Lykes v. Social Security Administration, Commissioner

Filing 12

MEMORANDUM OPINION and ORDER DISMISSING CASE that the decision of the Commissioner is AFFIRMED and costs are taxed against claimant as more fully set out in order. Signed by Judge C Lynwood Smith, Jr on 15/21/2015. (AHI )

FILED
2015 Dec-21 AM 09:25
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
AUREALIA KELLY LYKES,
Claimant,
vs.
CAROLYN W. COLVIN, Acting
Commissioner, Social Security
Administration,
Defendant.

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Case No. 2:15-cv-524-CLS

MEMORANDUM OPINION AND ORDER
Claimant, Aurealia Kelley Lykes, commenced this action on March 30, 2015,
pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final adverse decision of
the Commissioner, affirming the decision of the Administrative Law Judge (“ALJ”),
and thereby denying her claim for a period of disability, disability insurance, and
supplemental security income benefits.
The court’s role in reviewing claims brought under the Social Security Act is
a narrow one. The scope of review is limited to determining whether there is
substantial evidence in the record as a whole to support the findings of the
Commissioner, and whether correct legal standards were applied. See Lamb v.
Bowen, 847 F.2d 698, 701 (11th Cir. 1988); Tieniber v. Heckler, 720 F.2d 1251, 1253
(11th Cir. 1983).

Claimant contends that the Commissioner’s decision is neither supported by
substantial evidence nor in accordance with applicable legal standards. Specifically,
claimant asserts that the ALJ improperly considered the opinion of her treating
physician, improperly considered her non-exertional impairments, and failed to
properly develop the record. Upon review of the record, the court concludes that
these contentions lack merit, and that the Commissioner’s ruling is due to be
affirmed.
A.

Treating Physician
The opinion of a treating physician “must be given substantial or considerable

weight unless ‘good cause’ is shown to the contrary.” Phillips v. Barnhart, 357 F.3d
1232, 1240-41 (11th Cir. 2004) (internal citations omitted). Good cause exists when
“(1) [the] treating physician’s opinion was not bolstered by the evidence; (2) [the]
evidence supported a contrary finding; or (3) [the] treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records.” Id. (alterations
supplied). Additionally, the ALJ is not required to accept a conclusory statement
from a medical source, even a treating source, that a claimant is unable to work,
because the decision whether a claimant is disabled is not a medical opinion, but is
a decision “reserved to the Commissioner.” 20 C.F.R. § 416.927(e).
Social Security regulations also provide that, in considering what weight to

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give any medical opinion (regardless of whether it is from a treating or non-treating
physician), the Commissioner should evaluate: the extent of the examining or
treating relationship between the doctor and patient; whether the doctor’s opinion can
be supported by medical signs and laboratory findings; whether the opinion is
consistent with the record as a whole; the doctor’s specialization; and other factors.
See 20 C.F.R. § 404.1527(d). See also Wheeler v. Heckler, 784 F.2d 1073, 1075
(11th Cir. 1986) (“The weight afforded a physician’s conclusory statements depends
upon the extent to which they are supported by clinical or laboratory findings and are
consistent with other evidence as to claimant’s impairments.”).
Dr. Vanosia Faison, claimant’s treating physician at Birmingham Health Care,
wrote a letter “To Whom It May Concern” on July 30, 2013, stating, “Aurealia Lykes
. . . is a patient of mine, whom of which [sic] I feel at this time is unable to work due
to chronic back pain and knee pain.”1 The ALJ gave that opinion little weight
because “[t]he decision as to whether or not a claimant is unable to work is reserved
to the Commissioner,” and because “Dr. Faison’s opinion is not consistent with the
objective medical evidence suggesting that the claimant’s back impairment is stable.”2
That decision was in accordance with applicable law. See 20 C.F.R. §
416.927(e), supra.

Dr. Faison did not describe any of claimant’s functional

1

Tr. 505 (alteration supplied).

2

Tr. 28 (alteration supplied).
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limitations, cite any medical findings, or even specify whether claimant’s condition
had lasted, or could be expected to last, for at least twelve months. See 42 U.S.C. §
423(d)(1)(A) (defining “disability” as an “inability to engage in any substantial
gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12 months”). Accordingly,
the ALJ was not required to afford the opinion any special weight.
The ALJ’s decision to reject Dr. Faison’s conclusory opinion also was
supported by substantial evidence of record.

Claimant asserts that the ALJ

misinterpreted the use of the word “stable” in her medical records. The court does
not agree. In an MRI report dated November 13, 2012, Dr. Faison noted “left
lateralizing disc bulge at L5-S1 with superimposed central disc herniation.
Encroachment on the left lateral recess and slight posterior displacement of the
descending left S1 nerve root. Mild to moderate left neural foraminal stenosis.”3
Those findings reflected a condition that was “stable from 6/24/12.”4 Another MRI
report from June 3, 2013 stated that the point of comparison was November 13, 2012.
The findings were:
At L5-S1 there is moderate degenerative disk disease with a moderate
3

Tr. 473.

4

Id.
4

sized left paracentral disk protrusion. This creates moderate left
paracentral spinal stenosis with possible effacement of the left S1 nerve.
The overall appearance is stable.
There is moderate degenerative facet disease bilaterally at this
level that is also stable. There is moderate bilateral neural foraminal
stenosis, unchanged.
At L4-5 there is mild diffuse disk bulge and minimal overall
spinal stenosis. There is mild degenerative facet disease bilaterally.
The conus is at T12 the conus is unremarkable.5
The impression was: “Stable MRI lumbar spine when compared to November 13,
2012. Moderate sized left paracentral disk protrusion at L5-S1.”6 These records
simply reflect that the condition of claimant’s spine had not changed significantly
between June of 2012 and June of 2013. During that time period, claimant exhibited
no more than moderate findings, and her physical examination from June 24, 2012
revealed normal range of motion, no cranial nerve or sensory deficit, and full muscle
strength, other than 4/5 strength in her hip flexors.7 In summary, claimant’s condition
had, indeed, been “stable” for some time, and the record did not reflect disabling
limitations. While plaintiff has received diagnoses of lumbar nerve root disorder8 and
lumbar radiculopathy,9 and she no doubt experiences pain as a result of those
5

Tr. 493.

6

Id.

7

Tr. 262.

8

See, e.g., Tr. 252.

9

See, e.g., Tr. 479.
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conditions, the physical findings generally are consistent with no more than moderate
functional limitations.
B.

Non-Exertional Limitations
Claimant asserts that the ALJ failed to properly consider all of her impairments

in combination — including the non-exertional impairments of obesity, depression,
and fatigue. Social Security regulations state the following with regard to the
Commissioner’s duty in evaluating multiple impairments:
In determining whether your physical or mental impairment or
impairments are of a sufficient medical severity that such impairment or
impairments could be the basis of eligibility under the law, we will
consider the combined effect of all of your impairments without regard
to whether any such impairment, if considered separately, would be of
sufficient severity. If we do find a medically severe combination of
impairments, the combined impact of the impairments will be considered
throughout the disability determination process. If we do not find that
you have a medically severe combination of impairments, we will
determine that you are not disabled.
20 C.F.R. § 404.1523. See also 20 C.F.R. §§ 404.1545(e), 416.945(e) (stating that,
when the claimant has any severe impairment, the ALJ is required to assess the
limiting effects of all of the claimant’s impairments — including those that are not
severe — in determining the claimant’s residual functional capacity). Here, the ALJ
entered a finding that claimant did not have an impairment or combination of
impairments that met or medically equaled one of the listed impairments, and she

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stated that she had considered all of claimant’s symptoms.10 Under Eleventh Circuit
law, statements of that sort are sufficient to indicate that the ALJ properly considered
all of claimant’s impairments. See Wilson v. Barnhart, 284 F.3d 1219, 1224 (11th
Cir. 2002); Jones v. Dept. of Health and Human Services, 941 F.2d 1529, 1533 (11th
Cir. 1991).
Moreover, it is apparent from the ALJ’s decision that she adequately
considered claimant’s obesity, depression, and fatigue, despite the fact that she did
not consider any of those conditions to constitute severe impairments. With regard
to claimant’s obesity, the ALJ stated: “the effect that this condition has on the
claimant’s overall ability to perform work related functions, either singly or in
combination with other impairments, has been considered in accordance with SSR
02-1p.”11 Even so, there was “no suggestion in the record that she has any functional
limitations associated with this impairment . . . .”12 That decision was consistent with
the requirements imposed by Social Security Ruling 02-1p, which states the
following:
Obesity can cause limitation of function. The functions likely to
be limited depend on many factors, including where the excess weight
is carried. An individual may have limitations in any of the exertional
functions such as sitting, standing, walking, lifting, carrying, pushing,
10

Tr. 24.

11

Id.

12

Tr. 21.
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and pulling. It may also affect ability to do postural functions, such as
climbing, balancing, stooping, and crouching. The ability to manipulate
may be affected by the presence of adipose (fatty) tissue in the hands
and fingers. The ability to tolerate extreme heat, humidity, or hazards
may also be affected.
The effects of obesity may not be obvious. For example, some
people with obesity also have sleep apnea. This can lead to drowsiness
and lack of mental clarity during the day. Obesity may also affect an
individual’s social functioning.
An assessment should also be made of the effect obesity has upon
the individual’s ability to perform routine movement and necessary
physical activity within the work environment. Individuals with obesity
may have problems with the ability to sustain a function over time. As
explained in SSR 96-8p (“Titles II and XVI: Assessing Residual
Functional Capacity in Initial Claims”), our RFC assessments must
consider an individual’s maximum remaining ability to do sustained
work activities in an ordinary work setting on a regular and continuing
basis. A “regular and continuing basis” means 8 hours a day, for 5 days
a week, or an equivalent work schedule. In cases involving obesity,
fatigue may affect the individual’s physical and mental ability to sustain
work activity. This may be particularly true in cases involving sleep
apnea.
The combined effects of obesity with other impairments may be
greater than might be expected without obesity. For example, someone
with obesity and arthritis affecting a weight-bearing joint may have
more pain and limitation than might be expected from the arthritis alone.
For a child applying for benefits under title XVI, we may evaluate
the functional consequences of obesity (either alone or in combination
with other impairments) to decide if the child’s impairment(s)
functionally equals the listings. For example, the functional limitations
imposed by obesity, by itself or in combination with another
impairment(s), may establish an extreme limitation in one domain of
functioning (e.g., Moving about and manipulating objects) or marked
limitations in two domains (e.g., Moving about and manipulating objects
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and Caring for yourself).
As with any other impairment, we will explain how we reached
our conclusions on whether obesity caused any physical or mental
limitations.
SSR 02-1P, 2000 WL 628049, at *6-7. The ALJ’s findings also were supported by
substantial evidence. As discussed above, claimant only suffered from moderate
clinically determinable impairments, and the court’s review of the medical records did
not reveal any occasion on which a medical provider suggested that claimant’s
condition was being made worse by her obesity.
The ALJ also properly considered claimant’s depression. Despite finding that
claimant’s depression was a non-severe impairment, the ALJ discussed in detail the
effect depression had on claimant’s ability to function in multiple areas.13 The ALJ
also considered claimant’s depression in crafting her residual functional capacity
finding.14
Finally, the ALJ credited claimant’s complaints of fatigue, and accounted for
them by finding that “claimant must work in an environment that does not have
stringent production or speed requirements [and] thus [she] may not perform fast pace
assembly line work.”15 Claimant criticizes those restrictions as being “vague and

13

Tr. 22-23.

14

Tr. 27.

15

Tr. 28 (alterations supplied).
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subjective,” and asserts they were “not expressed in vocational terms which must
quantify the limitation in fractions or hours of the work day defined as for example
occasional or two hours total.”16 Claimant’s citation for that assertion is Social
Security Ruling 83-10, which addresses a claimant’s capability to do other work
under the Medical-Vocational Guidelines (“Grids”). SSR 83-10 defines terms like
“occasional” in the context of a claimant’s ability to do other work, but claimant has
not cited any authority — and this court has found none — applying SSR 83-10 to
hold that an ALJ must always use quantifiable terms like “occasional” when
describing a claimant’s limitations. Moreover, there actually is a quantification
implicit in the ALJ’s finding. The ALJ found that claimant’s work environment must
be free of all stringent production or speed requirements, implying that claimant can
never perform fast-paced assembly line work. Finally, the limitations the ALJ placed
on claimant’s ability to do fast-paced work appear to have been sufficiently clear and
specific for the vocational expert to determine their effect on claimant’s ability to
perform jobs existing in significant numbers in the national economy.17
C.

Failure to Develop Record
The claimant also argues that the ALJ failed to properly develop the

administrative record because she did not rely upon a medical source opinion in
16

Doc. no. 9 (Claimant’s Brief), at 8.

17

See Tr. 56-59.
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formulating claimant’s residual functional capacity. It is true that the ALJ
has an obligation to develop a full and fair record, even if the claimant
is represented by counsel. Cowart v. Schweiker, 662 F.2d 731, 735
(11th Cir. 1981). The ALJ is not required to seek additional
independent expert medical testimony before making a disability
determination if the record is sufficient and additional expert testimony
is not necessary for an informed decision. Wilson v. Apfel, 179 F.3d
1276, 1278 (11th Cir. 1999) (holding the record, which included the
opinion of several physicians, was sufficient for the ALJ to arrive at a
decision); Holladay v. Bowen, 848 F.2d 1206, 1209-10 (11th Cir. 1988)
(holding the ALJ must order a consultative exam when it is necessary
for an informed decision).
Nation v. Barnhart, 153 F. App’x 597, 598 (11th Cir. 2005) (emphasis supplied).
Furthermore, claimant bears the ultimate burden of producing evidence to support her
disability claim. See Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003)
(citing 20 C.F.R. §§ 416.912(a), (c)). The court concludes that the record in this case
was sufficient, even without a medical source statement from a treating or consulting
source, for the ALJ to arrive at an informed decision.
In summary, the court concludes the ALJ’s decision was based upon substantial
evidence and in accordance with applicable legal standards. Accordingly, the
decision of the Commissioner is AFFIRMED. Costs are taxed against claimant. The
Clerk is directed to close this file.
DONE this 21st day of December, 2015.

______________________________
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United States District Judge

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