Cooksey v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Sharon Lovelace Blackburn on 7/25/14. (CTS, )
2014 Jul-25 PM 02:29
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF ALABAMA
ESTER RUTH COOKSEY,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
) CIVIL ACTION NO. 5:12-CV-1750-SLB
The plaintiff, Ester Ruth Cooksey, brings this action pursuant to the provisions of
42 U.S.C. § 405(g), seeking judicial review of a final adverse decision of the
Commissioner of the Social Security Administration denying her application for disability
insurance benefits. Cooksey timely pursued and exhausted her administrative remedies
available before the Commissioner. Accordingly, this case is now ripe for judicial review
under 42 U.S.C. § 405(g). Based on the court’s review of the record and the briefs
submitted by the parties, the court finds that the decision of the Commissioner is due to be
I. STANDARD OF REVIEW
The sole function of this court is to determine whether the decision of the
Commissioner is supported by substantial evidence and whether the ALJ applied the
proper legal standards. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983).
To that end this court “must scrutinize the record as a whole to determine if the decision
reached is reasonable and supported by substantial evidence.” Id. (citations omitted).
Substantial evidence is “such relevant evidence as a reasonable person would accept as
adequate to support a conclusion.” Id. This court may not decide the facts anew, reweigh
the evidence, or substitute its judgment for that of the Commissioner. Id. Even if the
court finds that the evidence preponderates against the Commissioner’s decision, the
court must affirm if the decision is supported by substantial evidence. Id.
Unlike the deferential review standard applied to the Commissioner’s factual
findings, “no similar presumption of validity attaches to the [Commissioner’s]
conclusions of law, including determination of the proper standards to be applied in
reviewing claims.” Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982) (quoting
Smith v. Schweiker, 646 F.2d. 1075, 1076 (5th Cir. Unit A Jun.1981)). Therefore, this
court reviews de novo the Commissioner’s conclusions of law. Ingram v. Comm’r of Soc.
Sec., 496 F.3d 1253, 1260 (11th Cir. 2007). The Commissioner’s “failure to apply the
correct law or to provide the reviewing court with sufficient reasoning for determining
that the proper legal analysis has been conducted mandates reversal.” Cornelius v.
Sullivan, 936 F.2d 1143, 1145-46 (11th Cir.1991).
II. STATUTORY AND REGULATORY FRAMEWORK
To qualify for disability benefits, a claimant must be unable “to engage in any
substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than twelve months.” 42 U.S.C.
§§ 423(d)(1)(A), 1382c(a)(3)(A). A “physical or mental impairment” is “an impairment
that results from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42
U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).
Social Security regulations outline a five-step process that the Commissioner uses
to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v),
416.920(a)(4)(i)-(v). The Commissioner must determine in sequence:
whether the claimant is currently engaged in substantial gainful
whether the claimant has a severe impairment or combination of
whether the claimant’s impairment meets or equals the severity of an
impairment in the Listing of Impairments;1
whether the claimant can perform any of his or her past work; and
whether there are significant numbers of jobs in the national
economy that the claimant can perform.
Winschel v. Comm’r of Soc. Sec, 631 F.3d 1176, 1178 (11th Cir. 2011). The evaluation
process continues until the Commissioner can determine whether the claimant is disabled.
20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). A claimant who is doing substantial gainful
The Listing of Impairments, (“Listings”) found at 20 C.F.R. Part 404, Subpart
P, Appendix 1, are used to make determinations of disability based upon the presence of
impairments that are considered severe enough to prevent a person from doing any
gainful activity. 20 C.F.R. § 404.1525.
activity will be found not disabled at step one. 20 C.F.R. §§ 404.1520 (a)(i),
416.920(a)(4)(i). A claimant who does not have a severe impairment will be found not
disabled at step two. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). A claimant with
an impairment that meets or equals one in the Listing of Impairments will be found
disabled at step three. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).
Prior to considering steps four and five, the Commissioner must assess the
claimant’s residual functional capacity (RFC), which will be used to determine the
claimant’s ability to work. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). A claimant who
can perform past relevant work will be found not disabled at step four. 20 C.F.R.
§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). At step five the burden shifts to the
Commissioner to show other work the claimant can do. Foot v. Chater, 67 F.3d 1553,
1559 (11th Cir. 1995). To satisfy this burden the Commissioner must produce evidence
of work in the national economy that the claimant can do based on the claimant’s RFC,
age, education, and work experience. 20 C.F.R. §§ 404.1512(f), 416.912(f). A claimant
who can do other work will be found not disabled at step five. 20 C.F.R.
§§ 404.1520(a)(4)(v), 416.920 (a)(4)(v). A claimant who cannot do other work will be
found disabled. Id.
In the present case, the Administrative Law Judge (ALJ) determined Cooksey was
not engaged in substantial gainful activity, and found she had the following severe
impairments: “type 2 diabetes mellitus with severe insulin resistance, essential
hypertension, ‘mild’ diastolic dysfunction, congestive heart failure (compensated), and
morbid obesity (BMI of 46 percent).” R. 22. The ALJ concluded Cooksey did not suffer
from a listed impairment. R. 24. She found Cooksey had the residual functional capacity
(RFC) to perform “a full range of sedentary work as defined in 20 CFR 404.1567(a).” R.
25. With this RFC, the ALJ found Cooksey unable to perform her past relevant work. R.
32. However, the ALJ found Cooksey was not disabled under Medical-Vocational Rule
201.27, which directs a finding of not disabled for an individual of Cooksey’s age and
educational background who is able to perform a full range of sedentary work.2 R. 33.
III. FACTUAL BACKGROUND
Cooksey filed applications for a period of disability, disability insurance benefits,
and Supplemental Security Income (SSI) on August 18, 2008, and alleges she became
disabled on July 19, 2007. R. 20. Cooksey was 41 years old at the time of the ALJ’s
decision. R. 33-33. She has a high school education, and past relevant work as a
“daycare worker/teacher, door greeter (Wal-Mart), and cashier (grocery store).” R. 32.
Cooksey alleges she is disabled due to “diabetes, back problems, stomach, high blood
pressure, mitral valve prolapse, severe pain in left hand and right foot.” Pl.’s Br. 2.
Treatment records show Cooksey has been treated extensively for type II diabetes
mellitus and essential hypertension. These records show Cooksey’s essential
The Medical-Vocational Guidelines, found at 20 C.F.R. Part 404, Subpart P,
Appendix 2, are used to make determinations of disability based upon vocational factors
and the claimant’s residual functional capacity when the claimant is unable to perform
his vocationally relevant past work. 20 C.F.R. Part 404, Subpart P, Appendix 2,
§ 200.00(a). Such determinations, however, are only conclusive when all of the criteria
of a particular rule are met. 20 C.F.R. Part 404, Subpart P, Appendix 2, § 200.00(a).
hypertension was generally well controlled when she was compliant with prescribed
medications. See, e.g., R. 598. However, her diabetes was less well controlled, at least in
part due to Cooksey’s failure to follow prescribed treatment. For example, on December
3, 2008, Dr. Coccia noted Cooksey reported her blood sugar levels were better, and she
reported that her blood pressure medication seemed to be working well. R. 484.
However, on January 28, 2009, Dr. Coccia counseled Cooksey that her weight and
noncompliance with a diabetic diet made control of her diabetes difficult. R. 482. In any
event, the medical records do not show Cooksey’s diabetes had caused any end organ
damage, neuropathy, retinopathy, or neprhopathy.
In 2007 Cooksey was treated for a breast abscess. Her treating doctor completed a
return to work form indicating she could return to work with no restrictions on September
4, 2007. R. 232. The abscess ultimately required surgical drainage on November 1,
2001. R. 313. On November 19, 2007, Dr. McLaury noted Cooksey had done well after
the abscess was removed. R. 261.
In April 2009 an ultrasound of the thyroid gland showed a well-defined solid mass.
R. 445. After further testing, Cooksey underwent a total thyroidectomy on October 29,
2009. R. 562-65. Surgical pathology revealed the presence of two papillary carcinomas.
R. 560. On November 1, 2009, Cooksey received a dose of radioactive iodine. R. 569.
A December 21, 2009, treatment note states that a recent PET scan “was okay,” and Dr.
Coccia’s assessment was that things were going well with Cooksey’s thyroid cancer. R.
After complaining of chest pain in July 2009, Dr. Wu-Varquez ordered a graded
exercise test and myocardial perfusion scan. R. 508. The scan showed no evidence of
ischemia. R. 506.
Cooksey was treated for a variety of other complaints during the relevant time
period. However, treatment for those conditions was sporadic, and the treatment notes do
not suggest they caused a lasting and significant impairment to Cooksey’s ability to work.
IV. ISSUES PRESENTED
Cooksey raises the following issues on appeal: 1) whether the ALJ erred in
rejecting the opinion of Dr. Coccia, one of her treating physicians; 2) whether the ALJ
was required to obtain a medical source opinion from either a consultative examiner or a
medical expert; and 3) whether the ALJ erred by failing to properly consider her obesity
under Social Security Ruling 02-1p.
Cooksey argues the ALJ improperly rejected the opinions of Dr. Coccia, one of her
treating physicians. Pl.’s Br. 7-8. On February 24, 2009, Dr. Coccia wrote a letter to the
Cullman Department of Human Resources stating Cooksey was “unable to dependably
report for work and perform for a six to eight-hour day.” R. 448. He also stated Cooksey
would “be happier than anyone to get back to work as soon as possible but currently, with
her medical situation, that is not a realistic expectation.” R. 448. In addition, Dr. Coccia
completed a Food Stamp form on which he indicated Cooksey was unable to work, and
stated that morbid obesity, wide fluctuations in blood sugar, and hypoglycemia were the
medical conditions that prevented her from working. R. 496. On that form he also wrote
that Cooksey could return to work within a year if she lost weight and got her blood sugar
under control. R. 496.
In determining how much weight to give to each medical opinion, the ALJ must
consider several factors, including (1) whether the doctor has examined the claimant; (2)
whether the doctor has a treating relationship with the claimant; (3) the extent to which
the doctor presents medical evidence and explanation supporting his opinion; (4) whether
the doctor's opinion is consistent with the record as a whole; and (5) whether the doctor is
a specialist. 20 C.F.R. §§ 404.1527(c), 416.927(c). Under the Commissioner’s
regulations, a treating physician’s opinion will be given controlling weight if it is well
supported and not inconsistent with other substantial evidence in the record.
If we find that a treating source's opinion on the issue(s) of the nature and
severity of your impairment(s) is well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not inconsistent with the
other substantial evidence in your case record, we will give it controlling
20 C.F.R. § 404.1527(c)(2).
In considering whether an ALJ has properly rejected a treating physician’s opinion,
this court is not without guidance. “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.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). “Good
cause” exists when the evidence does not bolster the treating physician's opinion; a
contrary finding is supported by the evidence; or the opinion is conclusory or inconsistent
with the treating physician's own medical records. Id. If a treating physician’s opinion is
rejected, the ALJ must clearly articulate the reasons for doing so. Id. (“The ALJ must
clearly articulate the reasons for giving less weight to the opinion of a treating physician,
and the failure to do so is reversible error.”).
The ALJ articulated a number of reasons why she gave Dr. Coccia’s opinions little
weight. She found that Dr. Coccia’s “opinions contrast sharply with the other evidence of
record, including his own office notes.” R. 31. She also noted that Dr. Coccia’s opinions
were inconsistent with his treatment notes both before and after the time he rendered his
opinions. The ALJ observed that in January 2009 Cooksey “reported she was doing well
on her diet and [her] A1C level was ‘much better’ at 8.3.”3 R. 31, 453, 482. The ALJ
noted that subsequently Cooksey’s A1C level continued to improve to 7.5. R. 31, 452.
She noted that in June and July 2009, Dr. Coccia’s notes reflected Cooksey had lost
weight, was doing well on Lantus, and required less insulin. R. 31, 473, 465. The ALJ
also observed that during Dr. Coccia’s “actual examinations and long-term treatment of
[Cooksey] he never mentioned such limitations in his treatment notes.” R. 32.
“The A1C test is a common blood test used to diagnose type 1 and type 2
diabetes and then to gauge how well you’re managing your diabetes. . . . The A1C test
result reflects your average blood sugar level for the past two to three months.
Someone who's had uncontrolled diabetes for a long time might have an A1C level
above 8 percent. . . . For most people who have previously diagnosed diabetes, an A1C
level of 7 percent or less is a common treatment target.”
The inconsistencies between Dr. Coccia’s opinions and his treatment notes provide
“good cause” for rejecting those opinions. Lewis, 125 F.3d at 1440. Because this court
does not reweigh the evidence, there is no reversible error in the ALJ’s decision not to
credit Dr. Coccia’s opinions.
Although Cooksey acknowledges there is no express requirement for an RFC
assessment from a medical source, she argues that one is required as a practical matter to
avoid an ALJ substituting his judgment for that of a physician. Pl.’s Br. 9. However,
neither the Commissioner’s regulations nor the law of this circuit require that an RFC be
based upon a medical source statement from a doctor.
The regulations provides that opinions on issues reserved to the Commissioner,
such as a claimant’s RFC, are not medical opinions.
Opinions on some issues, such as the examples that follow, are not medical
opinions, . . . but are, instead, opinions on issues reserved to the
Commissioner because they are administrative findings that are dispositive
of a case; i.e., that would direct the determination or decision of disability.
§ 404.1527(d). One of the specifically excluded examples is a claimant’s RFC.
Although we consider opinions from medical sources on issues such as . . .
your residual functional capacity . . . the final responsibility for deciding
these issues is reserved to the Commissioner.
§ 404.1527(d)(2). Therefore, under the regulations, a claimant’s RFC is not a medical
opinion, and a doctor’s opinion was not required for the ALJ to assess Cooksey’s RFC.
The Eleventh Circuit has also recognized that determining a claimant’s residual
functional capacity and ability to work is a task for the ALJ, and not doctors. See
Robinson v. Astrue, 365 F. App’x 993, 999 (11th Cir. 2010) (unpublished) (“[T]he task of
determining a claimant's residual functional capacity and ability to work is within the
province of the ALJ, not of doctors.”). It has also found an ALJ’s RFC finding can be
supported by substantial evidence even if there is no medical source statement in the
record. In Green v. Social Security Administration, the Court found the ALJ had properly
refused to credit a Physical Capacities Evaluation (“PCE”) from the claimant’s treating
physician. 223 F. App’x 915, 922-23 (11th Cir. 2007) (unpublished). The Court in Green
rejected the claimant’s argument that without that PCE, there was nothing in the record
upon which the ALJ could base his RFC finding. Id. at 923. The Court held that other
evidence from the claimant’s doctors (which did not contain a PCE or RFC assessment)
was sufficient to support the ALJ’s finding that the claimant could perform light work.
Id. at 923-24; see also Langley v. Astrue, 777 F Supp. 2d. 1250, 1258 (N.D. Ala. 2011)
(holding RFC is not a medical opinion and need not be based upon a doctor’s RFC
In the present case, there was sufficient medical and other evidence in the record to
allow the ALJ to assess Cooksey’s RFC. The ALJ noted that one of Cooksey’s treating
doctors provided a note indicating she would be able to return to work with no restrictions
on September 4, 2007. R. 27, 232. She also relied on Cooksey’s reported daily activities,
which included cooking, cleaning, mopping weekly and shopping for groceries with her
husband. R. 30, 115-16. The ALJ noted Cooksey reported she “can stand and bend but
just not for prolonged periods or as often as she used to, she can walk for about one-half
mile or 20 minutes at a time, and lift 15-20 pounds for short periods.” R. 30, 118. She
found these activities were evidence that Cooksey can do sedentary work. R. 30. This
evidence is sufficient to allow a reasonable fact finder to conclude Cooksey was able to
perform sedentary work. Therefore, the ALJ’s RFC finding was based on substantial
Cooksey also argues the ALJ should have ordered a consultative examination or
utilized a medical expert to obtain a medical source opinion. Pl.’s Br. 9. However,
before remanding for further development of the record, a reviewing court must consider
“whether the record reveals evidentiary gaps which result in unfairness or ‘clear
prejudice.’” Smith v. Schweiker, 677 F.2d 826, 830 (11th Cir.1982) (quoting Ware v.
Schweiker, 651 F.2d 408, 413 (5th Cir. Unit A July 1981). Therefore, “although the ALJ
has a duty to develop a full and fair record, there must be a showing of prejudice before [a
reviewing court] will remand for further development of the record.” Robinson v. Astrue,
365 F. App’x 993, 995 (11th Cir. 2010) (unpublished) (citing Brown v. Shalala, 44 F.3d
931, 935 (11th Cir. 1995).
In the present case, there are extensive treatment records and other evidence
documenting the extent of Cooksey’s impairments. Cooksey has not identified any gaps
in the evidence that cause unfairness or prejudice in the absence of a consultative
examination or testimony from a medical expert. Therefore, she has not demonstrated the
ALJ committed a reversible error by failing to order a consultative examination or elicit
testimony from a medical expert.
Cooksey argues the ALJ failed to adequately consider her obesity under Social
Security Ruling 02-1p. Pl.’s Br. 10-11. Social Security Ruling (SSR) 02-01p provides
guidance in the evaluation of obesity. It provides that “[t]here is no specific level of
weight or BMI that equates with a ‘severe’ or ‘not severe’ impairment,” and that
“descriptive terms for levels of obesity (e.g., ‘severe,’ ‘extreme,’ or ‘morbid’ obesity)”
will not establish whether obesity is a “severe” impairment. SSR 02-1p, 2002 WL
34686281, *4 (S.S.A.). Rather, an ALJ must “do an individualized assessment of the
impact of obesity on an individual’s functioning.” Id. It also provides that obesity must
be considered in assessing a claimant’s RFC by assessing “the effect obesity has upon the
individual’s ability to perform routine movement and necessary physical activity within
the work environment.” Id. at * 6.
The ALJ discussed Cooksey’s obesity in her decision and found that it did not
result in restrictions that would prevent Cooksey from performing sedentary work. R. 2728. The ALJ noted Cooksey had been obese “during the period when she successfully
worked,” and that her weight “has essentially remained the same for years.” R. 27. The
ALJ also observed that Cooksey “has not specifically alleged any functional limitations
due to weight and the records of her treating physician likewise are not reflective of any.”
R. 27. Although Cooksey cites to Social Security Ruling 02-1p in her brief, she cites to
no evidence showing her obesity prevents her from performing sedentary work.
Therefore, the ALJ properly considered Cooksey’s obesity in accordance with SSR
02-01p. She gave reasons supported by substantial evidence for finding that Cooksey’s
obesity did not impose limitations on her ability to work greater than those reflected in the
RFC finding. Therefore, the ALJ did not err in her consideration of Cooksey’s obesity.
The court concludes the ALJ’s determination that Cooksey is not disabled is
supported by substantial evidence, and that the ALJ applied the proper legal standards in
arriving at this decision. Accordingly, the Commissioner’s final decision is due to be
affirmed. An appropriate order will be entered.
DONE this 25th day of July, 2014.
SHARON LOVELACE BLACKBURN
UNITED STATES DISTRICT JUDGE
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