Lewis v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Virginia Emerson Hopkins on 3/27/2017. (JLC)
2017 Mar-27 AM 11:40
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
) Case No.: 2:16-CV-181-VEH
NANCY A. BERRYHILL, ACTING )
Plaintiff Brandi Lewis (“Ms. Lewis”) 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”),1 who denied her application for Disability Insurance Benefits
(“DIB”). Ms. Lewis timely pursued and exhausted her administrative remedies
available before the Commissioner. The case is thus ripe for review under 42 U.S.C.
Nancy A. Berryhill was named the Acting Commissioner on January 23, 2017. See
https://www.ssa.gov/agency/commissioner.html. Under 42 U.S.C. § 405(g), “[a]ny action instituted
in accordance with this subsection shall survive notwithstanding any change in the person occupying
the office of Commissioner of Social Security or any vacancy in such office.” Accordingly, pursuant
to 42 U.S.C. § 405(g) and Rule 25(d) of the Federal Rules of Civil Procedure, the Court has
substituted Nancy A. Berryhill for Carolyn W. Colvin in the case caption above and HEREBY
DIRECTS the clerk to do the same party substitution on CM/ECF.
FACTUAL AND PROCEDURAL HISTORY
Ms. Lewis was 31-years old at the time of her hearing before the administrative
law judge (“ALJ”). (Tr. 43). She has completed twelfth grade. (Tr. 46). Her past work
experience includes employment as: (1) an inventory control worker at WalMart; (2)
an assembly worker; (3) an overnight stocker; (4) a cashier; (5) a coupon machine
installer and restocker; and (6) a waitress. (Tr. 77-82). Ms. Lewis claims that she
became disabled on September 24, 2012. (Tr. 14). Her last period of work ended on
September 24, 2012. (Tr. 16).
On October 1, 2012, Ms. Lewis protectively filed a Title II application for a
period of disability and DIB. (Tr. 14, 195-196). On December 13, 2012, the
Commissioner initially denied her claims. (Tr. 126-130). Ms. Lewis timely filed a
written request for a hearing on February 1, 2013. (Tr. 132-3). The ALJ conducted
a hearing on May 1, 2014, in Birmingham, Alabama. (Tr. 14); (see also Tr. 36-91).
On June 13, 2014, the ALJ issued a fully unfavorable decision concluding that Ms.
Lewis was not disabled and denying her DIB claim. (Tr. 11, 14-28). Ms. Lewis then
on June 25, 2014, timely petitioned the Appeals Council to review the ALJ’s decision
that was adverse to her. (Tr. 7-9). On December 11, 2015, the Appeals Council issued
a denial of review on her claim. (Tr. 1-3).
Ms. Lewis filed a Complaint with this court on January 31, 2016, seeking
review of the Commissioner’s determination. (Doc. 1). The Commissioner answered
on May 5, 2016. (Doc. 8). Ms. Lewis filed a supporting brief (Doc. 10) on June 17,
2016, and the Commissioner responded with her own (Doc. 11) on July 13, 2016.
With the parties having fully briefed the matter, the court has carefully considered the
record and remands the decision of the Commissioner for further development.
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). This court will
determine that the ALJ’s opinion is supported by substantial evidence if it finds “such
relevant evidence as a reasonable person would accept as adequate to support a
conclusion.” Id. Substantial evidence is “more than a scintilla, but less than a
preponderance.” Id. Factual findings that are supported by substantial evidence must
be upheld by the court. The ALJ’s legal conclusions, however, are reviewed 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, the ALJ’s decision must be reversed. 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.2 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” promulgated under the Social Security Act are listed in 20 C.F.R. Parts
400 to 499, revised as of March 16, 2017.
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;
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
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. Lewis met the insured status requirements of the Social
Security Act through June 20, 2017. (Tr. 16).
She had not engaged in substantial gainful activity since
September 24, 2012, the alleged onset date. Id.
She has the following severe impairments: degenerative disc
disease at four lower levels with right sided protrusions at L4-5
and L5-S1; obesity; bipolar disorder; and, borderline personality
Ms. Lewis did not have an impairment or combination of
impairments that met or medically equals the severity of one of
the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix
1. (Tr. 17).
She has the residual functional capacity (“RFC”) to perform light
work as defined in 20 C.F.R. 404.1567(b). She can lift, carry,
push, and pull the weights associated with work at the light
exertional level except that she could only ambulate short
distances of up to two city blocks per instance on flat solid
ground. She could frequently manipulate foot controls bilaterally.
She could occasionally climb ramps and stairs, but never ladders
and scaffolds. She can frequently balance and stoop, occasionally
kneel and crouch, but never crawl. Ms. Lewis should never be
exposed to unprotected heights, dangerous tools, dangerous
machinery, or hazardous processes. She should never operate
commercial motor vehicles. She could tolerate frequent exposure
to atmospheric conditions and weather, but only occasional
exposure to humidity, wetness, extreme cold and heat, and
workplace vibrations. She could tolerate moderate noise levels,
but should never be exposed to concentrated dust, fumes, gases,
or other pulmonary irritants. Ms. Lewis can only remember short,
simple instructions and would be unable to deal with detailed or
multi-step instructions. She should have only occasional contact
with the general public or co-workers, but could tolerate frequent
contact with supervisors. Ms. Lewis, in addition to normal breaks,
would be off task approximately five percent of an eight-hour
workday. She would require an at will sit/stand option with the
retained ability to stay on or at a workstation in no less than thirty
minute increments each without significant reduction or
remaining on task. (Tr. 19-20).
Ms. Lewis is unable to perform any past relevant work. (Tr. 26).
She was 29 years old on the alleged disability onset date, which
is defined as a younger individual age 18-49. Id.
She has a high school education and is able to communicate in
Transferability of job skills is not material to the determination of
disability because using the Medical-Vocational Rules as a
framework supports a finding that the claimant is “not disabled,”
whether or not the claimant has transferable job skills. Id.
There are jobs that exist in significant numbers in the national
economy that Ms. Lewis can perform. (Tr. 27).
Ms. Lewis has not been under a disability, as defined in the Social
Security Act, from September 24, 2012, through the date of this
decision. (Tr. 28).
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 standard is met if a reasonable
person would find that the evidence of record is sufficient to support the challenged
conclusion. Holladay v. Bowen, 848 F.2d 1206, 1208 (11th Cir. 1988). “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)).3 However, the court “abstains from reweighing the
evidence or substituting its own judgment for that of the Commissioner.” Walden,
672 F.2d at 838 (citing Laffoon v. Califano, 558 F.2d 253, 254 (5th Cir. 1977)).
The ALJ’s Conclusion that Ms. Lewis Was Not Disabled Is Not Supported
by Substantial Evidence.
Objecting only to the ALJ’s findings that are attributable to her mental
impairments, Ms. Lewis contends that the ALJ improperly applied the pain standard
(Doc. 10 at 3); and that he “erred in his evaluation of the opinion evidence in this
case.” (Doc. 10 at 9). In its review, the court agrees with Ms. Lewis that the ALJ
committed reversible error in his consideration of the medical evidence and that Ms.
Lewis’s case is due to be remanded for further development.4
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).
Thus, the court does not reach the merits of Ms. Lewis’s first contention concerning the
ALJ’s misapplication of the Eleventh Circuit pain standard.
The ALJ Misstated the Meaning of Ms. Lewis’s Multiple GAF
Scores of 50, Confusingly Addressed the Extent of His
Acceptance of Those Scores, and Completely Ignored Her
Lower GAF Score of 30.5
In assigning partial weight to the opinions of several doctors who Ms. Lewis
relies upon to substantiate her inability to work due to depression and other disabling
symptoms caused by her mental impairments of bipolar disorder and borderline
personality disorder, the ALJ stated:
[T]he undersigned assigns partial weight to the opinions of treating and
examining physicians, Dr. Lucas, Dr. Hammel, and Dr. Badari (Exhibits
2F-4F). All had the opportunity to examine the claimant and her medical
records. Their reports have been useful in determining the full scope of
the claimant’s impairments. Dr. Hammel and Dr. Lucas assigned her a
Global Assessment of Functioning (GAF) score of 50, indicative of only
moderately severe symptoms and limitations; however, the undersigned
finds that based on subsequent records and the claimant’s reported
abilities, she is less limited than indicated by Dr. Lucas, Dr. Hammel,
and Dr. Badari. Therefore, their opinions are assigned partial weight.
(Tr. 25-26 (emphasis added)).
“Axis V [of the Multiaxial Assessment] is for reporting the clinician’s judgment of the
individual’s overall level of functioning.”Diagnostic and Statistical Manual of Mental Disorders
[hereinafter DSM-IV-TR] at 32, American Psychiatric Association (4th ed. text revision, 2000). “This
[functional] information is useful in planning treatment and measuring its impact, and in predicting
outcome.” Id. GAF stands for “Global Assessment of Functioning” and the “GAF Scale” may be
used to report such “overall functioning.” Id. “The GAF Scale is to be rated with respect only to
psychological, social, and occupational functioning. . . . [and] is divided into 10 ranges of
functioning.” Id. The most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders [hereinafter DSM-5], American Psychiatric Association (5th ed. 2013), has dropped the
GAF Scale and included a different global functioning measure–“the WHO Disability Assessment
Schedule (WHODAS) . . . .” DSM-5 at 16.
The court finds several flaws in the ALJ’s GAF analysis. First, although the
ALJ acknowledged Ms. Lewis’s multiple GAF scores of 50 that were separately
documented by different doctors prior to filing her DIB claim (Tr. 283 (June 4, 2012,
by Dr. Joseph P. Lucas)); (Tr. 302 (July 10, 2012, by Dr. Jacey Hammel)), he
incorrectly stated the meaning of those mental functioning assessments. A GAF of 50
does not reflect “moderately severe” limitations in mental functioning. Instead, a
GAF of 50 indicates:
Serious symptoms (e.g., suicidal ideation, severe obsessional rituals,
frequent shoplifting) OR any serious impairment in social,
occupational, or school functioning (e.g., few friends, unable to keep
DSM-IV-TR at 34 (emphasis by underlining added); see McCloud v. Barnhart, 166
F. App’x 410, 418 (11th Cir. 2006) (“First, the parties agree that the ALJ erred when
he labeled McCloud’s 1998 GAF score as reflective of moderate symptoms.”).
Because the ALJ mistakenly described the import of Ms. Lewis’s GAF scores of 50,
his conclusion that Ms. Lewis’s limitations were less limited than “moderately
severe” is built upon a faulty premise and cannot be affirmed.
Second, the ALJ never expressly accepted or rejected Ms. Lewis’s GAF scores
of 50. Instead, based upon “subsequent records and the claimant’s reported abilities,”
the ALJ appears to have implicitly placed only partial weight on those GAF results
(i.e., treating the scores like medical opinions) that he incorrectly characterized as
reflecting a level of moderate limitations. (See Tr. 27 (“Therefore, [the opinions of
Drs. Lucas, Hammel, and Badari] are assigned partial weight.”)).
Third, the ALJ did not identify which specific subsequent documents or
reported activities he relied upon to dispute the validity of the reported GAF
measurements of Ms. Lewis’s mental functioning, much less explain why the
conclusion he drew–that Ms. Lewis was not as limited as her reported GAF scores of
50–made sense. As a result, the court is left to speculate as to the evidence relied
upon to support the ALJ’s reasoning and, in turn, the sufficiency of that evidence.
While the substantial evidence standard is a highly deferential one, the appellate
review process, nonetheless, demands an administrative decision that removes the
need for guesswork. See Owens v. Heckler, 748 F.2d 1511, 1514-15 (11th Cir. 1984)
(“A clear articulation of both fact and law is essential to our ability to conduct a
review that is both limited and meaningful.”).
Fourth, the ALJ completely ignored the GAF of 30 that was reported by Dr.
Lucas when Ms. Lewis was admitted to Brookwood Medical Center on May 22,
2012. (Tr. 283). A result of 30 signifies:
Behavior is considerably influenced by delusions or hallucinations
OR serious impairment in communication or judgment (e.g.,
sometimes in coherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in almost all areas (e.g., stays
in bed all day; no job, home, or friends.
DSM-IV-TR at 34. Assuming that the ALJ’s lack of clarity in the handling of Ms.
Lewis’s GAF scores of 50 falls short of reversible error, the totally unaddressed GAF
of 30 would, nonetheless, necessitate a remand because of the serious challenges that
are expected to be present in a claimant with that low level of mental functioning. “It
is not enough to discover a piece of evidence which supports the decision, but to
disregard other contrary evidence.” McCruter v. Bowens, 791 F.2d 1544, 1548 (11th
Cir. 1986); (see also Tr. 283 (“Long-term prognosis of course is guarded, but at this
point more stable.”) (emphasis added)); (cf. also Tr. 19 (acknowledging that Ms.
Lewis was hospitalized four times for decompensation in 2011)).
Fifth, the unaddressed GAF result of 30 is at odds with the well-settled rule
within the Eleventh Circuit that an ALJ must state specifically the weight accorded
each item of evidence and the reasons for his decision. See, e.g., Cowart v. Schweiker,
662 F.2d 731, 735 (11th Cir. 1981) (“What is required is that the ALJ state
specifically the weight accorded to each item of evidence and why he reached that
decision.”); Cowart, 662 F.2d at 735 (“In the absence of such a statement, it is
impossible for a reviewing court to determine whether the ultimate decision on the
merits of the claim is rational and supported by substantial evidence.”); Hudson v.
Heckler, 755 F.2d 781, 785 (11th Cir. 1985) (“The decision rendered by the ALJ also
does not make clear the weight accorded the evidence considered.”); Ryan v. Heckler,
762 F.2d 939, 942 (11th Cir. 1985) (“We cannot, however, conduct a review that is
both limited and meaningful if the ALJ does not state with sufficient clarity the legal
rules being applied and the weight accorded the evidence considered.” (citing Owens,
748 F.2d at 1514-15)).
In McCloud, the Eleventh Circuit reversed and remanded because the ALJ
completely disregarded a GAF score of 48 and was unclear about the weight he
afforded the claimant’s GAF of 45. 166 F. App’x 410, 418; see id. (“In addition to
this error, the ALJ failed to consider McCloud’s GAF score of 48 from June 2000,
which occurred just days before she filed for SSI benefits, when determining whether
she was disabled.”). Comparable to the situation in McCloud, the ALJ in the present
case misstated the meaning of Ms. Lewis’s GAF scores of 50 and then attempted to
implicitly discredit those scores in a vague manner, leaving this reviewing court to
guess as to the ALJ’s conclusion and reasoning. He also ignored Ms. Lewis’s lower
score of 30.6 Although McCloud is a non-binding Eleventh Circuit opinion, the court
The court questions, but is not entirely certain, whether the record contains other GAF
information for Ms. Lewis. (See Tr. 299 (reflecting “50” for session with Dr. Hammel on July 23,
2012)); (see Tr. 298 (reflecting “50” for session with Dr. Hammel on July 30, 2012)); (see Tr. 297
(reflecting “45” for session with Dr. Hammel on August 9, 2012)); (see Tr. 295 (reflecting “45” for
session with Dr. Hammel on August 21, 2012)); (see Tr. 293 (reflecting “50” for session on
September 14, 2012)).
agrees with its analysis that recognized the importance of considering or at least
explaining the weight of multiple, distinct GAF scores.7
The court acknowledges the Commissioner’s citation to several unpublished
Eleventh Circuit cases for the proposition that “the Commissioner has specifically
declined to endorse using the GAF scale because it does not have a direct correlation
to the severity requirements in the Commissioner’s mental disorders listings” and her
point that “the GAF scale was dropped from the most recent edition of the DSM.”
(Doc. 11 at 9-10); see also Hellman v. Barnhart, 48 F. App’x 26, 30 n.1 (3d Cir.
2002) (recognizing that a GAF score “is not in and of itself determinative of
Nonetheless, because the ALJ expressly relied upon Ms. Lewis’s GAF scores
of 50 to reach his decision, an examination of his handling of the GAF evidence on
appeal is appropriate. Also, although the Commissioner correctly points out in her
The undersigned has also rendered several decisions which relate to the ALJ’s inadequate
treatment of record evidence from which the analysis and disposition of this case persuasively flow.
See Roberson v. Astrue, No. 3:07-CV-1541-VEH, (Docs. 10, 11) (N.D. Ala. June 11, 2008)
(reversing and remanding under very similar circumstances where the court found that the ALJ’s
treatment of competing GAF scores was not adequate); see also Seidman v. Astrue, No. 6:07-CV1921-VEH, (Docs. 11, 12) (N.D. Ala. June 30, 2008) (reversing and remanding when “the ALJ failed
to explain why Dr. Harrison’s opinion was found to be consistent with the very medical evidence
that the ALJ used to conclude that [the claimant] was not disabled when Dr. Harrison used such
findings to determine that [the claimant] was disabled”); Banks v. Astrue, No. 7:08-CV-0395-VEH,
(Docs. 11, 12) (N.D. Ala. Oct. 21, 2008) (reversing and remanding when ALJ failed to adequately
address claimant’s multiple GAF scores); but compare Carlisle v. Astrue, No. 3:06-CV-0983-VEH,
(Docs. 11, 12) (N.D. Ala. June 5, 2007) (affirming the Commissioner’s decision when the ALJ
afforded little weight to a GAF score of 45, but clearly explained his reason for doing so).
brief that Ms. Lewis received a GAF score of 51 (Tr. 387); (Doc. 11 at 9) in March
2014, which is indicative of moderate mental limitations,8 the ALJ did not reference
this particular evidence anywhere in his decision, and the Commissioner cannot
amend the ALJ’s decision through her brief. Therefore, the lack of clarity in this
ALJ’s decision makes this appeal significantly distinguishable from the record
reviewed in McGriff v. Comm’r, Soc. Sec. Admin., 654 F. App’x 469, 472 (11th Cir.
2016) (“That argument fails because even if a GAF score of 50 denotes more than
nondisabling symptoms, the ALJ found that during the same time period, McGriff
obtained GAF scores greater than 50 and that her GAF scores continued to improve
with treatment.”) (emphasis added). Consequently, the court rejects the
Commissioner’s invitation (Doc. 11 at 9 n.2) to treat the ALJ’s GAF errors as
harmless ones–the court cannot conclude that correcting these errors would not
change the ALJ’s decision. Cf. Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983)
(applying harmless-error rule to irrelevant mistakes that ALJ made in his analysis of
(i) vocational factors and (ii) the claimant’s past work experience given the ALJ’s
overriding finding that the claimant had no severe impairment).
Therefore, Ms. Lewis’s case is due to be remanded on account of the ALJ’s
multiple errors in his treatment of the GAF evidence.
DSM-IV-TR at 34.
The ALJ Improperly Disregarded the Eleventh Circuit’s
Rules in Assigning Weight to the Various Medical Opinions.
The court also finds that the ALJ committed reversible error in his treatment
of the medical opinions. With respect to an ALJ’s consideration of medical opinions,
the following framework applies:
In assessing the medical evidence in this case, the ALJ was required to
state with particularity the weight he gave the different medical opinions
and the reasons therefor. MacGregor v. Bowen, 786 F.2d 1050, 1053
(11th Cir. 1986). Further, he was required to accord considerable weight
to appellant’s treating physician’s opinion absent good cause for not
doing so. Broughton v. Heckler, 776 F.2d 960, 961–62 (11th Cir. 1985)
(per curiam). The opinions of nonexamining, reviewing physicians, such
as those of Drs. Thomas and Register, when contrary to those of the
examining physicians, are entitled to little weight, and standing alone do
not constitute substantial evidence. See Spencer ex rel. Spencer v.
Heckler, 765 F.2d 1090, 1094 (11th Cir. 1985) (per curiam). Of course,
the ALJ may reject any medical opinion if the evidence supports a
contrary finding. Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir. 1985)
The ALJ, here, disregarded these rules in assigning weight to the
various medical opinions. The only opinions that indicated that
appellant could meet the medium work requirements of 20 C.F.R.
404.1567(c) (1986) were those of the nonexamining physicians, Drs.
Thomas and Register. Their opinions were entitled to little weight,
however, and could not serve as substantial evidence.
Shafarz v. Bowen, 825 F.2d 278, 279-80 (11th Cir. 1987) (emphasis added).
Here, the ALJ’s decision runs afoul of these rules. More specifically, in
evaluating the vocational impact of Ms. Lewis’s mental impairments, the ALJ
“assign[ed] great weight to the opinions expressed by the non-examining State agency
physician, Robert Estock, M.D.” rendered on December 13, 2012. (Tr. 26, 123). As
justification for doing so, the ALJ maintained that:
Dr. Estock had the opportunity to review the claimant’s available
medical records and completed a summary of the record on December
13, 2012. His opinion in regards to the claimant’s limitations is
supported by detailed reports based on comprehensive assessments of
the claimant’s abilities and significant experience and knowledge of
agency requirements. His opinion is consistent with the record when
considered in its entirety and consistent with the aforementioned
residual functional capacity and therefore assigned great weight.
(Tr. 26 (emphasis added)). The ALJ did not indicate which detailed reports Dr.
Estock relied upon in formulating his mental assessment of Ms. Lewis. Further, Dr.
Estock’s assessment did not refer to any such reports. (Tr. 120-24).
Dr. Estock provided the only opinion within the record that Ms. Lewis is not
disabled despite the impact of her mental impairments. (Tr. 123). His paper review
opinion is at odds with the import of Ms. Lewis’s GAF scores as set out above and
the opinions of her examining/treating physicians. (See, e.g., Tr. 283 (“Long-term
prognosis of course is guarded, but at this point more stable.”)).
The validity of Dr. Estock’s opinion is further undermined by the indication
that he did not consider the examining/treating source records of Drs. Lucas,
Hammel, and Badari, including Ms. Lewis’s GAF scores, when making his mental
capacity assessment of Ms. Lewis. (See Tr. 122 (reflecting in “RECONCILIATION
OF SOURCE OPINION” section that “[t]here is no indication that there is opinion
evidence from any source”)). Therefore, Dr. Estock’s opinion was entitled to little
weight and cannot serve as substantial evidence to support the ALJ’s decision.
Shafarz, 825 F.2d at 280.
Additionally, while the ALJ attempted to explain why he gave only partial
credit to the opinion of Dr. Hammel, who undoubtedly qualifies as Ms. Lewis’s
treating psychiatrist,9 the vagueness of that effort falls short of the good cause
measure. (See Tr. 26 (“[H]owever, the undersigned finds that based on subsequent
records and the claimant’s reported abilities, she is less limited than indicated by …
Dr. Hammel . . . .”)); see also Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir.
1997) (“The law of this circuit is clear that the testimony of a treating physician must
be given substantial or considerable weight unless ‘good cause’ is shown to the
contrary.” (citing MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986)));
Lewis, 125 F.3d at 1440 (“A similar preference for the opinions of treating doctors
is found in the Commissioner’s regulations[.]” (citing 20 C.F.R. § 404.1527(d)(2), but
According to the treatment notes from Grayson & Associates, P.C., Ms. Lewis saw Dr.
Hammel on an outpatient basis on July 10, 2012 (Tr. 302); July 23, 2012 (Tr. 299); July 30, 2012
(Tr. 298); August 9, 2012 (Tr. 297); August 15, 2012 (Tr. 296); August 21, 2012 (Tr. 295); and
September 14, 2012. (Tr. 293).
such treating-source preference (for claims filed before March 27, 2017) now appears
in 20 C.F.R. § 404.1527(c)(2))).10
In particular, the ALJ did not clarify which subsequent record or reported
ability he relied upon to discount Dr. Hammel’s opinion about the serious low level
of Ms. Lewis’s mental functioning. Further, without indicating the specific evidence
he did rely upon, it is impossible for the court to evaluate whether the ALJ’s cause
for discounting Dr. Hammel’s opinion was good or bad. See Jackson v. Astrue, No.
CV-107-020, 2008 WL 596769, at *7 (S.D. Ga. Mar. 4, 2008) (“[T]he law requires
the Commissioner to provide a well-reasoned, well articulated decision.”); id.
(“Without such an analysis, the federal courts are unable to provide claimants with
a sound, meaningful review of the administrative decision.”).
In arguing that the ALJ committed no error in his great reliance upon Dr.
Estock’s mental assessment of Ms. Lewis, the Commissioner claims that “[t]he
Eleventh Circuit has found that an ALJ may properly accord more weight to state
agency physician opinions than to treating physician opinions.” (Doc. 11 at 11). The
court has studied the two unpublished opinions cited by the Commissioner and finds
20 C.F.R. § 404.1520c establishes a new regulatory framework for considering and
articulating the value of medical opinions for claims filed on or after March 27, 2017. See 82 FR
5867, 2017 WL 168819 (revisions to medical evidence rules dated Jan. 18, 2017, and effective Mar.
them to be distinguishable.11
First, in Jarrett v. Comm’r of Soc. Sec., 422 F. App’x 869 (11th Cir. 2011), the
court explained why “the ALJ had good cause to not give [a particular opinion of one
of the claimant’s treating physicians–Dr. Mian] substantial weight.” 422 F. App’x at
874. Further, because the opinions of the state agency medical consultants “did not
otherwise contradict Dr. Mian’s or any other doctor’s treatment records, the ALJ did
not err in relying on the reports of these non-examining physicians.” Id. As pointed
out above, Ms. Lewis’s case is unlike Jarrett because of the conflict between the
GAF scores and other treatment information reported by Drs. Hammel and Lucas
versus Dr. Estock’s mental assessment of Ms. Lewis after reviewing only a partial
medical record. (See Doc. 11 at 11 (“Although Dr. Estock did not review the entire
medical record . . . .”)).
Forsyth v. Comm’r of Soc. Sec., 503 F. App’x 892 (11th Cir. 2013), is similarly
distinguishable because, in that case, the panel agreed that the ALJ had properly
discredited the opinions of the claimant’s treating physicians. 503 F. App’x at 893.
Also, the nonexamining board-certified neurologist in Forsyth, “had expertise in this
These decisions are also non-binding on this court. See Baker v. Birmingham Bd. of Educ.,
531 F.3d 1336, 1338 (11th Cir. 2008) (“However, because Palmer is an unpublished decision, it is
not binding precedent.”).
field, had studied the entire record, and was subjected to questioning by the ALJ and
Forsyth’s attorney.” Id. In sharp contrast to Forsyth, this court has found reversible
error in the ALJ’s efforts to discredit the opinion of Dr. Hammel. Further, the mental
functional assessment that Dr. Estock prepared on Ms. Lewis does not indicate that
he is a specialist (see Tr. 122 (“Robert Estock M.D.”)), the Commissioner has
confirmed that Dr. Estock reviewed an incomplete medical record (Doc. 11 at 11),
and Dr. Estock was not made available for questioning at the administrative hearing.
(See Tr. 34 (listing persons in attendance at hearing held on May 1, 2014)).
Therefore, the Commissioner’s cases are unpersuasive, and Ms. Lewis’s case
is alternatively due to be remanded on account of the ALJ’s failure to follow the
Eleventh Circuit’s framework for assigning weight to medical opinions.
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 not supported
by substantial evidence. Accordingly, the Commissioner’s decision is REVERSED
and the case REMANDED for further development.
DONE this 27th day of March, 2017.
VIRGINIA EMERSON HOPKINS
United States District Judge
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