Williams v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Abdul K Kallon on 9/18/2015. (YMB)
2015 Sep-18 PM 02:44
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CAROLYN , COMMISSIONER
OF SOCIAL SECURITY
Civil Action Number
Plaintiff Juanita Williams brings this action pursuant to Section 205(g) of
the Social Security Act (“the Act”), 42 U.S.C. § 405(g), seeking review of the final
adverse decision of the Commissioner of the Social Security Administration
(“SSA”). The court finds that the Administrative Law Judge’s (“ALJ”) decision—
which has become the decision of the Commissioner—is not supported by
substantial evidence because the ALJ relied primarily on the opinion of Dr. Robert
Heilpern, and therefore REMANDS the decision denying benefits.
I. Procedural History
Williams protectively filed for disability insurance benefits on September
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23, 2011, (R. 143), alleging a disability onset date of September 20, 2011, id., due
to breast cancer, Meuniere’s disease, vertigo, back pain related to a bulging disc,
degenerative disc disease, and bone spurs, (R. 176). After the SSA denied her
application on November 7, 2011, (R. 59), Williams requested a hearing, (R.
68–69). At the time of the hearing on April 1, 2013, Williams was fifty-three years
old, (R. 59), had received a G.E.D., (R. 38), and had past relevant light skilled
work as a medical assistant, light skilled work as an insurance sales agent, and
light semi-skilled work as an administrative clerk, (R. 37). Williams has not
engaged in substantial gainful activity her alleged onset date, (R. 21).
The ALJ denied Williams’ claim on April 16, 2013, (R. 16–32), which
became the final decision of the Commissioner when the Appeals Council refused
to grant review on August 29, 2014, (R. 1–6). Williams then filed this action
pursuant to section 1631 of the Act, 42 U.S.C. § 1383(c)(3). Doc. 1.
II. Standard of Review
The only issues before this court are whether the record contains substantial
evidence to sustain the ALJ’s decision, see 42 U.S.C. § 405(g); Walden v.
Schweiker, 672 F.2d 835, 838 (11th Cir. 1982), and whether the ALJ applied the
correct legal standards, see Lamb v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988);
Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). Title 42 U.S.C. §§ 405(g)
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and 1383(c) mandate that the Commissioner’s “factual findings are conclusive if
supported by ‘substantial evidence.’” Martin v. Sullivan, 894 F.2d 1520, 1529
(11th Cir. 1990). The district court may not reconsider the facts, reevaluate the
evidence, or substitute its judgment for that of the Commissioner; instead, it must
review the final decision as a whole and determine if the decision is “reasonable
and supported by substantial evidence.” See id. (citing Bloodsworth v. Heckler,
703 F.2d 1233, 1239 (11th Cir. 1983)).
Substantial evidence falls somewhere between a scintilla and a
preponderance of evidence; “[i]t is such relevant evidence as a reasonable person
would accept as adequate to support a conclusion.” Martin, 849 F.2d at 1529
(quoting Bloodsworth, 703 F.2d at 1239) (other citations omitted). If supported by
substantial evidence, the court must affirm the Commissioner’s factual findings
even if the preponderance of the evidence is against the Commissioner’s findings.
See Martin, 894 F.2d at 1529. While the court acknowledges that judicial review
of the ALJ’s findings is limited in scope, it notes that the review “does not yield
automatic affirmance.” Lamb, 847 F.2d at 701.
III. Statutory and Regulatory Framework
To qualify for disability benefits, a claimant must show “the inability to
engage in any substantial gainful activity by reason of any medically determinable
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physical or mental impairments 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
months.” 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 416(I). A physical or mental
impairment is “an impairment that results from anatomical, physiological, or
psychological abnormalities which are demonstrated by medically acceptable
clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3).
Determination of disability under the Act requires a five step analysis. 20
C.F.R. § 404.1520(a)-(f). Specifically, the Commissioner must determine in
whether the claimant is currently unemployed;
whether the claimant has a severe impairment;
whether the impairment meets or equals one listed by the Secretary;
whether the claimant is unable to perform his or her past work; and
whether the claimant is unable to perform any work in the national
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “An affirmative
answer to any of the above questions leads either to the next question, or, on steps
three and five, to a finding of disability. A negative answer to any question, other
than step three, leads to a determination of ‘not disabled.’” Id. at 1030 (citing 20
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C.F.R. § 416.920(a)-(f)). “Once a finding is made that a claimant cannot return to
prior work the burden shifts to the Secretary to show other work the claimant can
do.” Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995) (citation omitted).
IV. The ALJ’s Decision
As a preliminary matter, the ALJ noted that Williams meets the insured
status requirements of the Act through December 31, 2016, (R. 21). Turning to the
Five Step sequential analysis, the ALJ initially determined that Williams had not
engaged in substantial gainful activity since her alleged onset date and therefore
met Step One, (R. 21). Next, the ALJ acknowledged that Williams’ severe
impairments of history of breast cancer status post double mastectomy and
reconstruction, history of Meuniere’s disease, gastroesophageal reflux disease, and
cervical degenerative disc disease met Step Two. Id. The ALJ then proceeded to
the next step and found that Williams did not satisfy Step Three since she “does
not have an impairment or combination of impairments that meets or medically
equals the severity of one of the listed impairments.” Id. Although the ALJ
answered Step Three in the negative, consistent with the law, see McDaniel, 800
F.2d at 1030, the ALJ proceeded to Step Four, where he determined that Williams
has the residual functional capacity [(“RFC”)] to lift and carry 50 pounds
[occasionally] and 25 pounds frequently; stand and walk approximately six
hours in an eight-hour day; sit approximately six hours in an eight-hour day;
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and frequently climb ramps and stairs, stoop, kneel, crouch and crawl. She
is precluded from balancing on beams; she needs to avoid concentrated
exposure to noise; and she is precluded from unprotected heights or
dangerous or moving equipment, and from work around ladders, ropes or
(R. 22). In light of Williams’ RFC, the ALJ determined that Williams “is capable
of performing past relevant work as a medical assistant[,] . . . insurance sales, . . .
and as an optical office/administrative clerk” because “[t]his work does not require
the performance of work-related activities precluded by [Williams’ RFC],”
(R. 26). Therefore, because the ALJ answered Step Four in the negative, the ALJ
determined that Williams is not disabled. Id.; see also McDaniel, 800 F.2d at
Williams contends that the ALJ erred by improperly considering evidence
submitted by Williams’ medical providers, doc. 7 at 7–14, and by relying on the
opinion of Dr. Robert Heilpern, id. at 12. The court will consider each argument in
1. Dr. Hudgins, Dr. Mishra, and Salisia Valentine, R.N.P.
Williams contends that the ALJ erred by improperly considering evidence
submitted by Dr. Diana Hudgins, Williams’ chiropractor, Dr. Pranav Mishra, one
of Williams’ treating physicians, and Salisia Valentine, a nurse practitioner
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involved in Williams’ medical treatment.1 Id. at 7–14. The ALJ properly
discredited Dr. Hudgins’ opinion and gave it no weight, (R. 25).2 Dr. Hudgins
submitted a letter discussing Williams’ impairments and stating that “[d]ue to the
cervical spine instability it is my opinion that she has reached maximum medical
improvement and therefore [should] be considered for permanent medical
disability,” (R. 492). As the ALJ properly noted, Dr. Hudgins’ opinion that
Williams is permanently disabled is an opinion on an issue reserved to the
Commissioner, and therefore not entitled to any special significance, (R. 25); see
also 20 C.F.R. 404.1527(d). The ALJ also noted that Dr. Hudgins’ opinion is
inconsistent with the great weight of the objective medical evidence that
shows that [Williams’] orthopedic issues are not more than mild to moderate
in nature, and . . . is inconsistent with the fact that [Williams] has not sought
treatment from a specialist for her back pain and nothing other than
conservative treatment has been recommended.
(R. 26). Inconsistency with the record is grounds for discrediting a medical
As part of this argument, Williams contends that the ALJ erred by failing to recontact
Dr. Hudgins and Valentine for clarification. Doc. 7 at 11–12. Recontacting a medical source to
resolve an inconsistency or insufficiency is no longer required by the regulations. See 20 C.F.R.
Williams contends that the ALJ incorrectly concluded that Dr. Hudgins was not an
acceptable medical source. Doc. 7 at 11. To the contrary, the ALJ noted that while a chiropractor
is not an acceptable medical source pursuant to 20 C.F.R. § 404.1513(a), and therefore “cannot
establish the existence of a medically determinable impairment,” “[a] chiropractor is considered
to be a medical source whose opinion may be used to establish the nature and severity of
medically determinable impairments and the claimant’s ability to function,” (R. 25); see also 20
C.F.R. § 404.1513(d)(1).
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opinion. See 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.”).
Consequently, because Dr. Hudgins’ opinion regarded an issue reserved to the
Commissioner and was inconsistent with the record, the ALJ did not err by giving
it no weight.
The ALJ’s treatment of the material generated by Dr. Mishra and Valentine
is more problematic. Dr. Mishra and Valentine submitted identical3 letters on
Williams’ behalf in which they listed Williams’ diagnoses and described the
treatment Williams pursued, (R. 488–89; 551–52). The ALJ afforded little weight
to Valentine’s letter because “[w]hile [the] letter describes [Williams’] symptoms
as reported by [Williams], it does not give any objective medical evidence that
would support a finding that [Williams’] medical conditions disable her,” (R. 25).
He did not discuss Dr. Mishra’s letter at all.
The Commissioner contends that the ALJ did not err in affording little
weight to Valentine’s letter and failing to discuss Dr. Mishra’s letter because the
letters are not medical opinions. Doc. 8 at 4–8; see also Winschel v. Comm’r of
Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011) (emphasis added) (quoting Lewis
Dr. Mishra and Valentine belong to the same medical practice. See (R. 488–89;
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v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 2011) (“Absent ‘good cause,’ an ALJ
is to give the medical opinions of treating physicians ‘substantial or considerable
weight.’”)); 20 C.F.R. 404.1527(c) (emphasis added) (“Regardless of its source we
will evaluate every medical opinion we receive.”).
“Medical opinions are statements from physicians and psychologists or
other acceptable medical sources that reflect judgments about the nature and
severity of [the claimant’s[ impairment(s), including [the claimant’s]
symptoms, diagnosis and prognosis, what [the claimant] can still do despite
impairment(s), and [the claimant’s] physical or mental restrictions.”
Winschel, 631 F.3d at 1179–80 (quoting 20 C.F.R. § 404.1527(a)(2)). Although
the issue is not crystal-clear, the court is inclined to agree with the Commissioner
because the letters do not provide any insight into the functional limitations
created by Williams’ condition. “[T]he mere existence of . . . impairments does not
reveal the extent to which they limit [a claimant’s] ability to work or undermine
the ALJ’s determination in that regard.” Moore v. Barnhart, 405 F.3d 1208, 1213
n. 6 (11th Cir. 2005) (citing McCruter v. Bowen, 791 F.2d 1544, 1547 (11th Cir.
1986) (“‘severity’ of a medically ascertained disability must be measured in terms
of its effect upon ability to work”)). Fortunately, though, Williams’ claim does not
succeed or fail solely on this issue because the ALJ committed clear error in
relying on the opinion of Dr. Robert Heilpern.
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2. Dr. Robert Heilpern
The ALJ gave “significant” weight to the opinion of Dr. Robert Heilpern, a
non-examining state-agency physician,4 (R. 26); see also (R. 435–42). The opinion
of a non-examining reviewing physician “is entitled to little weight and taken
alone does not constitute substantial evidence to support an administrative
decision.” Swindle v. Sullivan, 914 F.2d 222, 226 n. 3 (11th Cir. 1990) (citing
Broughton v. Heckler, 776 F.2d 960, 962 (11th Cir. 1985)). Critically, although
the ALJ noted that Dr. Heilpern’s opinion was “consistent with the evidence as a
whole,” (R. 26), the court has thoroughly reviewed the record and concluded that
Dr. Heilpern’s opinion is the only basis for the ALJ’s assessment that Williams is
capable of medium work. See (R. 436) (positing that Williams can lift fifty pounds
occasionally and twenty-five pounds frequently). Because the opinion of a nonexamining reviewing physician, “taken alone[,] does not constitute substantial
evidence to support an administrative decision,” Swindle, 917 F.2d at 226 n. 3,
substantial evidence does not support the ALJ’s assessment of Williams’ RFC and,
consequently, his decision as a whole.
There is no mandatory requirement for an ALJ to order a consultative exam.
In fact, Dr. Heilpern’s opinion was the only medical opinion to which the ALJ afforded
any significant weight.
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See 20 C.F.R. § 404.1520b(c)(1)(3) (emphasis added) (“We may ask you to
undergo a consultative examination at our expense.”). Nonetheless, “[i]t is wellestablished that the ALJ has a basic duty to develop a full and fair record,” Ellison
v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003). Because Dr. Heilpern’s
opinion cannot be the sole basis of the ALJ’s RFC assessment, and in light of the
lack of any other evidence, aside from Williams’ testimony, which the ALJ
discredited, see (R. 25), this situation clearly warranted a consultative
examination. Consequently, the court remands this case with instructions to the
ALJ to further develop the record by ordering a consultative examination.
Based on the foregoing, the court concludes that the ALJ’s determination
that Williams is not disabled is not supported by substantial evidence. Therefore,
the court remands this case for proceedings consistent with this opinion. A
separate order in accordance with the memorandum of decision will be entered.
Done the 18th day of September, 2015.
ABDUL K. KALLON
UNITED STATES DISTRICT JUDGE
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