Gideon v. Social Security Administration, Commissioner

Filing 13

MEMORANDUM OPINION and ORDER DISMISSING CASE that the decision of the Commissioner is AFFIRMED and costs are taxed against the claimant as more fully set out in order. Signed by Judge C Lynwood Smith, Jr on 5/15/2018. (AHI )

FILED
2018 May-15 PM 02:52
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
SABRINA GIDEON,
Claimant,
vs.
NANCY A. BERRYHILL, Acting
Commissioner, Social Security
Administration,
Defendant.

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Civil Action No. 2:17-cv-1302-CLS

MEMORANDUM OPINION AND ORDER
Claimant, Sabrina Gideon, who is proceeding pro se, commenced this action
on August 3, 2017, 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, and thereby denying her claim for a period of disability, disability
insurance, and supplemental security income benefits. For the reasons stated herein,
the court finds that the Commissioner’s ruling is due to be affirmed.
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).
Briefs are not required from pro se parties in Social Security appeal cases,1 and
claimant did not file a supporting brief. Nevertheless, this court has carefully
reviewed the entire record in reaching its determination of the merits of claimant’s
appeal.
Claimant alleged that she became disabled on October 20, 2012, as a result of
fibromyalgia, neck and shoulder blade paralysis, chronic urinary tract infections,
chronic kidney infections, severe anemia, depression, anxiety, and chronic pain.2 The
ALJ found that claimant suffered from the severe impairments of fibromyalgia, major
depressive disorder, anxiety, degenerative disc disease, and degenerative joint
disease.3

Even so, she found that claimant did not have an impairment or

combination of impairments that met or medically equaled one of the listed
impairments.4 Moreover, claimant retained the residual functional capacity
to perform sedentary work as defined in 20 CFR 404.1567(a) and
416.9767(a) except for the additional restrictions described herein. The
claimant can occasionally climb ramps and stairs but can never climb
ladders, ropes, or scaffolds. She can occasionally balance, stoop, and
kneel, but never crouch or crawl. She can use her bilateral upper
1

See doc. no. 10 (briefing letter), at 1 (“Unless plaintiff is proceeding without counsel, initial
briefs will be required of all parties.”) (emphasis supplied).
2

Tr. 245.

3

Tr. 26.

4

Tr. 27.

2

extremities for constant reaching, handling, fingering, and feeling. She
should avoid work settings with concentrated exposure to extreme cold
or wetness, and she should not work around hazardous conditions, such
as unprotected heights or moving machinery. The claimant can
understand, remember, and carry out simple instructions but not those
that are more detailed or complex. She can adapt to workplace changes
that are infrequent and gradually introduced. The claimant can
occasionally interact with members of the public and frequently interact
with coworkers and supervisors. She can sustain attention and
concentration for two-hour blocks to complete an eight-hour workday
with customary breaks.
Tr. 28. The ALJ then relied upon vocational expert testimony to determine that a
person of claimant’s age, education, work experience, and residual functional
capacity could perform jobs that exist in significant numbers in the national
economy.5 Accordingly, the ALJ found that claimant was not under a disability, as
defined by the Social Security Act, from October 20, 2012, the alleged onset date,
through the date of the decision.6
Claimant requested the Appeals Council to review the ALJ’s decision ,7 but the
Appeals Council denied her request on June 9, 2017, stating that there was “no reason
under our rules to review the Administrative Law Judge’s decision.”8 The Appeals
Council also stated that it had not considered additional evidence submitted by

5

Tr. 31.

6

Tr. 32.

7

Tr. 180.

8

Tr. 1.

3

claimant.

Part of that evidence was duplicative of evidence already in the

administrative record, and the remainder of the evidence did not “show a reasonable
probability that it would change the outcome of the decision.”9 The ALJ’s decision
thus became the final decision of the Commissioner.10
Upon review of the entire record, the court concludes that the Commissioner’s
decision was supported by substantial evidence and in accordance with applicable
law. First, the ALJ correctly evaluated claimant’s eligibility under Listings 12.04 and
12.06. Both Listings require a claimant to show at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence,
or pace; or
4. Repeated episodes of decompensation, each of extended
duration.
20 C.F.R. pt. 404, subpt. P, appx. 1, §§ 12.04B, 12.06B (listings) (“B criteria”). The
ALJ found that claimant experienced no more than moderate restriction of activities
of daily living, and no more than moderate difficulties in maintaining social
functioning, concentration, persistence, or pace. To support that finding, the ALJ

9

Tr. 2, 5-6.

10

Tr. 1.

4

stated that the “record documents very limited mental health treatment,” and
claimant’s pharmacy records “reflect only intermittent use of antidepressant
medication.”11 The ALJ also found that claimant had never experienced extended
episodes of decompensation, because there was no evidence “that claimant has ever
required any inpatient or intensive psychiatric treatment or experienced any
prolonged episodes of exacerbated emotional symptoms.”12 The record supports
those conclusions.
Claimant’s records from Cooper Green Pharmacy reflect that long periods of
time — sometimes a year or more — would go by before claimant refilled her
prescription for anti-depressant medication.13 Additionally, while claimant’s function
reports reflect some limitations in daily activities, social functioning, and
concentration, those limitations were not marked. Claimant reported that she could
care for her personal needs, remember to take her medication, prepare meals, drive,
go out alone, shop, handle money, attend Bible study, and care for her children.14
Despite the fact that state agency psychiatrist Dr. Robert Estock stated on May 28,
2014, that claimant had experienced “one or two” extended episodes of

11

Tr. 27.

12

Id.

13

Tr. 310-12.

14

Tr. 268-75, 580.

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decompensation,15 there simply is no evidence that claimant has been unable to live
outside a highly supportive environment on more than one occasion. To the contrary,
claimant told the consultative psychological examiner on May 10, 2014, that she had
never had any psychiatric treatments or hospitalizations.16
Substantial evidence also supports the ALJ’s residual functional capacity
finding. The ALJ accounted for claimant’s mental impairments by limiting her to
simple instructions, infrequent and gradual workplace changes, occasional interaction
with the public, frequent interaction with coworkers and supervisors, and two-hour
blocks of attention and concentration with customary breaks. The medical record
does not support the imposition of any additional limitations. As discussed above,
claimant received only intermittent treatment for her mental conditions. Additionally,
Sharon D. Waltz, Psy.D., the consultative psychological examiner, found claimant to
exhibit full orientation, adequate attention and concentration, good memory and fund
of information, adequate abstractions, normal thought processes and content, and fair
insight and judgment. Dr. Waltz assessed claimant with depressive disorder, not
otherwise specified, and assessed a GAF score of 60, indicating moderate symptoms.
Claimant’s prognosis for improvement with treatment was fair. Dr. Waltz also stated:

15

Tr. 123.

16

Tr. 578.

6

Ms. Gideon does not likely have a life-long history of mental
slowness. Ms. Gideon is able to manage financial benefits with
assistance. Ms. Gideon has mental impairment present to a moderate
degree. Her behavior was cooperative. She has restriction of activities.
She has constriction of interests and difficulties relating to others due to
mental health symptoms. Ms. Gideon is able to function primarily
independently with assistance. Based on the medical findings, Ms.
Gideon’s ability to understand, to carry out and to remember instructions
and to respond appropriately to supervision, co-workers and work
pressures in a work setting despite her impairments is Moderately
Impaired. She may benefit from vocational, employability and/or social
skills training to assist her in being successful in a work environment.
Tr. 580. Dr. Waltz’s findings are consistent with the ALJ’s residual functional
capacity finding. The ALJ’s findings also are consistent with Dr. Estock’s state
agency assessment, except insofar as Dr. Estock found that claimant had experienced
episodes of decompensation and would need to be absent from work 1-2 times per
week as a result of her symptoms, and the ALJ adequately explained why those
findings by Dr. Estock were not supported by the record.17
The ALJ also accounted for claimant’s physical impairments by limiting her
to a reduced range of sedentary work, and the record does not dictate the imposition
of any additional physical limitations. During a May 10, 2014 consultative physical
examination by Dr. T. Gaston, claimant exhibited normal coordination, station, and
gait; normal but painful range of motion; twelve of eighteen trigger points for
17

Tr. 29. See also Tr. 127-29 (Dr. Estock’s assessment). The ALJ also properly rejected
statements by Dr. Estock that were not consistent with the Commissioner’s vocational guidelines,
including the need for a “flexible schedule” and “supportive” supervision.

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fibromyalgia; and full grip and motor strength. Dr. Gaston assessed claimant with
fibromyalgia and possible cervical spine pathology. He found that claimant could
stand and walk for up to six hours during an eight-hour work day, and could sit with
no limitations. She had no limitations on lifting, carrying, handling, or fingering.
She could frequently reach and climb stairs and steps; occasionally climb ladders,
scaffolds, and ropes; and frequently stoop, crouch, kneel, and crawl. She had no
workplace environmental limitations. Dr. Gaston noted that claimant’s clinical
examination was “essentially normal,” although claimant did consistently express
pain throughout.18 Additionally, Dr. Max Michael, claimant’s treating physician,
stated on November 30, 2012, that claimant’s fibromyalgia was “moderately severe,”
an assessment that does not indicate disabling limitations.19 Even though Dr. Michael
went on to state that claimant was “unable to maintain any gainful employment
because of her conditions and is therefore disabled,” the ALJ properly rejected that
statement because the decision of whether a claimant is disabled is not a medical
opinion, but is a decision “reserved to the Commissioner.” 20 C.F.R. §§ 404.127(d),
416.927(d).20
Finally, none of the new evidence presented to the Appeals Council warrants
18

Tr. 571-76.

19

Tr. 640.

20

See Tr. 30, 640.

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overturning the ALJ’s decision.
When a claimant submits new evidence to the AC [i.e., Appeals
Council], the district court must consider the entire record, including the
evidence submitted to the AC, to determine whether the denial of
benefits was erroneous. Ingram[ v. Commissioner of Social Security
Administration], 496 F.3d [1253,] 1262 [(11th Cir. 2007)]. Remand is
appropriate when a district court fails to consider the record as a whole,
including evidence submitted for the first time to the AC, in determining
whether the Commissioner’s final decision is supported by substantial
evidence. Id. at 1266-67. The new evidence must relate back to the
time period on or before the date of the ALJ’s decision. 20 C.F.R. §
404.970(b).
Smith v. Astrue, 272 F. App’x 789, 802 (11th Cir. 2008) (alterations supplied).
Claimant submitted pharmacy records to the Appeals Council,21 but, as discussed
above, those records show only intermittent refills for psychiatric medications. The
records do reflect that claimant was consistently prescribed medication for her
physical ailments, but the medication list says nothing about her functional
limitations, which is the central issue in determining disability status. Claimant also
submitted bills for treatment received from Radiology Associates,22 a letter from
Pfizer reflecting that she has been prescribed Lyrica,23 and a September 28, 2010
treatment note from Dr. Mark Wilson reflecting that she had been diagnosed with

21

Tr. 9-20.

22

Tr. 38-40.

23

Tr. 41-42. Lyrica is a drug used for treating, among other conditions, fibromyalgia. See,
e.g., www.lyrica.com.

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fibromyalgia.24

None of those documents reflect any new information about

plaintiff’s medical condition and the resulting limitations.
In summary, while is it apparent that claimant suffers from medical and
psychiatric conditions and is in some amount of pain, the mere existence of those
conditions, and even of the pain resulting from them, is not sufficient to establish
claimant’s disability. Instead, the relevant consideration is the combined effect of all
of claimant’s conditions on her ability to perform substantial gainful work activities.
See 20 C.F.R. §§ 404.1505(a), 416.905(a) (defining a disability 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 12 months”). See also
Bowen v. Yuckert, 482 U.S. 137, 146 (1987) (“The [Social Security] Act ‘defines
“disability” in terms of the effect a physical or mental impairment has on a person’s
ability to function in the workplace.’”) (quoting Heckler v. Campbell, 461 U.S. 458,
459-60 (1983)) (alteration supplied).
Without any evidence to support functional limitations greater than those
imposed by the ALJ, the decisions of the ALJ and the Appeals Council must stand.
The decision of the Commissioner is AFFIRMED because it was based upon
24

Tr. 43-44.

10

substantial evidence and in accordance with applicable legal standards. Costs are
taxed against claimant. The Clerk is directed to close this file.
DONE this 15th day of May, 2018.

______________________________
United States District Judge

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