Jones v. Social Security Administration, Commissioner

Filing 12

MEMORANDUM OPINION. Signed by Judge Madeline Hughes Haikala on 9/5/14. (ASL)

FILED
2014 Sep-05 AM 09:16
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
JANICE MARIE JONES,
Plaintiff,
vs.
CAROLYN W. COLVIN
Acting Commissioner of the
Social Security Administration,
Defendant.

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Civil Action No.
13-CV-905-MHH-5

MEMORANDUM OPINION
Pursuant to 42 U.S.C. § 405(g), 1 claimant Janice Marie Jones asks this Court
to review a final adverse decision of the Commissioner of Social Security. The
Commissioner affirmed the decision of the Administrative Law Judge (“ALJ”)
who denied Ms. Jones’s claim for a period of disability and disability insurance
benefits. (R. 1-3). As discussed below, the Court finds that substantial evidence

1

42 U.S.C. § 405(g) provides, in pertinent part:

Any individual, after any final decision of the Commissioner of Social Security made after a
hearing to which he was a party, irrespective of the amount in controversy, may obtain a review
of such decision by a civil action commenced within sixty days after the mailing to him of notice
of such decision or within such further time as the Commissioner of Social Security may allow.
Such action shall be brought in the district court of the United States for the judicial district in
which the plaintiff resides, or has his principal place of business, or, if he does not reside or have
his principal place of business within any such judicial district, in the United States District
Court for the District of Columbia.

supports the ALJ’s decision. Consequently, the Court affirms the Commissioner’s
ruling.
STANDARD OF REVIEW:
The scope of review in this matter is limited. “When, as in this case, the
ALJ denies benefits and the Appeals Council denies review,” the Court “review[s]
the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir.
2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the ALJ’s findings. “Substantial evidence is more than a scintilla and is
such relevant evidence as a reasonable person would accept as adequate to support
a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). In making this evaluation, the Court may not “reweigh the evidence or
decide the facts anew,” and the Court must “defer to the ALJ’s decision if it is
supported by substantial evidence even if the evidence may preponderate against
it.” Gaskin v. Comm’r of Soc. Sec., 533 Fed. Appx. 929 (11th Cir. 2013).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in
the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
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then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d
1143, 1145-46 (11th Cir. 1991).
PROCEDURAL AND FACTUAL BACKGROUND:
On September 7, 2010, Ms. Jones applied for a period of disability and
disability insurance benefits by filing an application for disability insurance
benefits under Title II of the Social Security Act. (R. 22).

The Social Security

Administration denied Ms. Jones’s application on December 6, 2010. (R. 61). At
Ms. Jones’s request, on October 14, 2011, an Administrative Law Judge conducted
a hearing concerning Ms. Jones’s application. (R. 34-59). Ms. Jones and an
impartial vocational expert testified at the hearing. (R. 34). At the time of his
hearing, Ms. Jones was 49 years old. (R. 40).2 Ms. Jones has a high school
education. (Doc. 11, p. 2; R. 137). Her past relevant work experience is as a court
clerk. (Doc. 11, p. 2; R. 137, 158).
On November 21, 2011, the ALJ denied Ms. Jones’s request for disability
benefits, concluding that Ms. Jones did not have an impairment or a combination
of impairments listed in, or medically equal to one listed in, the Regulations. (Doc.
11, p. 2; R. 26). In his fifteen page decision, the ALJ described the “five-step
sequential evaluation process for determining whether an individual is disabled”

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At 49 years of age, Ms. Jones is considered a “younger person” under the Regulations. See 20
C.F.R. § 404.1563(c) (“If you are a younger person (under age 50), we generally do not consider
that your age will seriously affect your ability to adjust to other work. . . .”).
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and explained that “[i]f it is determined that the claimant is or is not disabled at a
step of the evaluation process, the evaluation will not go on to the next step.” (R.
19-33).
The ALJ found that Ms. Jones had not “engaged in substantial gainful
activity since June 1, 2010, the alleged onset date.” 3 (R. 24). In addition, the ALJ
concluded that Ms. Jones had “the following severe impairments: low back pain
and status post left knee lateral meniscectomy and chondroplasty of the medial
femoral condyle.”4 (Doc. 9, p. 4; R. 24). The ALJ stated, “these impairments are .
. . ‘severe’ within the meaning of the Regulations because they cause more than a
minimal limitation on [Ms. Jones’s] ability to perform basic work activities.” (R.
24).5 Still, the ALJ opined that:
[Ms. Jones’s low back pain] does not satisfy the criteria
of section 1.04. Specifically, the record is devoid of
evidence of nerve root compression, spinal arachnoiditis,
or lumbar stenosis with accompanying ineffective
ambulation . . . [Ms. Jones’s residual left knee pain] does
3

The Court reviewed not only the ALJ’s decision, but also Ms. Jones’s medical records. The
Court finds that the ALJ’s description of Ms. Jones’s medical evaluations is accurate. In a
number of instances in this opinion, the Court has provided citations not only to the ALJ’s
decision but also to the underlying records to illustrate that there is no discrepancy between the
two.
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The ALJ concluded that Ms. Jones had severe medical impairments pursuant to 20 C.F.R.
§404.1520(c); however, Ms. Jones’s impairments do not meet the requirements listed in, or are
medically equivalent to, the listed impairments in 20 C.F.R. §404.1520(d), 20 C.F.R. §404.1525,
and 20 C.F.R. §404.1526, because her impairments “cause no more than a minimal limitation on
her ability to perform basic work activities.” (R. 24).
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The ALJ found that Ms. Jones’s mental impairments of depression and adjustment disorder
were non-severe. (R. 25).
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not satisfy the requirements of section 1.02A.
Specifically, the record does not contain evidence of a
major dysfunction of a major peripheral weight-bearing
joint, resulting in the inability to ambulate effectively.
(R. 26). Based on these factual findings, the ALJ concluded that Ms. Jones had the
“residual functional capacity to perform light work . . . except that [she] is only
capable of performing postural activities on occasion.” (R. 26).
In reaching his conclusion, the ALJ considered a report from Dr. Will
Crouch, a physician who examined Ms. Jones at the state’s request as a
consultative examiner. (Doc. 11, p. 6; R. 27). Dr. Crouch opined that Ms. Jones did
not require an assistive device and was able to heel and toe walk. (Doc. 11, p. 6;
R. 277). Dr. Couch noted that Ms. Jones “[could] get[] on and off the exam table
without assistance.” (Doc. 11, p. 6; R. 277).
The ALJ took into account the treatment notes of Dr. Larry Gazzini, a
physician who Ms. Jones saw for treatment of fatigue, hypertension, and diabetes
mellitus, type II. (Doc. 11, p. 5-6; R. 28, 203-274). Dr. Gazzini noted that Ms.
Jones’s hypertension and diabetes mellitus were “well controlled.” (Doc. 11, p. 56; R. 28, 305-308). In February 2011, Dr. Gazzini observed that Ms. Jones “was
exercising regularly, using a treadmill at home and going to Curves, an exercise
center.” (Doc. 11, p. 5-6; R. 28, 302-308). The ALJ determined that “[Ms. Jones]’s
complaints of pain were inconsistent with her testimony regarding her activities of
daily living.” (R. 28).
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The ALJ also took into account the results of a psychological evaluation that
Dr. Kristine Lokken Edmondson performed. Dr. Edmondson found that Ms. Jones
has “major depressive disorder and assigned limitations, as a consequence that
would be disabling.” (Doc. 11, p. 8; R. 25, 313). The ALJ gave little weight to Dr.
Edmonson’s findings because there were “no treatment notes from the
psychologist to support [the] opinion” and because Dr. Mary Arnold, an examining
psychologist, assigned Ms. Jones a global assessment of functioning (GAF) of 65.6
(Doc. 11, p. 8; R. 25, 286). According to the ALJ, the DSM-IV shows a GAF score
of 65, which “is indicative of only mild difficulties in social, occupational or
school functioning.” (R. 25). The ALJ determined “there is no other evidence in
the record, which reflects the existence of a severe mental impairment.” (R. 25). 7
The ALJ reviewed records from Dr. Thomas Powell, the physician who
performed surgery on Ms. Jones’s left knee. (Doc. 11, p. 7; R. 28, 372). In those
records, Dr. Powell wrote that Ms. Jones “was doing fairly well” and “‘getting
along pretty well’ since her surgery.” (Doc. 11, p. 7; R. 28, 372-378). The ALJ
also considered the opinion that a vocational expert offered at Ms. Jones’s October
14, 2011 SSA review hearing. The expert testified that a person with Ms. Jones’s
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The ALJ noted that Ms. Jones had a GAF score of 65 in her last psychological examination,
however Dr. Arnold assigned Ms. Jones a GAF score of 57 at her last evaluation. (R. 286). A
lower GAF score is indicative of a lower level of functional capacity.
7

See Diagnostic and Statistical Manual of Mental Disorders (Fourth Addition “DSM-IV”), §
309.81 (Am. Psychiatric Ass’n 4th ed.) (1994).
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residual functional capacity would be capable of performing work at the less than
light level such as Ms. Jones’s past relevant work as a court clerk. (R. 28, 58).
The ALJ acknowledged that Ms. Jones’s treating physician, Dr. Mary Altz
Smith, “noted . . . that the claimant was unable to perform most postural activities,
could only lift and/or carry five pounds or less, sit for two hours, and stand for one
hour” and that Ms. Jones has “suffered from severe fatigue, and pain severe
enough to distract from work.” (Doc. 11, pp. 4-6; R. 27). The ALJ afforded little
weight to Dr. Smith’s opinion because “despite the minimal evidence of a back
injury, [Dr. Smith] has been administering lumbar injections for . . . lumbar
spondylosis. However, there are no clinical notes from Dr. Smith to support this
diagnosis.” (R. 27-28). In addition, the ALJ cited Dr. Smith’s lack of a diagnosis of
fatigue, as well as Dr. Smith’s omission of a determining factor of fatigue as
reason to afford Dr. Smith’s opinion little weight. (Doc. 11, pp. 8-9; R. 28). The
ALJ determined that Dr. Smith’s opinions lacked medical support, and clear
contradictory evidence existed in regard to Ms. Jones’s back pain in the record.
(R. 28).
Ultimately, the ALJ found that Ms. Jones “is capable of performing work at
the less than light level . . . [Ms. Jones] is able to perform her past relevant work as
a court clerk.” (R. 28). The ALJ reasoned that Ms. Jones had:
…worked as a court clerk from 1980-2010. [Ms. Jones]’s
work as a court clerk was substantial gainful activity,
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performed for over a year, within the past fifteen years.
Thus, [Ms. Jones’s] past relevant work meets the criteria
for past relevant work.
In comparing [Ms. Jones]’s residual functional capacity
with the physical and mental demands of this work, [the
undersigned] find[s] that [Ms. Jones] is able to perform it
as actually and generally performed. [Ms. Jones]’s past
relevant work as a court clerk was semi-skilled work
performed at the sedentary level. The vocational expert
also opined [Ms. Jones] would be able to perform her
past work with the assigned residual functional capacity.
As [the undersigned] found that [Ms. Jones] is capable of
performing work at the less than light level, the demands
of [Ms. Jones]’s past relevant work do not exceed her
residual functional capacity. Accordingly, I find that the
claimant is able to perform her past relevant work as a
court clerk.
(R. 28). Consequently, the ALJ decided that Ms. Jones “is not disabled under
sections 216(i) and 223(d) of the Social Security Act.” (R. 29). The ALJ found
that Ms. Jones retained the residual functional capacity to perform work-related
activities at the less than light level of physical exertion and that there would be
sedentary jobs that would accommodate Ms. Jones’s limitations, including her past
relevant work. (R. 28).
On March 12, 2013, this became the final decision of the Commissioner of
the Social Security Administration when the Appeals Council refused to review the
ALJ’s decision. (R. 1). Having exhausted all administrative remedies, Ms. Jones
filed this action for judicial review pursuant to §205(g) of the Social Security Act.
See 42 U.S.C. § 405(g).
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ANALYSIS:
To be eligible for disability insurance benefits, a claimant must be disabled.
Gaskin, 533 Fed. Appx. at 930. “A claimant is disabled if he is unable to engage in
substantial gainful activity by reason of a medically-determinable impairment that
can be expected to result in death or which has lasted or can be expected to last for
a continuous period of at least 12 months.” Id. (citing 42 U.S.C. § 423(d)(1)(A)).
A claimant must prove that he is disabled. Id. (citing Ellison v. Barnhart,
355 F.3d 1272, 1276 (11th Cir. 2003)). To determine whether a claimant is
disabled, the Social Security Administration applies a five-step sequential analysis.
Gaskin, 533 Fed. Appx. at 930.
This process includes a determination of whether the claimant (1) is
unable to engage in substantial gainful activity; (2) has a severe and
medically-determinable physical or mental impairment; (3) has such
an impairment that meets or equals a Listing and meets the duration
requirements; (4) can perform his past relevant work, in the light of
his residual functional capacity; and (5) can make an adjustment to
other work, in the light of his residual functional capacity, age,
education, and work experience.
Id. (citation omitted).

“The claimant’s residual functional capacity is an

assessment, based upon all relevant evidence, of the claimant’s ability to do work
despite his impairments.” Id. at 930 (citing Lewis v. Callahan, 125 F.3d 1436,
1440 (11th Cir. 1997); 20 C.F.R. § 404.1545(a)(1)).

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Here, in assessing whether Ms. Jones is disabled, the ALJ found that Ms.
Jones’s low back pain and status post left knee lateral meniscectomy and
chondroplasty of the medial femoral condyle constitute severe physical
impairments that “cause [Ms. Jones] more than a minimal limitation on [Ms.
Jones]’s ability to perform basic work activities.” (R. 24). Nevertheless, the ALJ
concluded that Mrs. Jones is not disabled because she is able to perform her past
relevant work as a court clerk despite her impairments. (See R. 28). The ALJ
based his decision on the following substantial evidence: Dr. Crouch’s opinion
from his consultative examination that Ms. Jones, “did not require an assistive
device and was able to heel and toe walk;” Dr. Gazzini’s report that Ms. Jones’s
hypertension and diabetes mellitus, type II are well-controlled; Dr. Powell’s notes
that indicated that Ms. Jones was “getting along pretty well” after her knee
surgery; and the vocational expert’s opinion that a person of Ms. Jones’s age,
education, and work experience with Ms. Jones’s residual functional capacity
would be capable of performing work such as Ms. Jones’s past relevant work as a
court clerk. (Doc. 9, p. 5; R. 26-28).
Ms. Jones argues that despite this substantial evidence, she is entitled to
relief from the ALJ’s decision because the ALJ did not give sufficient weight to
the opinions of Dr. Smith, Ms. Jones’s treating physician, and the ALJ failed to
develop Ms. Jones’s medical record. (Doc. 9, pp. 6-8). The Court disagrees.
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The opinion of a treating physician “must be given substantial or
considerable weight unless ‘good cause’ is shown to the contrary.” Phillips v.
Barnhart, 357 F.3d 1232, 1240-41 (11th Cir. 2004). Good cause exists when “(1)
[the] treating physician’s opinion was not bolstered by the evidence; (2) [the]
evidence supported a contrary finding; or (3) [the] treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records.” Id.; see also
Crawford, 363 F.3d at 1159. “The ALJ must clearly articulate the reasons for
giving less weight to a treating physician’s opinion, and the failure to do so
constitutes error. ‘Moreover, the ALJ must state with particularity the weight
given to different medical opinions and the reasons therefor.’” Gaskin, 533 Fed.
Appx. at 932 (citing Lewis, 125 F.3d at 1440, and quoting Winschel v. Comm’r of
Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011)).
In this case, the ALJ clearly articulated his reasons for affording Dr. Smith’s
opinion little weight. The ALJ expressly found that evidence contained in the
record contradicted Dr. Smith’s opinion that Ms. Jones could lift five pounds only
occasionally or less frequently, could sit for a total of only two hours in an eight
hour day, and could stand for a total of only one hour in an entire eight hour day.
(Doc. 9, p. 5; R. 369).

The ALJ also noted that Dr. Smith’s opinion was

unsupported by medical evidence. (Doc. 11, p. 5-7; R. 28). For example, while
Dr. Smith determined that Ms. Jones’s fatigue and weakness precluded her from
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adequate performance of daily work activities, Dr. Smith never diagnosed the
cause of the fatigue and weakness. (R. 28). In addition, in 2009, despite the
“minimal evidence of a back injury,” Dr. Smith administered lumbar injections to
Ms. Jones for lumbar spondylosis and failed to support the diagnosis with
appropriate case notes. (R. 27). Medical records from 2010 and early 2011 from
Dr. Gazzini are inconsistent with Dr. Smith’s opinion. (see, e.g., R.239-46).

In

October 2010, a state consultative examiner, Dr. Crouch, conducted diagnostic
testing that indicated that Ms. Jones’s physical impairments were merely “minimal
degenerative changes” to the lumbar spine. (Id.). Substantial evidence supports
the ALJ’s decision to give little weight to Dr. Smith’s opinion. Crawford, 363
F.3d at 1159-61 (finding that substantial evidence supported the ALJ’s decision to
discredit the opinions of the claimant’s treating physicians where those physicians’
opinions regarding the claimant’s disability were inconsistent with the physicians’
treatment notes and unsupported by the medical evidence).
Ms. Jones argues that the ALJ erred by failing to develop the record with
supplemental medical evidence from a consultative exam or a state hired medical
expert. (Doc. 9, pp. 8-9). The Court has located no such requirement in the
regulations that Ms. Jones cites. 20 C.F.R. § 404.1519a(b)(4) provides:
Situations that may require a consultative examination. We may
purchase a consultative examination to try to resolve an inconsistency
in the evidence, or when the evidence as a whole is insufficient to
allow us to make a determination or decision on your claim. Some
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examples of when we might purchase a consultative examination to
secure needed medical evidence, such as clinical findings, laboratory
tests, a diagnosis, or prognosis, include but are not limited to: . . .
There is an indication of a change in your condition that is likely to
affect your ability to work, but the current severity of your impairment
is not established.
20 C.F.R. § 404.1519a(b)(4). Ms. Jones’s medical records do not indicate that
there has been a change in her condition that is likely to affect her ability to work.
An ALJ has a duty to purchase a consultative examination only when a final
determination cannot be made from the record as a whole. Johnson v. Barnhart,
138 Fed. Appx. 266, 270 (11th Cir. 2005). As the Eleventh Circuit has stated:
In making disability determinations, the Commissioner
considers whether the evidence is consistent and
sufficient to make a determination. If it is not consistent,
the Commissioner weighs the evidence to reach her
decision. If, after weighing the evidence, the
Commissioner cannot reach a determination, then she
will seek additional information or recontact the
physicians.
Johnson, 138 Fed. Appx. at 270-71; see also Castle v. Colvin, 557 Fed. Appx.
849, 854 (11th Cir. 2014) (holding that when the record is fully and fairly
developed, it is not necessary for an ALJ to order a consultative examination to
make an informed decision). The record contains evidence regarding one
consultative report from Dr. Crouch. (R. 277). Because substantial evidence
supports the ALJ’s decision, the ALJ did not have to order a second consultative
examination.

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Having examined the available evidence thoroughly, the ALJ determined
that Ms. Jones is not disabled. That finding rests on substantial evidence. The
Court will not reweigh the evidence or substitute its judgment for that of the
Commissioner.
CONCLUSION:
Consistent with the foregoing, the Court concludes that the ALJ’s decision is
based upon substantial evidence and is consistent with applicable legal standards.
Accordingly, the decision of the Commissioner is AFFIRMED. The Court will
enter an order consistent with this memorandum opinion.
DONE and ORDERED this September 5, 2014.

_________________________________
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE

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