)
of his light duty opinions by indicating that he did consider Ms. Coleman’s subjective
pain when returning her to light work duty.
The ALJ’s lack of clarity in his allocation of weight to Dr. Davis’s opinions is
cured by his analysis in determining the extent of Ms. Coleman’s limitations, which
was appropriately consistent with Dr. Davis’s opinions. Dr. Davis recommended that
Ms. Coleman return to work according to the limitations of her FCE, restricting her
to light work activity.8 Likewise, the ALJ determined that Ms. Coleman could
perform light work activity with the restrictions he enumerated in his findings.9 (Tr.
29). In coming to the same conclusions as Dr. Davis, the ALJ acknowledged the same
medical evidence Dr. Davis considered in making his recommendations. The ALJ
(“Moreover, Dr. Warren’s opinions do not otherwise contradict the ALJ’s findings. Accordingly, the
ALJ’s failure to state what weight she gave to the opinions was harmless error.”). Cf. East v.
Barnhart, 197 F. App’x 899, 901 n.3 (11th Cir. 2006) (“East also argues that the ALJ erred in failing
to consider the consulting psychologist’s report by Dr. Priscilla Wilson, Ph.D. However, any error
in failing to address this report explicitly in the ALJ’s determination was harmless given that Dr.
Wilson’s observations in the report were consistent with the ALJ’s determination.”).
On November 27, 2012, Dr. Davis recommended “no change in [Ms. Coleman’s] work
restrictions for her functional capacity evaluation.” (Tr. 456). Ms. Coleman’s most recent FCE was
performed in October 2012, which reported her “current work capacity” as “light based on FCE
Performances.” (Tr. at 481).
The ALJ found Ms. Coleman could occasionally push/pull with arm/leg controls;
occasionally climb, balance, bend, and stoop; frequently perform gross and fine manipulation; and
never reach with left upper extremity. The ALJ also found that she could operate motor vehicles and
work around dust, allergens and fumes. (Tr. 29). These findings are consistent with Dr. Davis’s PCE
(Tr. 348), and are consistent with or more restrictive than the FCEs Ms. Coleman participated in and
Dr. Davis refers to in making his recommendations regarding Ms. Coleman’s functional capacity.
(Tr. 287, 294, 481).
noted that the “[f]unctional capacity evaluations performed in the years 201010 and
2012 illustrated [Ms. Coleman] had a capacity to perform light work activity.” (Tr.
at 31). The ALJ also referred to the PCE by Dr. Davis, noting that, “[a] physical
capacity evaluation completed by Dr. Jeffrey Davis in October 2011 reflected [Ms.
Coleman] could perform a restricted range of light work activity.” Id. Furthermore,
the ALJ recognized that “[i]n the years 2011 and 2012, Dr. Davis made no changes
to [Ms. Coleman’s] MMI, impairment ratings or work restrictions.” Id. The ALJ
clearly considered Dr. Davis’s reports in making his RFC determination, and made
findings that are consistent with this evidence and the record taken as a whole.
Additionally, Ms. Coleman’s allegations of pain have been accounted for
through the ALJ’s effective adoption of the opinions of Dr. Davis. Dr. Davis’s reports
note Ms. Coleman’s complaints of pain, which demonstrate his consideration of her
pain when making his recommendations. For example, Dr. Davis reviewed Ms.
Coleman’s December 2010 FCE in January of 2011 and noted in his report that “[t[he
patient had some right hip and lower back pain during the testing.”11 (Tr. 282). In
The ALJ is referring to Ms. Coleman’s earliest FCE performed in August 2010. (Tr. 287291). The FCE reported, “[t]he minimal physical demands Ms. Coleman demonstrates is LIGHT to
low medium,” but limited her “[o]verhead lifting and reaching,” as well as “kneeling, squatting, stair
climbing, ladder climbing, crawling and bending,” to an “occasional basis.” (Tr. 287).
The December FCE demonstrated Ms. Coleman had the ability to perform work at the
medium work activity level. (Tr. 287). Dr. Davis’s recommendation that Ms. Coleman could work
as per that FCE was less restrictive than his ultimate opinion in 2012, which recommended Ms.
determining Ms. Coleman could be released to work as per her FCE, Dr. Davis
acknowledged and accounted for Ms. Coleman’s pain when participating in the
examination. Similarly, in November 2012, Dr. Davis recorded that, “[Ms. Coleman]
states she still has ongoing shoulder pain,” that, “[s]he has a lot of tenderness,” and
that, “[her shoulder] hurts with use,” and yet made no changes to his opinion of Ms.
Coleman’s functional abilities. (Tr. 455).
Furthermore, Dr. Davis’s FCEs factored in when Ms. Coleman limited herself
in performing physical tasks and when she experienced pain performing these tasks.12
Even though the ALJ did not give any weight to the CAP Dr. Davis conducted, it is
clear from the record that Dr. Davis took this pain assessment into account when he
made his own recommendations regarding Ms. Coleman’s functional capacity. This
court finds it significant that Dr. Davis recommended no changes from Ms.
Coleman’s work restrictions that the FCE imposed, to her work restrictions in his
Coleman could work at the light work activity level as per her most recent FCE from October 2012.
(Tr. 481). Nonetheless, Dr. Davis took into account Ms. Coleman’s pain at the relevant time when
issuing this opinion in January of 2011.
The August 2010 FCE report indicated Ms. Coleman “[complains of] left shoulder pain”
when she tried to lift overhead with her right arm, and that she “[complains of] pain at 6/10 left
shoulder” when she performs elevated work. (Tr. at 288). The December 2010 FCE report notes that,
“right hip pain was the biggest limiting factor during this Functional Capacity Evaluation,” (Tr. 294),
and indicates with an asterisk on a “Daily Tolerance Grid” which tasks were “[l]imited by complaints
of right hip pain,” and which were “[l]imited by low back pressure and pain.” (Tr. 297). The October
2012 FCE report noted that, “[p]atient manages pain with rest and avoidance of any heavy lifting,”
and that “[c]lient gave good effort throughout FCE and worked through pain in all activities.” (Tr.
December 2011 report (Tr. 377), and his November 2012 report (Tr. 455-56).
Notably, these evaluations occurred after Dr. Davis conducted the PCE and CAP.
Thus, notwithstanding the confusing language used by the ALJ about Dr.
Davis’s pain assessment, the ALJ properly considered Dr. Davis’s medical
evaluations in determining Ms. Coleman’s RFC, and he applied the appropriate level
of deference to these opinions. Further, in relying upon Dr. Davis’s opinions, Dr.
Davis’s assessment of Ms. Coleman’s pain was considered and credited indirectly in
the ALJ’s determination of her RFC. Any alleged error of the ALJ was harmless.
Accordingly, consistent with the foregoing analysis, the ALJ appropriately evaluated
and relied upon Dr. Davis’s opinions about Ms. Coleman’s functional capacity, and
his disability decision is supported by substantial evidence.
THE ALJ APPROPRIATELY EVALUATED AND ASSIGNED
WEIGHT TO DR. HARRIS’S OPINION, AND THE DECISION IS
SUPPORTED BY SUBSTANTIAL EVIDENCE.
Ms. Coleman also contends that the ALJ’s decision is not based on substantial
evidence because he failed to “properly evaluate and state the weight given to Dr.
Harris’[s] significant opinion.” (Doc. 10 at 12). She argues that, “[t]he ALJ’s failure
to provide proper analysis of how he reached his conclusion as to Dr. Harris’[s]
opinion is cause for a reversal of the decision.” Id.
Upon his examination of Ms. Coleman, Dr. Richard Rex Harris concluded that
she had the ability to perform light to sedentary work activity. (Tr. 81) (“It is my
medical opinion that this claimant is capable of light to sedentary work in the work
place.”). Although Dr. Harris’s opinion partially supports the ALJ’s RFC finding,13
the ALJ discounts the more restrictive end of the range of work activity that Dr.
Harris finds Ms. Coleman can perform.
The Eleventh Circuit has held that the ALJ may properly discount a physician’s
opinion when the evidence supports a conclusion which differs from that physician’s
opinion. Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11th Cir. 1983) (citing
Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir. 1981) (“[T]he Secretary may
reject the opinion of any physician when the evidence supports a contrary
conclusion.”). However, the ALJ must “state with particularity the weight he gave the
different medical opinions and the reasons therefor.” Sharfarz v. Bowen, 825 F.2d
278, 279 (11th Cir. 1987) (citing MacGregor v. Bowen, 976 F.2d 1050, 1053 (11th
In his decision, the ALJ did not afford “controlling weight” to the medical
source opinion of Dr. Harris. (Tr. 33). He determined that Dr. Harris’s opinions
“appear to be inconsistent with his own clinical findings of record and largely based
The ALJ’s finding that Ms. Coleman can perform light work activity is partially supported
by the less restrictive end of the range of work activity Dr. Harris opined Ms. Coleman can perform.
upon [Ms. Coleman’s] subjective allegations, which are not credible.” Id. This court
finds that the ALJ’s assignment of the weight attributed to Dr. Harris’s medical
opinion is adequate, and that his conclusion to not give Dr. Harris’s opinion
controlling weight was supported by substantial evidence.
The record supports the ALJ’s reasoning that Dr. Harris’s medical source
opinion contained inconsistencies with his own clinical evidence. Dr. Harris opined
that Ms. Coleman could only occasionally reach, handle, finger, feel, and push and
pull. (Tr. 34). However, he notes in his report that she has full range of motion of her
neck, shoulders, arms, wrists and fingers, and that she can open and close doors, and
button and unbutton her clothing.14 Dr. Harris indicated that Ms. Coleman could only
walk for an hour out of the day and ten minutes at a time, and stand for only two
hours out of the day and ten minutes at a time. (Tr. 83). However, his findings state
that she has “full range of motion of the hips, knees and ankles,” and that her “[g]ait
is normal.” (Tr. 80). Although Ms. Coleman experiences “diffuse tenderness
throughout the [left] shoulder,” Dr. Harris noted that, “[t]here is very mild atrophy of
the left posterior shoulder girdle and of the shoulder.” Id. Dr. Harris indicated that
Ms. Coleman could “keep up [the] house,” (Tr. 83), which certainly would involve
“There is full range of motion of the neck. There is full range of motion of the right
shoulder, elbow, wrist and fingers…. There is full range of motion of the left shoulder. There is full
range of motion of the left wrist. The claimant can make a fist with both hands…. She can open and
close doors. She can button and unbutton clothes.” (Tr. 80).
slightly demanding physical activity, but concluded that she could only perform light
to sedentary work. Thus, the ALJ’s conclusion that Dr. Harris’s opinion contains
inconsistencies with his clinical findings is supported by substantial evidence, and the
ALJ may properly discount that part of Dr. Harris’s medical source opinion that Ms.
Coleman should be restricted to sedentary work.
Furthermore, Social Security regulations specifically direct the ALJ to consider
the extent to which a medical opinion is consistent with other evidence in the record.
20 C.F.R. § 404.1527(c)(4) (“Generally, the more consistent an opinion is with the
record as a whole, the more weight we will give to that opinion.”). The ALJ’s
conclusion that Ms. Coleman had the RFC to perform light work activity was
supported by the opinion of Ms. Coleman’s treating physician, Dr. Davis. As
discussed previously, Dr. Davis’s opinion is consistent with the objective medical
evidence provided by the FCEs Ms. Coleman participated in as well as diagnostic
On the other hand, Dr. Harris came to the conclusion that Ms. Coleman had a
more restrictive ability to perform work-related activity based upon his single
examination of her on August 24, 2012.15 As a consulting physician who only
In particular, Dr. Harris found that Ms. Coleman could only sit for 3 hours, stand for 2
hours, and walk for 1 hour in an 8 hour work day. (Tr. 83). This is inconsistent with Ms. Coleman’s
most recent FCE which notes that Ms. Coleman’s ability to walk, stand or sit is unrestricted (Tr.
482), and Dr. Davis’s physical capacity examination in which he determined Ms. Coleman could sit
examined Ms. Coleman on one occasion, Dr. Harris’s opinion is not entitled to
deference. McSwain v. Bowen, 814 F.2d 617, 619 (11th Cir. 1987) (citing Gibson v.
Heckler, 779 F.2d 619, 623 (11th Cir. 1986)) (“[Drs. Davis’s and Simpson’s]
opinions are not entitled to deference because as one-time examiners they were not
treating physicians.”). By contrast, Dr. Davis saw Ms. Coleman on a regular basis
beginning in October 2010 through December 2011. (Tr. 381). The ALJ appropriately
assigned more weight to the opinion of Dr. Davis, Ms. Coleman’s treating physician,
than he did to Dr. Harris’s opinion. The opinion of a claimant’s treating source is
generally entitled to special weight because such a source is “able to provide a
detailed, longitudinal picture of [a claimant’s] medical impairment(s).” 20 C.F.R. §
404.1527(c)(2). Dr. Davis’s on-going treatment of Ms. Coleman provides him with
more insight into the particulars of her pain allegations and capacity to perform workrelated activities. Accordingly, it was entirely appropriate for the ALJ to reject that
part of Dr. Harris’s opinion that was inconsistent with the opinion of Ms. Coleman’s
treating physician, Dr. Davis.
for 8 hours and walk and stand for 5 hours combined in an 8 hour work day. (Tr. 348). In addition,
Dr. Harris found that Ms. Coleman could only occasionally lift and carry up to 10 lbs. but never
more (Tr. 82), which contradicts Dr. Davis’s opinion that she could lift and carry up to 20 lbs.
occasionally and 10 lbs. frequently (Tr. 348), and her latest FCE which reported she could
occasionally lift and carry between 15 lbs. and 20 lbs. (Tr. 482). Dr. Harris also found that Ms.
Coleman could never balance, stoop, kneel, or crouch (Tr. 85), but her latest FCE reported Ms.
Coleman was unrestricted in stooping, kneeling, and crouching (Tr. 482), and Dr. Davis opined that
she could occasionally balance and stoop. (Tr. 348).
Thus, the ALJ afforded proper weight and provided adequate analysis of
consulting physician Dr. Harris’s medical opinion, and his conclusions regarding Dr.
Harris’s opinion are supported by substantial evidence. Therefore, a reversal of the
ALJ’s decision as requested by Ms. Coleman is not in order and remand for further
consideration of Dr. Harris’s medical opinion is unnecessary.
THE ALJ DID NOT HAVE A DUTY TO RECONTACT DR. DAVIS
OR DR. HARRIS BECAUSE THE RECORD WAS FULLY
Ms. Coleman also requests that her case be remanded for further development
of the record and consideration because, she contends, the ALJ had a duty to
recontact Dr. Davis and Dr. Harris to clarify their medical source opinions. Ms.
Coleman argues that the ALJ was required under SSR 96–5p17 to recontact Dr. Davis
if he found Dr. Davis’s opinions to be inconsistent.18 Without citing any legal
authority, Ms. Coleman also argues that, “[i]f the ALJ truly believed there was some
The undersigned has rendered a comparable decision from which the framework, analysis,
and disposition of this issue, in part, persuasively flows. See Pierson v. Colvin, No. 4:12-CV-2095VEH, (Doc. 13 at 16-17) (N.D. Ala. Mar. 3, 2014).
SSR 96–5p states that: “[f]or treating sources, the rules also require that [the ALJ] make
every reasonable effort to recontact such sources for clarification when they provide opinions on
issues reserved to the Commissioner and the bases for such opinions are not clear to [him].”
Ms. Coleman’s brief states that, “even if the ALJ finds Dr. Davis’[s] opinion inconsistent,
he is not free to dismiss this opinion out of hand.” (Doc. 10 at 10). She asserts that it is an “egregious
error” for the ALJ “to dismiss this opinion because the ALJ believes it to be inconsistent without
first contacting Dr. Davis.” Id.
inconsistency in Dr. Harris’[s] opinion, it was incumbent upon the ALJ to recontact
Dr. Harris for clarification.” (Doc. 10 at 12).
Under Social Security Regulations, the ALJ makes a disability determination
based on what the record shows, and will consider the consistency and sufficiency of
the evidence in doing so. If evidence is inconsistent, the ALJ will “weigh the relevant
evidence” to reach a disability decision using the information contained in the record.
20 C.F.R. § 404.1520b(b). If the evidence in the record is insufficient, or after
weighing inconsistent evidence the ALJ “determine[s] [h]e cannot reach a conclusion
about whether [the claimant is] disabled,” the ALJ may recontact a physician for
additional information. 20 C.F.R. § 404.1520b(c).
In the Eleventh Circuit, a court determining whether a duty to recontact a
medical source arises is guided by “whether the record reveals evidentiary gaps which
result in unfairness or clear prejudice.” Couch v. Astrue, 267 F. App’x 853, 855 (11th
Cir. 2008) (quoting Brown v. Shalala, 44 F.3d 931, 935 (11th Cir. 1995). “The
likelihood of unfair prejudice may arise if there is an evidentiary gap that ‘the
claimant contends supports [his] allegations of disability.’” Couch, 267 F. App’x at
855 (quoting Brown, 44 F.3d at 936 n.9).
The record reflects that the duty to recontact did not arise here. While the
record may contain some inconsistent information, in particular between the opinions
provided by Drs. Davis and Harris, and within Dr. Harris’s report and clinical notes,
the record does not indicate that the medical sources were in control of additional
records that would clarify any inconsistencies. Overall, the record contained
substantial evidence supporting the ALJ’s disability determination.19
It appears that the ALJ was in possession of all of Dr. Davis’s medical records,
and the information contained therein was adequate to enable the ALJ to determine
that Ms. Coleman was not disabled. Any inconsistencies the ALJ would have found
in the evidence from Dr. Davis would have been cured by the ALJ’s adoption of Dr.
Davis’s conclusions regarding Ms. Coleman’s functional capacity. The ALJ did not
simply “dismiss this opinion,” but factored in any of Dr. Davis’s determinations
pertaining to Ms. Coleman’s physical abilities and pain through his acceptance of Dr.
Davis’s recommendations for Ms. Coleman’s work restrictions. Therefore, there was
no need for additional information or clarification from Dr. Davis.
Furthermore, the ALJ applied the proper weight to Dr. Harris’s medical
opinion, and made his disability determination accordingly. As explained above, the
ALJ adopted Dr. Davis’s opinion, and Dr. Harris’s statements actually partially
corroborated this opinion. Dr. Harris indicated Ms. Coleman could perform light to
sedentary work activity, while Dr. Davis indicated she could perform light work
See discussion above regarding the ALJ’s evaluation of Drs. Davis’s and Harris’s opinions.
activity. The ALJ applied the appropriate relative weight between these two
physicians, given that Dr. Davis was Ms. Coleman’s treating physician and Dr. Harris
was simply a consulting physician. Additionally, the record contained Dr. Harris’s
clinical notes. These notes provided the necessary information for the ALJ to find that
Ms. Coleman could perform light work activity, the less restrictive level of work
activity Dr. Harris stated Ms. Coleman could perform.
After properly weighing the relevant evidence from Ms. Coleman’s medical
sources, the ALJ found that he could make a disability determination despite these
inconsistencies. Therefore, remand for further development of the record is not
necessary. The record contains sufficient evidence for the ALJ to make an informed
determination as to whether Ms. Coleman is disabled.
Based upon the court’s evaluation of the evidence in the record and the parties’
submissions, the court finds that the decision of the Commissioner is supported by
substantial evidence and that she applied proper legal standards in arriving at it.
Accordingly, the decision will be affirmed by separated order.
DONE and ORDERED this 12th day of November, 2015.
VIRGINIA EMERSON HOPKINS
United States District Judge
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