Vaughn v. Social Security Administration, Commissioner
Filing
12
MEMORANDUM OF DECISION. Signed by Judge R David Proctor on 2/16/2016. (AVC)
FILED
2016 Feb-16 PM 04:21
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
LEE PATRICK VAUGHN,
Plaintiff
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security
Defendant.
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Civil Action No.: 2:14-CV-01990-RDP
MEMORANDUM OF DECISION
Plaintiff, Lee Patrick Vaughn, brings this action pursuant to Section 205(g) of the Social
Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security
(“Commissioner”) denying his claim for Disability Insurance Benefits (“DIB”). See also 42
U.S.C. § 405(g). Based on the court’s review of the record and the briefs submitted by the
parties, the court finds that the decision of the Commissioner is due to be affirmed.
I.
Proceedings Below
Plaintiff filed an application for DIB on September 30, 2011, alleging disability as of
September 1, 2008. (Tr. 75, 127-30). On November 16, 2001, Plaintiff’s claim for DIB was
denied by the Social Security Administration. (Tr. 77). Plaintiff requested and received a hearing
on January 23, 2013; he appeared before Administrative Law Judge George Merchant
(hereinafter “ALJ”), presiding from Birmingham, Alabama. (Tr. 36-74, 85-86). Steve Rice, an
impartial vocational expert, also appeared at the hearing. (Tr. 38, 68-73).
In his decision dated March 12, 2013, the ALJ determined that Plaintiff was not disabled under
the Act from his alleged onset date, September 1, 2008, through his date last insured,1 June 30,
2009. (Tr. 20; See also Tr. 132, 139). After appealing the ALJ’s decision, the Appeals Council
denied Plaintiff’s request in a letter dated April 8, 2014. (Tr. 1-3). Plaintiff exhausted his
administrative remedies, and filed a timely action in this court. Accordingly, Plaintiff’s case is
ripe for review under Section 205(g) of the Act. See also 42 U.S.C. § 405(g).
II.
Facts
At the time of his hearing, Plaintiff was 43 years of age and had a college degree. (Tr. 41-
42, 139-49). Plaintiff alleges a disability onset date of September 1, 2008, due to his bipolar
disorder with depressed mood, neck pain, and back pain. (Tr. 142). Plaintiff worked as an
advertising sales representative, and claims he quit working because of his alleged disability. (P.
26, 68-69, 143, 161). Plaintiff testified that, after his alleged onset date, he was able to care for
his children, cook, wash dishes, and do laundry. (Tr. 171). Plaintiff is able to drive, shop, handle
money, and spend time with his children, despite having a hard time coping with people. (Tr. 48,
173-74). In addition to being the primary, stay-at-home parent, Plaintiff was able to work at
concerts for a few hours at a time, a couple times each month, where he helped monitor the
handicapped section. (Tr. 43).
The medical evidence of record, dating back to 2003, documents Plaintiff’s history of
both physical impairments (degenerative disk disease of the cervical and lumbar spine, and
migraine headaches), and mental impairments (bipolar disorder with depressed mood, and
chronic pain syndrome). Medical records from Plaintiff’s previous treating psychiatrist, Dr.
1
To be eligible for disability insurance benefits, Plaintiff must show he was disabled from September 1,
2008 through June 30, 2009. See 42 U.S.C. §§ 416(i)(3), 423(a)(c); 20 C.F.R. §§ 404.101, 404.130, 404.131; Moore
v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005)(Plaintiff must prove that he was disabled before the date last
insured to be eligible for disability benefits.).
2
Thomas G. Shafer, document chronic depression and bipolar disorder with episodic mania. (Tr.
213-53). Dr. Shafer indicated in a letter dated June 2007 that he had treated Plaintiff’s Bipolar
Disorder, Type I since March 2004. (Tr. 239). Dr. Shafer’s examination records indicate that
Plaintiff reported a good response to medication with no significant exacerbations of mood or
symptoms. (Tr. 25, 28, 263).
During his hearing, Plaintiff testified that he had changed psychiatrists in 2011 because
he felt like Dr. Shafer did not understand bipolar disorder. In May 2011, almost two years after
Plaintiff’s date last insured, he began seeing Dr. Emily Lazenby at Psychiatry South. Medical
records from Psychiatry South document bipolar disorder, and assign Plaintiff a Global
Assessment of Functioning (“GAF”) score of 50 or below. (Tr. 940, 945-49, 952, 999, 1005-08,
1116). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
a GAF score of 50 or below is indicative of “serious symptoms or any serious impairment in
social, occupational, or school functioning.” (DSM-IV, p. 32). In October 2012, it is noted that
Plaintiff reported that he felt stable but was experiencing dissociative episodes while on his
medication. (Tr. 1114). On February 15, 2012, Dr. Lazenby, joined by Plaintiff’s treating
therapist, Jill Kelly, Completed a Supplemental Questionnaire as to Mental Residual Functional
Capacity (“SQ”). (Tr. 969-72). After a psychological evaluation, Dr. Lazenby opined that
Plaintiff had both “marked” and “extreme” impairments in several areas of mental functioning.
(Tr. 969-72).
Additionally, Plaintiff testified that as a result of his bipolar disorder with depressed
mood, he was afraid to leave the house during the relevant time period, and was either overly
agitated or overly talkative. (Tr. 44). Additionally, Plaintiff testified to frequent crying spells,
suicidal ideation, and severe problems with in-laws because they felt he was not taking care of
3
their daughter. (Tr. 44-45). Plaintiff reports having difficulty keeping commitments due to his
depression and migraine headaches, and testified that he still experiences shooting pain in his
legs radiating from his back. (Tr. 48-49). Plaintiff reports still having problems with migraines,
estimates that his headaches occur 4 to 8 times each month, and that they sometimes last for
days. (Tr. 55-56).
III.
The ALJ Decision
Disability under the Act is determined under a five-step test. 20 C.F.R. § 404.1520. First,
the ALJ must determine whether the claimant is engaging in substantial gainful activity. 20
C.F.R. § 404.1520(a)(4)(i). Work activity involving significant physical or mental activities is
“substantial,” while “gainful” work is done for pay or profit. See 20 C.F.R. § 404.1572(a)-(b). A
claimant is presumed to have the ability to engage in a substantial gainful activity when his
earnings from employment rise above the amount allowed under 20 C.F.R. §§ 416.974, 416.975.
Engaging in substantial gainful activity precludes a claim of disability. 20 C.F.R. § 404.1520(b).
Second, the ALJ must determine whether the claimant has a medically determinable impairment,
or combination thereof, that significantly limits the claimant’s ability to perform basic work
activities. 20 C.F.R. § 404.1520(a)(4)(ii). Absent such impairment, the claimant may not claim
disability. Id. Third, the ALJ must determine whether the claimant’s impairment meets or
medically equals the criteria of an impairment listed in 20 C.F.R. Pt. 404, Subpt. P, App’x 1. See
20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526. If such criteria are met, the claimant is
declared disabled. 20 C.F.R. § 404.1520(a)(4)(iii).
If the claimant does not meet the listed criteria, the ALJ may still find disability, after a
residual functional capacity (“RFC”) assessment.2 20 C.F.R. § 404.1520(e). The ALJ applies the
2
A claimant’s RFC indicates the most a claimant can do despite his physical and mental limitations. See 20
C.F.R. § 404.1545(a); Social Security Ruling (SSR) 96-8p, 196 WL 374184. The assessment of a claimant’s RFC is
4
RFC assessment to determine whether the claimant can perform past relevant work. 20 C.F.R. §
404.1520(a)(4)(iv). If capable of performing past relevant work the claimant is not disabled;
however, a finding that the claimant cannot perform past relevant work, requires the ALJ to
determine if he is able to perform any other work commensurate with his RFC, age, education,
and work experience. 20 C.F.R. §§ 404.1520(a)(4)(iv)-(v), 404.1520(g). Here, the burden shifts
to the ALJ to prove that, given the claimant’s RFC, age, education, and work experience, he is
capable of making a successful adjustment to other jobs, available in substantial numbers within
the national economy. 20 C.F.R. §§ 404.1520(g) and 404.1560(c).
Here, upon considering the record in its entirety, the ALJ found that Plaintiff last met the
insured status requirements of the Act on June 30, 2009 and that Plaintiff has not engaged in
substantial gainful activity during the period from his alleged onset date, September 1, 2008,
through his date last insured, June 30, 2009. See 20 CFR § 404.1571 et seq. (Tr. 21). Further, the
ALJ found that, through his last insured date, Plaintiff suffered from a combination of severe
impairments, including: degenerative disk disease of the cervical spine; degenerative disk disease
of the lumbar spine; status post lumbar laminectomy and discectomy; migraine headaches;
bipolar disorder with depressed mood; and chronic pain syndrome.3 (Tr. 21). However, the ALJ
determined that Plaintiff’s impairments, individually and in combination, neither met nor
medically equaled the severity of Listings 1.02, 1.04, or 12.04. See 20 C.F.R. §§ 404.1520(d),
404.1525, and 404.1526. (Tr. 24).
based on an evaluation of all the relevant evidence, including medical evidence and testimony concerning the
claimant’s abilities and limitations. See 20 C.F.R. § 4041545(a); SSR 96-8p.
3
The ALJ found that Plaintiff’s hypertension, gastroesophageal reflux disease, hypercholesterolemia,
olecranon bursitis, status post right rotator cuff repair, and Barre-Lieou syndrome were non-severe. See 20 C.F.R. §
404.1521; SSRs 85-28, 96-3p, and 96-p4). (Tr. 24).
5
After evaluating the medical evidence of record, the ALJ noted that “[Plaintiff’s]
medically determinable impairments could reasonably be expected to cause some of the alleged
symptoms; however, [Plaintiff’s] statements and other allegations concerning the intensity,
persistence, and limiting effects of these symptoms are not entirely credible ….” (Tr. 26-27). The
ALJ further found that, through his last insured date, Plaintiff had the RFC to perform a range of
light work as defined in 20 C.F.R. § 4041567(b) with the following limitations: occasionally
climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; should not climb ladders, ropes,
or scaffolds; avoid exposure to extreme cold, excessive vibration, unprotected heights; and
neither operate nor control hazardous, moving machinery. (Tr. 25). Plaintiff can understand,
remember and carryout simple instructions, but should not be required to make more than
occasional decisions in a work setting with, at most, occasional changes. (Id.) In tailoring
Plaintiff’s RFC, the ALJ found that Plaintiff should interact only on an occasional basis with
coworkers, supervisors, and the public. (Tr. 25).
The ALJ determined that, although unable to perform past relevant work through his last
insured date, Plaintiff was capable of making a successful adjustment to other jobs that are
available in significant numbers within the national economy. (Tr. 28-30). Accordingly, the ALJ
concluded that from September 1, 2008 to June 30, 2009, Plaintiff was not disabled under the
Act, and therefore, he was not entitled to disability benefits. (Tr. 30).
IV.
Plaintiff’s Argument for Reversal or Remand
Plaintiff seeks to have the ALJ’s decision reversed, or in the alternative, remanded. (See
Pl.’s Mem. at 12-13). Plaintiff argues only that the ALJ’s RFC finding is not supported by
substantial evidence because the ALJ failed to accord adequate weight to the opinion of
Plaintiff’s treating psychiatrist, Dr. Lazenby. (See Pl.’s Mem. at 8-12).
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V.
Standard of Review
The only issues before this court are whether the record reveals substantial evidence to
sustain the ALJ’s decision, and whether the correct legal standards were applied. See 42 U.S.C. §
405(g); Lamb v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988), Walden v. Schweiker, 672 F.2d 835,
838 (11th Cir. 1982). The Commissioner’s findings are conclusive if supported by “substantial
evidence.” 42 U.S.C. § 405(g); Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). The
district court may not reconsider the facts, reevaluate the evidence, nor substitute its judgment
for that of the Commissioner. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).
Considering the final decision as whole, the court may only decide if the decision is reasonable
and supported by substantial evidence. See id.
Substantial evidence is the relevant evidence “a reasonable person would accept as
adequate to support a conclusion.” Martin, 894 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at
1239). When substantial evidence exists in support of the Commissioner’s decision, his decision
must be affirmed, even if the evidence preponderates to the contrary. See id. However, the court
notes that judicial review, although limited “does not yield automatic affirmance” of the ALJ’s
decision. Lamb v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988).
VI.
Discussion4
In light of the legal standards that apply in this case, the court rejects Plaintiff’s argument
for remand or reversal. For the reasons outlined below, the court finds that, in making his
decision, the ALJ applied the proper legal standards and relied on substantial evidence.
4
Although at the administrative level Plaintiff claimed physical and mental impairments, on appeal, he
refers only to his mental impairments. (See Pl.’s Mem. at 8-13). Accordingly, Plaintiff has abandoned any claim
with respect to any purported physical impairments. See Hernandez v. Comm’r of Soc. Sec., 433 F. App’x 821, 823
(11th Cir. 2011). Further, Plaintiff’s sole contention of error is that the ALJ should have credited Dr. Lazenby’s
treating opinion regarding his mental capacities. As a result, Plaintiff has waived all other issues on this appeal. See
Outlaw v. Barnhart, No 05-15996, 2006 WL 2640223 at *2n.3 (11th Cir. Aug. 10, 2006).
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A.
Substantial Evidence Supports the ALJ’s Decision to Assign Less Weight to
Dr. Lazenby’s Opinion
Plaintiff’s argument that the ALJ failed to properly consider the opinion of Dr. Lazenby,
Plaintiff’s treating psychiatrist is off the mark. “[T]he nature of the relationship between the
doctor and the claimant is only one factor used to determine the weight given to a medical
opinion.” Chambers v. Astrue, 2013 WL 486307, at *27 (N.D. Ga. Jan. 11, 2013)(citing 20
C.F.R. § 404.1527). When determining the weight to give a physician’s opinion, the ALJ
considers a number of factors, including whether the physician examined the claimant, whether
the physician treated the claimant, the evidence presented in support of the physician’s opinion,
whether the physician’s opinion is consistent with the record as a whole, and whether the
physician is specialized in the relevant field. See 20 C.F.R. § 404.1527(c)(2) (the factors within
the regulations are applied by the ALJ in order to determine the weight given to the opinion);
SSR 96-2p, 1996 WL 374188. Although a treating physician’s opinion is generally due more
weight that the opinions of non-treating medical personnel, an ALJ may discount a treating
physician’s opinion with good reason. See 20 C.F.R. § 404.1527(c)(2); SSR 96-2p; Winschel v.
Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). An ALJ may discount a treating
physician’s opinion if the opinion is conclusory, is not supported by objective medical evidence,
is inconsistent with the record as a whole, or if the evidence otherwise supports a contrary
finding. See 20 C.F.R. 404.1527(c); Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1159-60
(11th Cir. 2004); Phillips v. Comm’r of Soc. Sec., 357 F.3d 1232, 1240-41 (11th Cir. 2004).
Plaintiff correctly asserts that absent good cause to the contrary, the ALJ must accord substantial
or considerable weight to the treating physician’s opinion. However, here the ALJ articulated
“good cause” for discounting Dr. Lazenby’s opinion, and that decision is supported by
substantial evidence. See Lamb v. Bowen, 847 F.2d 698, 703 (11th Cir. 1988).
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In the present case, the ALJ assigned Dr. Lazenby’s opinion little weight finding that Dr.
Lazenby’s opinion did not relate to the relevant time period. 5 The ALJ explained that Dr.
Lazenby’s opinion was completed after the date Plaintiff was last insured and was unrelated to
the time period at issue. See, e.g. Hughes v. Comm’r of Soc. Sec. Admin., 486 F. App’x 11, 14
(11th Cir. 2012)(noting doctor’s opinions did not appear to be based on the claimant’s condition
prior to the expiration of the claimant’s insured status, and thus, the “opinions were not
particularly relevant to whether [the claimant] was disabled for purposes of DIB”); Mason v.
Comm’r of Soc. Sec., 430 F. App’x 830, 833 (11th Cir. 2011)(holding ALJ properly determined
opinion “was irrelevant because it did not specify that it pertained to [the claimant’s] condition
during the disability period”).
Substantial evidence supports the ALJ’s determination that Dr. Lazenby’s medical
opinion is unrelated to the relevant time period. In May 2011, nearly two years after Plaintiff’s
last insured date, Plaintiff began treatment at Psychiatry South under the care of Dr. Lazenby.
(Tr. 27-28, 939). In February 2012, after treating Plaintiff for eight months, Dr. Lazenby, and
Plaintiff’s treating therapist, Jill Kelly, evaluated Plaintiff’s mental condition and indicated that
Plaintiff had “marked” to “extreme” impairments in multiple areas of mental functioning. (Tr.
969-70). Dr. Lazenby did not expressly indicate that her opinion was related to Plaintiff’s
condition pre-date last insured.
Furthermore, Plaintiff’s objective medical evidence from the relevant time period does
not support utilizing Dr. Lazenby’s opinion retroactively. See 20 C.F.R. § 404.1527(c)(2)-(4);
5
Again, to be eligible for disability insurance benefits, Plaintiff was required to show that he was disabled
before June 20, 2009, the date his disability insured status expired. See 42 U.S.C. §§ 416(i)(3), 423(a), (c); 20 C.F.R.
§§ 404.101, 404.130, 404.131; Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). (See Tr. 139). Further,
showing that an impairment became disabling after the expiration of a claimant’s insured status is insufficient to
establish eligibility for disability insurance benefits. See Hughes v. Comm’r of Soc. Sec. Admin., 486 F. App’x 11,
13 (11th Cir. 2012)(citing Demandre v. Califano, 591 F.2d 1088, 1090 (5th Cir. 1979)(adopted as binding precedent
by Bonner v. City of Pritchard, 661 F.2d 1206, 1207 (11th Cir. 1981)).
9
Crawford, 363 F.3d at 1159-60; see also Mason, 430 F. App’x at 832 (“Where the medical
record contained a retrospective diagnosis, that is, a physician’s post-insured-date opinion that
the claimant suffered a disabling condition prior to the insured date, we affirm [the retrospective
diagnosis] only when that opinion was consistent with pre-insured-date medical evidence.”). The
ALJ has noted numerous inconsistencies between Dr. Lazenby’s opinion and Plaintiff’s pre-date
last insured mental health records. (Tr. 969-70). Despite presenting to his former psychiatrist, Dr.
Shafer, in August 2008 with complaints of a “melt down,” later that month Plaintiff denied all
mental symptomology. (Tr. 22, 267, 329-30).
The ALJ also noted that beginning in September 2008 Plaintiff’s mental health records
reflect mostly issues regarding medication management, and has pointed to Dr. Shafer’s
examination records. (Tr. 22, 27-28, 265). Those records describe no more than mild to
moderate symptoms, and document Plaintiff’s positive response to medication. In March 2009,
Dr. Shafer determined that Plaintiff was stable and recommended that Plaintiff participate in
vocational rehabilitation, which the ALJ found indicated Dr. Shafer believed Plaintiff was
capable of working. (Tr. 24, 265). In April, Plaintiff had a calm demeanor and later reported that
he was doing well overall, presenting with no complaints. (Tr. 255, 309). The ALJ noted that in
September 2010, after Plaintiff’s last insured date, Plaintiff reported acting as “Mr. Mom” and
was generally stable. (Tr. 24, 253). Ultimately, the ALJ found Plaintiff’s treatment history did
not reflect the marked or extreme limitations contained in Dr. Lazenby’s opinion. (Tr. 27, 96970).
The ALJ also noted that his findings were supported by Plaintiff’s daily activities. See 20
C.F.R. § 404.1529(c)(3); Dyer, 395 F.3d at 1212. Plaintiff functioned independently and was
able to serve as a primary caretaker for his children. (Tr. 24, 27, 170-74). Additionally, Plaintiff
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testified that since his alleged onset date, he has interacted with the public while working at
concert events, monitoring the handicapped section for a couple of hours, two-to-three times a
month. (Tr. 26, 43). Plaintiff’s testimony as to his daily activities during the relevant period did
not indicate the marked or extreme impairments described in Dr. Lazenby’s opinion.
Plaintiff points to Dr. Lazenby’s records, created after Plaintiff’s date last insured, to
argue that the record, as a whole, supports Dr. Lazenby’s opinion. (See Pl.’s Br. at 9-10; Tr. 940,
945-49, 952, 999, 1005-08, 1116). But that argument is without merit. The ALJ considered these
records and determined that they did not relate to the relevant disability period. (Tr. 23, 28). For
the reasons stated above, substantial evidence supports the ALJ’s decision to assign little weight
to Dr. Lazenby’s February 2012 opinion. Accordingly, the ALJ’s decision is due to be affirmed.
VII.
Conclusion
The court concludes that the ALJ applied the proper legal standards, and substantial
evidence supports his determination that Plaintiff was not disabled from September 1, 2008
through June 30, 2009. Accordingly, the Commissioner’s final decision is due to be affirmed. A
separate order in accordance with this memorandum of decision will be entered.
DONE and ORDERED this February 16, 2016.
_________________________________
R. DAVID PROCTOR
UNITED STATES DISTRICT JUDGE
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