Washington v. Social Security Administration, Commissioner
Filing
20
MEMORANDUM OPINION - For the reasons set forth herein, and upon careful consideration of the administrative record and memoranda of the parties, the decision of the Commissioner of Social Security denying Washingtons claim for SSI is AFFIRMED and this action DISMISSED WITH PREJUDICE. Signed by Magistrate Judge John H England, III on 3/20/2018. (KEK)
FILED
2018 Mar-20 AM 11:28
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
MIDDLE DIVISION
GRETA WASHINGTON,
Plaintiff,
v.
COMMISSIONER OF THE SOCIAL
SECURITY ADMINISTRATION
Defendant.
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Case Number: 4:16-cv-00850-JHE
MEMORANDUM OPINION1
Plaintiff Greta Washington (“Washington”) seeks review, pursuant to 42 U.S.C. § 405(g),
§ 205(g) of the Social Security Act, of a final decision of the Commissioner of the Social Security
Administration (“Commissioner”), denying her application for Supplemental Security Income.
(“SSI”). (Doc. 1). Washington timely pursued and exhausted her administrative remedies. This
case is therefore ripe for review under 42 U.S.C. §§ 405(g), 1383(c)(3). The undersigned has
carefully considered the record and, for the reasons stated below, the Commissioner’s decision is
AFFIRMED.
I. Factual and Procedural History
Washington protectively filed her application for SSI on February 21, 2013, alleging she
became unable to work beginning November 1, 2010.2 (Tr. 43, 168-172). The Agency initially
1
In accordance with the provisions of 28 U.S.C. § 636(c) and Federal Rule of Civil
Procedure 73, the parties have voluntarily consented to have a United States Magistrate Judge
conduct any and all proceedings, including trial and the entry of final judgment. (Doc. 16).
2
Because an individual cannot receive SSI for any period prior to the month in which he
or she files an application, 20 C.F.R. §§ 416.330, 416335, February 2013 is the relative
beginning date to consider whether Washington has been under a disability.
denied Washington’s application (tr. 43, 107-17), and Washington requested a hearing (tr. 43, 12830) where she appeared on August 11, 2014 (tr. 43, 60-106). After the hearing, the Administrative
Law Judge (“ALJ”) denied Washington’s claim on October 31, 2014. (Tr. 40-59). Washington
sought review by the Appeals Council, but it declined her request on March 21, 2016. (Tr. 1-7).
On that date, the ALJ’s decision became the final decision of the Commissioner. On May 24,
2016, Washington initiated this action. (See doc. 1).
Born in 1968, Washington was forty-seven-years old when the ALJ denied her claim. (Tr.
55, 168). She has a GED (tr. 208), and previously worked as a fast food cashier, cleaner, packer,
and at a plant nursery (tr. 209). Washington alleges disability due to a dislocated shoulder, heel
spurs, arthritis, high blood pressure, bad ankles, left side constantly hurts, carpal tunnel, and back
pain. (Tr. 207). Washington states she stopped working on November 1, 2010, because of her
condition. (Id.).
II. Standard of Review3
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).
Substantial evidence is “such relevant evidence as a reasonable person would accept as adequate
3
In general, the legal standards applied are the same whether a claimant seeks Disability
Insurance Benefits (“DIB”) or SSI. However, separate, parallel statutes and regulations exist for
DIB and SSI claims. Therefore, citations in this opinion should be considered to refer to the
appropriate parallel provision as context dictates. The same applies to citations for statutes or
regulations found in quoted court decisions.
2
to support a conclusion.” Id. It is “more than a scintilla, but less than a preponderance.” Id.
This Court must uphold factual findings supported by substantial evidence. “Substantial
evidence may even exist contrary to the findings of the ALJ, and [the reviewing court] may have
taken a different view of it as a factfinder. Yet, if there is substantially supportive evidence, the
findings cannot be overturned.” Barron v. Sullivan, 924 F.2d 227, 230 (11th Cir. 1991). However,
the Court reviews the ALJ’s legal conclusions 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 the proper legal analysis
has been conducted, it must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 1143,
1145-46 (11th Cir. 1991).
III. 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.4 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 entitlement to disability
benefits, a claimant must provide evidence of a “physical or mental impairment” which “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.
4
3
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 sequence:
(1)
(2)
(3)
(4)
(5)
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 national
economy.
Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to the formerly applicable C.F.R.
section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 562-63 (7th Cir. 1999);
accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “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 such work exists in the national economy in significant numbers. Id.
IV. Findings of the Administrative Law Judge
After consideration of the entire record and application of the sequential evaluation
process, the ALJ made the following findings:
At Step One, the ALJ found Washington had not engaged in substantial gainful activity
since February 21, 2013, the application date. (Tr. 45). At Step Two, the ALJ found Washington
has the following severe impairments: plantar fasciitis (heel pain) NOS, chronic left hip pain,
bilateral carpal tunnel syndrome (CTS), depression, and anxiety. (Id.). At Step Three, the ALJ
found Washington did not have an impairment or combination of impairments that meets or
medically equals one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr.
4
45-47).
Before proceeding to Step Four, the ALJ determined Washington’s residual functioning
capacity (“RFC”), which is the most a claimant can do despite her impairments. See 20 C.F.R. §
404.1545(a)(1). The ALJ determined that Washington had the RFC to perform light work as
defined in 20 C.F.R. 416.967(b), with certain exertional and non-exertional limitations. (Tr. 4753).
At Step Four, the ALJ determined Washington is unable to perform any past relevant work.
(Tr. 53). At Step Five, the ALJ determined, based on Washington’s age, education, work
experience, and RFC, jobs exist in significant numbers in the national economy Washington could
perform. (Tr. 53-54). Therefore, the ALJ determined Washington has not been under a disability
and denied her claim. (Tr. 54-55).
V. Analysis
Although the court may only reverse a finding of the Commissioner if it is not supported
by substantial evidence or because improper legal standards were applied, “[t]his 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)). The court,
however, “abstains from reweighing the evidence or substituting its own judgment for that of the
[Commissioner].” Id. (citation omitted).
Here, substantial evidence supports the ALJ’s determination Washington failed to
demonstrate a disability, and the ALJ applied the proper standards to reach this conclusion.
Washington challenges the Commissioner’s decision on eight grounds. (See doc. 10 at 1-2, 4).
These challenges will be addressed as follows: (A) challenges based on lack of substantial
5
evidence: (1) Dr. Herrera’s opinion and (2) the ALJ’s RFC assessment; (B) challenge to finding
regarding severe impairments; (C) evaluation of Washington’s subjective complaints: (1)
credibility assessment, (2) SSR 16-3p, and (3) lack of medical treatment; and (D) challenges
related to the Appeals Council.
A. Challenge to Dr. Herrera’s Opinion and the ALJ’s RFC Assessment
1. Dr. Herrera’s Opinion
Washington asserts that the ALJ improperly considered Dr. Pascual Herrera’s opinion in
assessing Washington’s residual functioning capacity (“RFC”). (Doc. 10 at 17-20). An ALJ
considers numerous factors when evaluating a doctor’s opinion, including whether the doctor
examined the claimant, whether the doctor treated the claimant, the evidence the doctor presents
to support his or her opinion, whether the doctor’s opinion is consistent with the record as a whole,
and the doctor’s specialty. See 20 C.F.R. § 416.927(c). A treating doctor’s opinion generally is
entitled to more weight, and an ALJ must give good reasons for the weight given a treating doctor’s
opinion. See 20 C.F.R. § 416.927(c)(2); Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179
(11th Cir. 2011). However, an ALJ may discount a doctor’s opinion, including a treating doctor’s
opinion, when the opinion is conclusory, the doctor fails to provide objective medical evidence to
support his or her opinion, the opinion is inconsistent with the record as a whole, or the evidence
otherwise supports a contrary finding. See 20 C.F.R. § 416.927(c); Crawford, 363 F.3d at 115960.
Moreover, although doctors’ opinions about what a claimant can still do or the claimant’s
restrictions are relevant evidence, such opinions are not determinative because the ALJ has the
responsibility of assessing the claimant’s RFC. See 20 C.F.R. §§ 416.912(b)(2), 416.913(b)(6),
416.927(d)(2), 416.945(a)(3), 416.946(c); SSR 96-5p, 1996 WL 374183 (July 2, 1996). See also
6
Beegle v. Soc. Sec. Admin., Comm’r, 482 F. App’x 483, 486 (11th Cir. 2012) (“A claimant’s [RFC]
is a matter reserved for the ALJ’s determination, and while a physician’s opinion on the matter
will be considered, it is not dispositive”).
Specifically, Washington argues the ALJ erred because Dr. Herrera “stated the claimant
had limitations which precluded employment.” (Doc. 10 at 17-20). This argument is unavailing.
As noted, statements regarding a claimant’s RFC or that a claimant is “disabled” or “unable to
work” are not medical opinions; they are administrative findings within the ALJ’s discretion and
entitled to no special deference. See 20 C.F.R. § 416.927(d); Herron v. Soc. Sec. Admin., Comm’r,
649 F. App’x 781, 786 n.5 (11th Cir. 2016). Additionally, Dr. Herrera’s treatment records do not
support such a conclusion, as they document unremarkable examinations and conservative
treatment (e.g., medication therapy for diabetes and neuropathy and his finding that Plaintiff had
some decreased pinprick sensation in the legs but her feet were normal and she had no gait
disturbance) (Tr. 52-53, 376-382, 391-395, 402-03) and do not support his statements regarding
limitations. See 20 C.F.R. § 416.927(c)(3), (c)(4). Moreover, as the ALJ noted, the overall
objective medical evidence showed no significant limitations associated with her diabetes mellitus
(Tr. 52).
Washington fails to address the ALJ’s discussion of Dr. Herrera’s opinion, simply arguing
Dr. Herrera was a treating physician whose opinion “is entitled to greater weight.” (Doc. 10 at 1718). A review of the ALJ’s opinion and Dr. Herrera’s treatment records shows that the ALJ
assessed Dr. Herrera’s opinion based on proper regulatory factors. See 20 C.F.R. § 416.927(c).
The ALJ noted Dr. Herrera was a treating physician and found his opinion was inconsistent with
the overall record and was not supported by his own records, which are proper considerations. (Tr.
52). See 20 C.F.R. § 416.927(c)(2), (3), (4). The ALJ also found Dr. Herrera’s opinion was
7
unexplained and therefore conclusory. (Tr. 53).
See 20 C.F.R. § 416.927(c)(4). The ALJ
explained:
He rates her pain level as moderate. Nevertheless, his brief record of treatment
certainly does not disclose why his limitations are so drastic, especially with regards
to sitting, walking, etc. He opines “no sitting and one hour of standing and walking”
but then states she can “sit up to two hours in a day”. There is no reconciling his
limitations to any consistent pattern. Dr. Herrera also limits [Washington] to a sixhour workday but he fails to provide a rationale for his opinion.
(Tr. 53). Washington ignores these findings in her brief. (See doc. 10 at 17-20).
Washington also cites diagnoses and symptoms and argues Dr. Herrera’s opinion is entitled
to greater weight. (Doc. 10 at 18). This argument misses the point. The issue is not whether there
are facts that support an opinion different from the ALJ’s; the issue is whether there is substantial
evidence to support the ALJ’s decision, which there is as explained in the ALJ’s decision and
above. (Tr. 45-53). See 42 U.S.C. § 405(g); Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir.
2005); Wilson, 284 F.3d at 1221. This argument also ignores the fact the ALJ found Washington’s
subjective complaints “not entirely credible,” as discussed infra.
Washington’s argument that the ALJ failed to provide “good cause” for according
diminished weight to Dr. Herrera’s opinion (doc. 10 at 18-20) lacks support. The ALJ extensively
explained his evaluation of Dr. Herrera’s opinion and explained his reasons for according only
“partial weight” to his opinion. (Tr. 52-3). Essentially, the ALJ found Dr. Herrera’s “opinion was
not bolstered by the evidence; (2) evidence supported a contrary finding; or (3) treating physician’s
opinion was conclusory or inconsistent with the doctor’s own medical records,” which, as the
Eleventh Circuit held in Phillips, is “good cause” to support the ALJ’s decision. (Tr. 53). Phillips,
357 F.3d at 1240-41.
2. RFC Assessment
Washington next contends the ALJ’s RFC determination is conclusory and violates Social
8
Security Ruling (“SSR”) 96-8. (Doc. 10 at 32-35). A claimant’s RFC is the most she can still do
despite her limitations. See 20 C.F.R. §§ 416.920(e), 416.945(a)(1), (a)(3); SSR 96-8p, 1996 WL
374184 (July 2, 1996)). At the hearing level, the ALJ has the responsibility for assessing the
claimant’s RFC. See 20 C.F.R. § 416.946(c); SSR 96-5p, 1996 WL 374183 (July 2, 1996); see
also 20 C.F.R. § 416.927(d)(2) (stating that the assessment of a claimant’s RFC is an issue reserved
for the Commissioner). Thus, “the task of determining a claimant’s [RFC] and ability to work is
within the province of the ALJ, not of doctors.” Robinson, 365 F. App’x at 999.
The ALJ properly considered the relevant evidence in assessing Washington’s RFC (Tr.
47-53). See 20 C.F.R. §§ 416.927(c), 416.945(a)(3); SSR 96-8p, 1996 WL 374184 at *5; SSR 967p, 1996 WL 374186 (July 2, 1996); Wilson, 284 F.3d at 1225-26. He found the objective medical
findings did not indicate Washington was as limited as she claimed, and he provided substantial
evidence to support his RFC finding. (Tr. 50-52).
For example, as the Commissioner points out, Washington alleged shoulder pain; however,
the ALJ found the record shows only one ER visit in January 2004 for complaints of shoulder pain
and dislocation. (Tr. 50). At the hearing, Plaintiff noted additional X-rays (tr. 64-5), but no
additional X-rays were provided, and the ALJ found there were no shoulder treatment records after
the 2004 ER visit. (Tr. 50 citing Exhibit 4F (Tr. 307-32)).
In April 2013, consultative examiner Ronald Borlaza, M.D. examined Washington, who
reported left shoulder pain but stated she was taking only over-the-counter Tylenol or Advil. (Tr.
50, 341). Dr. Borlaza’s examination revealed some decreased range of motion at the left shoulder
with tenderness and moderate pain but was otherwise normal throughout. (Tr. 50, 343). Dr.
Borlaza found Washington was limited to occasional reaching but had no limitations with
handling, fingering, and feeling. (Tr. 50 citing Exhibit 7F (Tr. 344-45)). Moreover, the ALJ noted
9
that throughout the records from both Quality of Life and Dr. Herrera, Washington had no shoulder
complaints. (Tr. 50 citing Exhibits 3F (Tr. 297-306), 8F (Tr. 346-367), 11F (Tr. 376-3820, and
13F - 15F (Tr. 391-404)).
Regarding Washington’s allegations of left sided, low back, foot, and hip pain, the ALJ
found little evidence to consider. (Tr. 50). For example, Dr. Borlaza’s examination revealed
Washington had normal gait without an assistive device. (Tr. 50, 342). “She took her shoes off
and walked to the exam table with ease and without assistance. She did not use an assistive device
to walk.” (Tr. 342). She had full range of motion of the left hip but complained of pain. (Tr. 50,
343). She had normal range of motion of the lumbar spine, ankles, knees, cervical spine, wrist, and
fingers. (Tr. 50, 343). Washington was right-handed with no muscle atrophy. (Tr. 50, 344). Dr.
Borlaza assessed chronic left-shoulder pain due to history of dislocation, status post-surgery (1993)
(tr. 344), bilateral carpal tunnel syndrome, and chronic left hip pain. (Tr. 50, 344). He opined
Washington had no limitations with standing and sitting but was limited to walking six to eight
hours (Tr. 50, 344). He limited her to occasional reaching and climbing but no limitations with
climbing stairs, stooping, crouching, kneeling, and crawling (tr. 50, 344), and she should avoid
hazards. (Tr. 50, citing Exhibit 7F (Tr. 340-45)).
The ALJ found the Quality of Life clinic records showed one visit in December 2009, for
left ankle pain but no swelling with normal extremities. (Tr. 50, 299-300). Phillip Rogers, CRNP,
prescribed medication (Mobic) and home exercise. (Tr. 50, 300). Washington returned January
2010. (Tr. 50, 301-02). An x-ray showed calcaneal heel spur (plantar fasciitis) with mild to
moderate degenerative joint disease of the left ankle. (Tr. 50, 301). Nurse Rogers prescribed nonsteroid anti-inflammatory medication (“NSAIDS”). (Tr. 50, 302). On her visit on June 10, 2013,
Washington complained of heel, left arm, and back pain with radiation to the left thigh (Tr. 50).
10
She stated that she was not taking any prescribed medications (Tr. 51, 350). Examination showed
positive straight leg raise test on the left and edema in the hands and feet. (Tr. 51, 350). However,
a follow-up examination in July 2013, indicated negative straight leg raise test and minimal spasm
to the back. (Tr. 51, 365). She had tenderness to the heel. (Tr. 51, 365). An x-ray was scheduled,
but there is no evidence it was taken. (Tr. 51, 366).
The ALJ noted Washington sought no treatment and had no ER visits from July 2013 to
March 2014. (Tr. 51). On March 8, 2014, Dr. Herrera treated Washington’s complaints of left leg
and left-sided pain. (Tr. 51, 382). Washington’s examination was completely normal as well as
were her examinations on March 22, 2014 and May 31, 2014. (Tr. 51, 381-82, 393). Medication
adjustments were made, and her pain improved. (Tr. 51, 393). It was not until June 28, 2014, that
Dr. Herrera noted a positive straight leg raise test on the left and decreased sensation in her legs.
(Tr. 51, 394). However, in July 2014, her positive signs had returned to normal range. (Tr. 51,
402). She had normal gait with a negative straight leg raise test, and she used no assistive device
(Tr. 51, 402). An x-ray of the lumbar spine showed transitional L5/S1 element with minor
posterior fusion defect, minor underlying rotatory scoliosis with multi-level minor osteophytic
spurring, and mild to moderate lower facet and SI joint degenerative joint disease. (Tr. 51, 403).
Washington fails to show or even argue that the diagnostic imaging or other objective medical
findings established that she had disabling limitations.
The ALJ considered that Dr. Herrera restricted Washington to sitting, standing, and
walking two hours in an entire eight-hour day, occasionally push/pull with the lower extremities,
and occasionally squat and crawl. (Tr. 52-53). He also noted, however, that throughout the
treatment notes, Washington had no gait disturbance and used no assistive device. (Tr. 52 citing
Exhibit 14F). The ALJ found that Washington’s objective medical evidence showed no more than
11
mild to moderate symptoms that would limit her to occasionally climb ramps and stairs, crouch,
kneel, and crawl but no ladders or scaffolds. (Tr. 52). Thus, the ALJ found that Washington’s
symptoms would not prevent all work activity and the medical record findings were consistent
with the established RFC. (Tr. 52). Importantly, Washington raises no complaint regarding these
ALJ findings and, therefore, waives argument on these issues. Washington also cites no evidence
to undermine these ALJ findings. (Doc. 10 at 17-20). See e.g., Outlaw v. Barnhart, 197 F. App’x
825, 828 n.3 (11th Cir. 2006).
The ALJ also properly considered Washington’s activities in evaluating her RFC. (Tr. 46,
49-50). For example, at step three, when applying the Psychological Review Technique (“PRT”)
(see 20 C.F.R. § 416.920a), the ALJ found Washington had “mild” limitations in activities of daily
living. (Tr. 46). The ALJ also noted Washington reported to consultative examiner Dr. Borlaza
that she cooks, bathes, dresses, and watches TV, and frequently reads. (Tr. 46, 341). Importantly,
Washington raises no complaint regarding these findings. (Doc. 10 at 17-20, 32-38) and therefore
waives all argument on those issues. See Cunningham v. Dist. Att’y Office for Escambia Cnty., 592
F.3d 1237, 1254 n.9 (11th Cir. 2010); Copher v. Comm’r of Soc. Sec., 429 F. App’x 928, 930 n.1
(11th Cir. 2011).
After consideration of the entire record, the ALJ found Washington had the following RFC:
to perform light work as defined in 20 CFR 416.967(b) with certain exertional and
non-exertional limitations including: She would need an at will sit/stand option
with the retained ability to stay on or at work station in no less than 30 minute
increments each without significant reduction of remaining tasks. She can ambulate
short distances up to 100 yards per instance on flat hard surfaces. The claimant
could manipulate left foot controls frequently, and frequently manipulate hand
controls bilaterally. She can reach overhead with her dominate hand frequently but
only occasionally with her non-dominate left hand. She can reach in all directions
frequently, bilaterally. She could occasionally climb ramps and stairs but not
ladders or scaffolds. The claimant could frequently balance and stoop but only
occasionally crouch, kneel, and crawl. She should avoid working around
unprotected heights, dangerous tools, dangerous machinery or hazardous processes.
12
She cannot operate a commercial vehicle. The claimant could tolerate frequent
exposure to humidity, wetness, atmospheric conditions, extreme heat and cold, but
only tolerate occasional vibration and moderate noise levels. She is limited to
routine and repetitive tasks and simple work-related decisions. She would be able
to accept constructive non-confrontational criticism, work in small group settings,
and be able to accept changes in the work place setting if introduced gradually and
infrequently. In addition to normal breaks, she would be off task 5% of the time
(nonconsecutive) in an 8-hour day.
(Tr. 47).
Washington’s contention that the ALJ’s RFC “is his own opinion and is conclusory” (doc.
10 at 18-19), is simply incorrect. A claimant’s RFC is an issue reserved to the Commissioner and
the ALJ’s RFC assessment is an administrative finding based on the overall evidence. See 20
C.F.R. §§ 416.912(b)(2), 416.913(b)(6), 416.927(d), 416.945(a)(3), 416.946(c); SSR 96-5p, 1996
WL 374183 (July 2, 1996). See also Beegle, 482 F. App’x at 486; Herron v. Soc. Sec. Admin.,
Comm’r, 649 F. App’x 781, 786 n.5 (11th Cir. 2016). It is the Commissioner’s duty to weigh the
evidence, resolve material conflicts and determine the case accordingly, as the ALJ did in this case.
See Wheeler v. Heckler, 784 F.2d 1073, 1075 (11th Cir. 1986); Watson v. Heckler, 738 F.2d 1169,
1172 (11th Cir. 1984).
Washington’s claim the ALJ’s RFC is conclusory and contrary to SSR 96-8p (doc. 10 at
32-35), is also incorrect.
The ALJ’s RFC assessment is lengthy and explains in detail
Washington’s limitations as required in the regulations as explained above. See 20 C.F.R. §
416.945. Although the rationale for the ALJ’s RFC is not specifically set out in the one-paragraph
RFC assessment (tr. 47 Finding 4), his evaluation of the overall evidence and the basis for the RFC
assessment are explained at length in the pages following the assessment. (Tr. 47-53). Washington
ignores the ALJ’s discussion and offers no record evidence to undermine the ALJ’s basis for his
assessment. Washington’s assertion that “[t]he explanation given by the ALJ for not accepting the
opinion of the treating physician was not adequate,” (doc. 14 at 3) is supported by neither argument
13
nor evidence. Moreover, Washington cites no regulation requiring the ALJ to state the rationale
for his or her RFC assessment in the actual RFC paragraph of the opinion (in this case Tr. 47,
Finding 4). The ALJ’s RFC complies fully with SSR 96-8p, and Washington’s assertion to the
contrary fails.
Additionally, citing Thomason v. Barnhart, 344 F. Supp. 2d 1326 (N.D. Ala. 2004), and
Coleman v. Barnhart, 264 F. Supp. 2d 1007 (S.D. Ala. 2003), Washington appears to argue the
RFC is not supported by substantial evidence because there was no opinion from a physician
matching the limitations in the ALJ’s RFC finding. (Doc. 10 at 33-34; see also doc. 14 at 2). As
noted above, the RFC determination is an administrative determination reserved to the
Commissioner, not a medical assessment. See 20 C.F.R. §§ 416.927(d), 416.946; SSR 96-5p, 1996
WL 374183. Additionally, the assessment of a claimant’s RFC is based on all the relevant
evidence and not simply a doctor’s opinion. See 20 C.F.R. §§ 416.945(a)(3), 416.946(c); SSR 965p, 1996 WL 374183, at *5. Although physicians’ opinions about what a claimant can still do are
relevant evidence, such opinions are not determinative because the ALJ has the responsibility of
assessing the claimant’s RFC. See 416.912(b)(2), 416.913(b)(6), 416.927(d)(2), 416.945(a)(3),
416.946(c); Beegle, 482 F. App’x at 486. In Langley v. Astrue, 777 F. Supp. 2d 1250 (N.D. Ala.
2011), the court held that “[b]inding precedent in this Circuit does not require an RFC from a
physician,” and expressly declined to follow Coleman’s reasoning because it was “inconsistent
with the Commissioner’s regulations, Supreme Court precedent and unpublished decisions in this
Circuit.” Id. at 1258, 1260. The ALJ here properly considered the entire record and assessed
Washington with the ability to perform a reduced range of light work (tr. 48-53), which is
supported by substantial evidence.
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B. Step Two Finding Regarding Severe Impairments
Washington next contends the ALJ failed to consider all of her severe impairments. (Doc.
10 at 20-21; doc. 14 at 3-4). This argument is not supported by the law. Although the ALJ did
not discuss Washington’s alleged post-traumatic stress disorder (“PTSD”), depressive disorder
with psychotic features, diabetic retinopathy, hypertension, or fatigue, Washington did not allege
these conditions were disabling either in claim forms submitted to the agency or in her hearing
testimony (Tr. 67-96, 196-203, 201, 206-12, 223, 229). It was not until more than a year after the
ALJ’s decision that Washington’s counsel sent a letter to the Appeals Council, which contained a
listing of additional alleged impairments.5 (Tr. 234-57). See Kushnir v. Comm’r of Soc. Sec., No.
6:13-cv-711, 2014 WL 2860328, at *4 (M.D. Fla. June 23, 2014); Mathis v. Colvin, No. 8:12-civ2072, 2013 WL 6498453, at *4-5 (M.D. Fla. Dec. 11, 2013). Moreover, diagnoses do not establish
work-related limitations stemming from that condition. See Moore, 405 F.3d at 1213 n.6; see also
Higgs v. Bowen, 880 F.2d 860, 863 (6th Cir. 1988). As Washington has identified no limitation
caused by PTSD, depressive psychotic features, diabetic retinopathy, hypertension, or fatigue, the
ALJ committed, at most, harmless error in not discussing these conditions. See Winters v. Colvin,
No. 8:13-cv-290, 2014 WL 869105, at *7 (M.D. Fla. Mar. 5, 2014).
Furthermore, contrary to Washington’s arguments (doc. 10 at 20-21; doc. 14 at 3-4), the
ALJ considered and discussed Washington’s alleged low back pain, (tr. 46, 48-51, 53), left
The Appeals Council considered the reasons Washington disagreed with the ALJ’s
decision and found “that this information does not provide a basis for changing the [ALJ’s]
decision.” (Tr. 2). Washington’s counsel also submitted additional medical records to the
Appeals Council. (Tr. 8-14, 19-22, 30-38). The Appeals Council stated: “[w]e also looked at
[the medical records you provided]” and “[t]he Administrative Law Judge decided your case
through October 31, 2014. This new information is about a later time. Therefore, it does not
affect the decision about whether you were disabled beginning on or before October 31, 2014.”
(Tr. 2). See also discussion in Subsection D.
5
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shoulder pain, (tr. 48, 50), and diabetes (tr. 49, 51-2), and made findings regarding these
conditions. Washington raised no complaint regarding these findings and, therefore, waived
argument on this issue. See Rowe v. Schreiber, 139 F.3d, 1381, 1382 n.1 (11th Cir. 1998) (in the
absence of an argument, the issue is deemed abandoned).
Finally, as the Eleventh Circuit has stated, “[n]othing requires that the ALJ must identify,
at step two, all of the impairments that should be considered severe,” provided the ALJ considered
the claimant’s impairments in combination. See Heatly v. Comm’r of Soc. Sec., 382 F. App’x 823,
825 (11th Cir. 2010). See also Swindle v. Sullivan, 914 F.2d 222, 226 (11th Cir. 1990); Walker v.
Bowen, 826 F.2d 996, 1001 (11th Cir. 1987); Perry v. Astrue, 280 F. App’x 887, 894 (11th Cir.
2008). This requirement results because, while no impairment considered alone may be disabling,
the combined effect of the impairments may be enough to render a claimant disabled. Bowen v.
Heckler, 748 F.2d 629, 635 (11th Cir. 1984). In this case, the ALJ found Washington had severe
impairments, as explained above (tr. 45 Finding 2). Then, at step three, the ALJ found Washington
“does not have an impairment or combination of impairments” (emphasis added) that meets or
medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P,
App’x 1. (Tr. 45 Finding 3). See 20 C.F.R. § 416.920(a)(4)(iii). The ALJ’s statement shows he
properly considered the combined effect of Washington’s impairments. See Wheeler, 784 F.2d at
1076. Washington has shown no error in the ALJ’s step two finding of severe impairments.
C. Evaluation of Washington’s Subjective Complaints
Washington asserts three errors related to the ALJ’s assessment of her subjective
complaints. (Doc. 10 at 22-28, 30-32). Each will be addressed in turn.
1. Credibility Assessment
Washington claims the “ALJ failed to state adequate reasons for finding Claimant not
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credible.” (Doc. 10 at 22-24). As an initial matter, Washington’s two-plus page argument consists
almost entirely of citations to cases related to credibility determinations, without any citation to
record facts in this case, with no discussion of how the cited cases apply to the facts here. (See id.:
see also doc. 14 at 4-6 (reply brief)). Washington has not sufficiently developed this argument to
allow for a proper response and has therefore waived this issue. See Rowe, 139 F.3d at 1382 n.1.
Regardless of waiver, and contrary to Washington’s assertion, the ALJ cited record
evidence and fully explained his “credibility” assessment. (Tr. 48-52). Initially, the ALJ set out a
detailed discussion of Washington’s testimony and allegations (tr. 48-49), about which
Washington raises no complaint. (See doc. 10 at 22-24). The ALJ also considered Washington’s
allegations in comparison to her daily activities and stated:
In spite of her alleged pain, the claimant has described daily activities, which are
not limited to the extent one would expect, given the complaints of disabling
symptoms and limitations. She reported living alone and maintaining the
household. She described preparing simple meals, cleaning and shopping in stores.
. . . [S]he needs no assistance with daily activities and she is completely independent
of personal care. . . . She indicated that she reads and watches TV most of the day.
. . . Further, [Plaintiff] pays her bills and manages her finances. (Exhibits 1E and
7F) She also indicated that she reports to her probation officer on a regular basis.
Based on the foregoing, the claimant’s symptoms and subjective complaints are
found not to be fully credible and are not consistent with the objective medical
evidence and other evidence based on the requirements of 20 CFR § 416.1529.
(Tr. 49-50). Importantly, Washington does not complain about the ALJ’s detailed summary of her
allegations and does not criticize or even mention the ALJ’s credibility assessment based on her
daily activities. (Doc. 10 at 22-24; doc. 14 at 4-6; tr. 49-50). The record shows the ALJ properly
considered Washington’s activities of daily living. See 20 C.F.R. § 416.1529(c)(3)(i); Macia v.
Bowen, 829 F.2d 1009, 1012 (11th Cir. 1987).
The ALJ also specifically discussed record evidence regarding Washington’s alleged
shoulder pain (tr. 50) and her allegations of left sided, low back, foot, and hip pain (tr. 50) as
17
explained above. He also discussed Washington’s allegations of carpal tunnel syndrome, diabetes
mellitus, depression and anxiety, and obesity (Tr. 51-52). In addition to the above, the ALJ found
that:
Overall, the evidence abundantly demonstrates that her pain is, at worst at a
moderate level, which would limit her to an at-will sit/stand option and to ambulate
short distances up to 100 yards per instance on flat hard surfaces. The claimant is
also independent of activities of daily living and personal care. Therefore, the
undersigned finds that the relevant evidence shows at worst moderate symptoms
that would not prevent her from performing all work activity. These findings are
consistent with the established residual functional capacity.
(Tr. 51). The ALJ also found Washington’s symptoms related to diabetes would not prevent all
work activity (tr. 52), that his findings regarding Washington’s alleged anxiety and depression
were consistent with the established RFC (tr. 52), and that Washington’s obesity did not prevent
her from performing a modified range of light work (tr. 52). Thus, the ALJ fully explained his
“credibility” assessment. (Tr. 50-52). Washington cites no record evidence to undermine these
findings, and the ALJ’s credibility assessment is due to be affirmed.
2. SSR 16-3p
Next, Washington contends the issuance of Social Security Ruling (“SSR”) 16-3p
necessitates remand. (Doc. 10 at 24-28). SSR 16-3p, effective March 28, 2016, superseded SSR
96-7p, which was in effect when the ALJ issued his decision. SSR 16-3p eliminates the use of the
term “credibility” and clarifies that the ALJ “will consider any personal observations of the
individual in terms of how consistent those observations are with the individual's statements about
his or her symptoms as well as with all of the evidence in the file.” SSR 16-3p, 2016 WL 1119029,
*7 (March 16, 2016). In a published opinion issued on November 6, 2017, the Eleventh Circuit
ruled that SSR 16-3p does not apply retroactively. See Hargress v. Soc. Sec. Admin., Comm’r,
874 F.3d 1284, 1290 (11th Cir. 2017) (“SSR 16-3p applies only prospectively and does not provide
18
a basis for remand.”). Accordingly, the issuance of SSR 16-3p does not support remand, as it was
not in effect at the time of the ALJ’s decision.
3. Lack of Medical Treatment
Washington contends the ALJ improperly drew adverse inferences from her lack of
medical treatment, which resulted in an adverse decision, even though she explained she had no
insurance and no income. (Doc. 10 at 30-32; doc. 14 at 8-10). Again, Washington fails to develop
this argument in her brief. (See doc. 10 at 30-32). Although Washington cites several statements
in the ALJ’s decision and testimony regarding her not obtaining medical treatment and claims the
ALJ drew an adverse inference, she fails to identify the nature of any adverse inference the ALJ
purportedly made or explain any prejudice she sustained as a result of the adverse inference. See
Burgin v. Comm’r of Soc. Sec., 420 F. App’x 901, 903 (11th Cir. 2011) (applying the harmless
error doctrine to social security cases); see also Shinseki v. Sanders, 556 U.S. 396, 408-10 (2009)
(“[T]he burden of showing that an error is harmful normally falls upon the party attacking the
agency’s determination.”).
The ALJ is required to consider the overall record evidence in a case, which necessarily
includes the extent of medical treatment a claimant receives. See 20 C.F.R. §§ 416.920(e), 416.929,
416.945(a)(1), (a)(3); SSR 96-8p, 1996 WL 374184 (July 2, 1996)). Washington has shown the
ALJ considered her medical treatment, which the ALJ was required to consider; but she has not
shown any improper inference the ALJ purportedly drew from that record evidence. Moreover, the
ALJ’s decision shows his RFC and credibility assessments were based on proper considerations,
as explained above. Washington has shown no error in the ALJ’s consideration of the evidence to
support remand.
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D. Appeals Council
Washington next contends the Appeals Council improperly refused to consider new
evidence. (Doc. 10 at 36-38; doc. 14 at 12-14). Almost fifteen months after the ALJ’s decision,
Washington submitted additional evidence to the Appeals Council. (Tr. 8-14, 19-22, 30-38, 234238). The Appeals Council reviewed the additional evidence and found it did not provide a basis
for changing the ALJ’s decision because it “was about a later time” and did not affect the decision
about whether Washington was disabled during the relevant period in this case from February 21,
2013, the SSI application date, through October 31, 2014, the ALJ’s decision date (i.e., the relevant
period) (Tr. 2).
Washington’s argument that the Appeals Council failed to determine whether the
additional evidence was chronologically relevant is unavailing. Evidence submitted to the Appeals
Council must be new, material, and chronologically relevant to the ALJ’s decision. See 20 C.F.R.
§ 404.970(b); Ingram v. Comm’r, Soc. Sec. Admin., 496 F.3d 1253, 1261 (11th Cir. 2007); see also
Wilson v. Apfel, 179 F.3d 1276, 1279 (11th Cir.1999). Although the additional evidence is “new”
in the sense that it is dated after the ALJ’s decision and not previously submitted, Washington has
not shown the additional evidence is both material and chronologically relevant to the ALJ’s
decision.
As to the records from Northeast Alabama Regional Medical Center (tr. 30-38),
Washington argues these records confirm the diagnoses of depression and post-traumatic disorder,
as shown in earlier records. (Tr. 301-02, 382, 393, 402) (Doc. 10 at 36). Washington’s argument
is unavailing because the ALJ found Washington’s depression was a severe impairment (tr. 43
Finding 2); therefore, additional post-decision evidence confirming that diagnosis is cumulative
and not material. Similarly, evidence regarding PTSD is not material because Washington did not
20
claim disability due to PTSD, as explained above.
Similarly, despite her assertion to the contrary, Washington’s records from Dr. Myron
Wilson at Cherokee Eye Clinic (tr. 19-22) are not material. (See doc. 10 at 36). The ALJ noted
Washington was diagnosed with diabetes mellitus in January 2014 (tr. 51), so no confirmation was
necessary. The ALJ also found that there were no noted functional limitations from the diagnosis
(i.e., there was no evidence of visual changes and eye examination showed 20/20 with lenses) (tr.
51), and Dr. Wilson’s newly offered report (tr. 20-22) contains no information about limitations
during the relevant period.
Finally, Washington posits that the January 11, 2016 report from Dr. Wilson at Gadsden
Psychological Services (tr. 8-14) confirms the diagnoses of depression and post-traumatic stress
disorder as shown in earlier records. (Doc. 10 at 36). However, as explained above, confirmation
of diagnoses for those impairments is cumulative and not material. Washington also argues Dr.
Wilson’s report is chronologically relevant and material. (Doc. 10 at 37-38). She cites cases and
statutes noting the proper standards of analysis; however, she offers no argument based on record
facts and, instead, assumes the standards are satisfied here but they are not. 20 C.F.R. §
416.1470(b); Wilson, 179 F.3d at 1278-79 (“While [the physician’s] opinion one year later may be
relevant to whether a deterioration in [claimant’s] condition subsequently entitled her to benefits,
it is simply not probative of any issue in this case”). Washington fails to meet her burden of proving
the additional evidence is material and chronologically relevant. Her challenges to the Appeals
Council’s findings do not warrant remand.
VI. Conclusion
For the reasons set forth herein, and upon careful consideration of the administrative record
and memoranda of the parties, the decision of the Commissioner of Social Security denying
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Washington’s claim for SSI is AFFIRMED and this action DISMISSED WITH PREJUDICE.
DONE this 20th day of March, 2018.
_______________________________
JOHN H. ENGLAND, III
UNITED STATES MAGISTRATE JUDGE
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