Gorham v. Social Security Administration, Commissioner
MEMORANDUM OPINION Signed by Chief Judge Karon O Bowdre on 2/17/15. (SAC )
2015 Feb-17 PM 12:04
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CAROLYN W. COLVIN,
OF SOCIAL SECURITY,
CIVIL ACTION NO.
The claimant, Terry Dale Gorham, filed a Title II application for a period of disability
and disability insurance benefits on February 17, 2012, alleging disability beginning June 30,
2009. The claimant alleges disability resulting from problems with his back, shoulder, and knees;
arthritis pain; degenerative disc disease; Major Depression; and anxiety. (R. 22, 165). The
Commissioner denied the claim initially on April 17, 2012. The claimant requested a hearing on
June 14, 2012, and the Administrative Law Judge conducted a video hearing on February 28,
2013. On February 29, 2013, and again on March 5, 2013, the claimant’s attorney submitted
written statements indicating the claimant amended his alleged onset date to July 22, 2011. (R.
On May 15, 2013, the ALJ determined that the claimant was not disabled as defined by
the Social Security Act and, thus, not eligible for supplemental security income. (R. 34). On
December 13, 2012, the Appeals Council denied the claimant’s request for review; consequently,
the ALJ’s decision became the final decision of the Commissioner of the Social Security
Administration. (R. 1). The claimant has exhausted his administrative remedies, and this court
has jurisdiction pursuant to 42 U.S.C. § § 405 (g) and 1383(c)(3). For the reasons stated below,
this court affirms the decision of the Commissioner.
II. ISSUES PRESENTED
The claimant presents the following issues for review: 1) whether the ALJ properly
discredited the opinion of the treating physician, Dr. Ismail; and 2) whether substantial evidence
in the record supports the ALJ’s RFC assessment.
III. STANDARD OF REVIEW
The standard for reviewing the ALJ’s decision is limited. This court must affirm the
ALJ’s decision if the ALJ applied the correct legal standards and if the factual conclusions are
supported by substantial evidence. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420,
1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
“No...presumption of validity attaches to the [ALJ’s] legal conclusions, including
determination of the proper standards to be applied in evaluating claims.” Walker, 826 F.2d at
999. This court does not review the ALJ’s factual determinations de novo. The court will affirm
those factual determinations that are supported by substantial evidence. “Substantial evidence” is
“more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971).
The court must keep in mind that opinions, such as whether a claimant is disabled, the
nature and extent of a claimant’s Residual Functional Capacity, and the application of vocational
factors, “are not medical opinions, . . . but are, instead, opinions on issues reserved to the ALJ
because they are administrative findings that are dispositive of a case; i.e., that would direct the
determination or decision of disability.” 20 C.F.R. §§ 404.1527(e), 416.927(d). Whether the
claimant meets the listing and is qualified for Social Security disability benefits is a question
reserved for the ALJ, and the court “may not decide facts anew, re-weigh the evidence, or
substitute [its] judgment for that of the ALJ.” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir.
2005). Thus, even if the court were to disagree with the ALJ about the significance of certain
facts, the court has no power to reverse that finding as long as substantial evidence in the record
The court must “scrutinize the record in its entirety to determine the reasonableness of the
[ALJ]’s factual findings.” Walker, 826 F.2d at 999. A reviewing court must not look only to
those parts of the record that support the decision of the ALJ, but also must view the record in its
entirety and take account of evidence that detracts from the evidence relied on by the ALJ.
Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).
IV. LEGAL STANDARD
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the
person cannot “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 result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To make this determination, the
Commissioner employs a five-step, sequential evaluation process:
(1) Is the person presently unemployed?
(2) Is the person’s impairment severe?
(3) Does the person’s impairment meet or equal one of the specific
forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?
(4) Is the person unable to perform his or her former occupation?
(5) Is the person unable to perform any other work within the
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.
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986); 20 C.F.R. §§ 404.1520, 416.920.
Absent a good showing of cause to the contrary, the ALJ must accord substantial or
considerable weight to the opinions of treating physicians. Lamb v. Bowen, 847 F.2d 698, 703
(11th Cir. 1988). The ALJ must credit the opinions of treating physicians over those of
consulting physicians unless good cause exists for treating the opinions differently. Lewis v.
Callahan, 125 F.3d 1436, 1440-41 (11th Cir. 1997). The ALJ may discount a treating physician's
report when it is not accompanied by objective medical evidence or is wholly conclusory.
Crawford v. Commissioner, 363 F.3d at 1159. Where the ALJ articulated specific reasons for
failing to give the opinion of a treating physician controlling weight and those reasons are
supported by substantial evidence, the ALJ commits no reversible error. Moore v. Barnhart, 405
F.3d 1208, 1212 (11th Cir. 2005).
The ALJ must complete an RFC assessment of each claimant. Social Security Ruling
96–8p provides regarding RFC assessment:
The RFC assessment must first identify the individual's functional
limitations or restrictions and assess his or her work-related
abilities on a function-by-function basis, including the functions in
paragraphs (b), (c), and (d) of 20 CFR 404.1545 and 416.945. Only
after that may RFC be expressed in terms of the exertional levels of
work, sedentary, light, medium, heavy, and very heavy.
SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The ALJ must first assess the claimant's
functional limitations and restrictions and then express his functional limitations in terms of
exertional levels. See Castel v. Comm'r of Soc. Sec., 355 F. App'x 260, 263 (11th Cir.2009);
Freeman v. Barnhart, 220 F. App'x 957, 959–60 (11th Cir.2007); see also Bailey v. Astrue,
5:11–CV–3583–LSC, 2013 WL 531075 (N.D.Ala. Feb. 11, 2013).
The ALJ must consider all of the relevant evidence in assessing the claimant’s functional
medical history, medical signs and laboratory findings, the effects
of treatment, including limitations or restrictions imposed by the
mechanics of treatment (e.g., frequency of treatment, duration,
disruption to routine, side effects of medication), reports of daily
activities, lay evidence, recorded observations, medical source
statements, effects of symptoms, including pain, that are
reasonably attributed to a medically determinable impairment,
evidence from attempts to work, need for a structured living
environment, and work evaluations, if available.
SSR 96–8p at *4–*5.
“‘Sedentary work’ involves lifting no more than ten pounds at a time and occasionally
lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is
defined as one which involves sitting, a certain amount of walking and standing is often
necessary in carrying out job duties. Jobs are sedentary if walking and standing are required
occasionally and other sedentary criteria are met.” 20 C.F.R. § 404.1567(a), [20 C.F.R. §
416.967(a)]. Social Security Ruling 83-10 elaborates on the definition of sedentary by providing
that “‘[o]ccasionally means occurring from very little up to one-third of the time,” and that
“periods of standing or walking should generally total no more than about two hours of an eight
hour workday, and sitting should generally total approximately six hours of an eight hour
workday.” Kelly v. Apfel, 185 F.3d 1121, 1213 n.2 (11th Cir. 1999).
“Light work involves lifting no more than 20 pounds at a time with frequent lifting or
carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a
job is in this category when it requires a good deal of walking or standing, or when it involves
sitting most of the time with some pushing and pulling of arm or leg controls. To be considered
capable of performing a full or wide range of light work, [a claimant] must have the ability to do
substantially all of these activities. If someone can do light work, [the Commissioner determines]
that he or she can also do sedentary work, unless there are additional limiting factors such as loss
of fine dexterity or inability to sit for long periods of time.” 20 C.F.R. § 404.1567(b), [20 C.F.R.
§416.967(b)]; see also Walker v. Bowen, 826 F.2d 996, 1000 (11th Cir. 1987).
If the claimant’s work level falls somewhere in the middle of a higher work level that
calls for a finding of not disabled and a lower work level that calls for a finding of disabled, then
the assistance of a vocational expert to determine that impact of the claimant’s impairment upon
his ability to work is acceptable. S.S.R. 83-12.
The claimant is a high school graduate and was forty-nine years old at the time of the
hearing. (R. 166). He alleges his disability started on July 22, 2011. (R. 20). The claimant last
worked in the textile industry as a dye machine operator/weigher from October 1999 until July
2009. Prior to this, he printed t-shirts at a screen shop. (R. 166).
In 2011, the claimant visited the Pain and Wound Center of Gadsden, Alabama on
thirteen occasions: January 4, February 9, March 2, March 30, May 11, June 8, June 29, July 27,
August 31, September 21, October 31, November 28, and December 21. At each visit, he
complained of a constant ache in an unspecified area of his body rated anywhere from a four to
seven on a scale of ten. On each occasion, the claimant also complained that the pain affected his
ability to sleep, his mood, and his physical activity, but not his appetite or concentration; he
participated in a straight leg raise test, sciatic stretch test, and Patrick’s test with negative results;
his cervical range of motion was mildly decreased; and his lumbar range of motion was
moderately decreased. On December 21, he complained of numbness in his right arm. Odeane
Connor, M.D., conducted each examination, and on each occasion, she prescribed the claimant
Lunesta, Celebrex, Valium, Soma, Fentanyl Patch, Prevacid, and Cymbalta. Dr. Connor
diagnosed the claimant with a right rotator cuff tear and repair, impingement, and tendinitis.
Unfortunately, the court is unable to determine the rest of Dr. Connor’s diagnosis because the
notes are illegible. (R. 232-56).
On January 25 and February 6 of 2012, the claimant returned to the Pain and Wound
Center. The claimant reported the same type and amount of pain as before, and again complained
of numbness in his right arm. Dr. Connor appears to have made the same diagnosis and treatment
plan for the claimant, however, portions of this assessment and diagnosis are, again, illegible.
In 2012, the claimant also visited the Scottsboro Quick Care Clinic on multiple occasions.
On April 10, Younus M. Ismail, M.D., a general practioner at Scottsboro Quick Care Clinic,
conducted a medical examination for a disability physical examination. Dr. Ismail noted that the
claimant was an average, overweight male, alert, awake, talkative, constantly complaining of
pain and asking for pain medications during the examination. Dr. Ismail also noted that the
claimant could move from the chair to the examination table without any difficulty, and that he
was not using any assistive device. Dr. Ismail indicated that the claimant said that he had some
pain when moving his shoulder, but was not willing to raise his extremities above his shoulder.
Dr. Ismail noted that the claimant had a normal range of motion in all of his extremities;
complained of pain in his mid and lower back; and showed a reduced range of motion in his
spine. However, Dr. Ismail noted that he was unable to determine an exact range of motion
because the claimant would not relax his muscles and provided resistance when the doctor tried
to determine his range of motion.
Dr. Ismail concluded his report by diagnosing the claimant with chronic back pain,
degenerative disc disease of the spine, osteoarthritis, depression, and anxiety. He also
commented that the claimant had “some pain” in his back and “some limitations” in his shoulder
movements. Dr. Ismail noted that the claimant asked for prescription pain medication during the
examination. Dr. Ismail suggested that a further evaluation, as well as occupational and physical
rehabilitation, would be beneficial for the claimant. (R. 261-262).
On August 6, September 9, and October 3, the claimant returned to the Clinic for followup appointments with Dr. Ismail. Dr. Ismail reported that, on each of these occasions, the
claimant denied having any pain and was not receiving medical attention or taking any
medication for pain control at this time. (R. 280-85).
On March 3, 2013, upon request of the claimant’s attorney, Dr. Ismail completed a
Physical Capacities Evaluation Form. He noted that the claimant could lift ten pounds
occasionally or less frequently; sit up to six hours a day and walk one hour a day; could never
perform pulling and pushing movements or stooping; and could occasionally perform climbing
and balancing, gross manipulation (grasping, twisting, and handling), fine manipulation, bending,
and reaching. Additionally, Dr. Ismail indicated that the claimant could not operate motor
vehicles or work around machinery. (R. 340).
On the same day, in response to a request by the claimant’s attorneys, Dr. Ismail
completed a Clinical Assessment of Pain. He reported that “pain is present to such an extent as to
be distracting to adequate performance of daily activities of work”; that physical activity such as
prolonged sitting, walking, standing, bending, stooping, or moving of extremities, “will greatly
increase [the claimant’s pain] and to such a degree as to cause distraction from tasks or total
abandonment of tasks”; and that the patient had an underlying medical condition consistent with
the pain he was experiencing. (R. 341-42).
On July 6, 2012, the claimant was arrested and taken to the Huntsville Hospital after
making threats to himself and his family; he was diagnosed with personality disorder and drug
abuse and released the next day. On July 12, 2012, after a suicide attempt, the claimant was
diagnosed with Major Depressive Disorder. The claimant received treatment for Major
Depressive disorder on several occasion from July 12, 2012 through October 15, 2012. On
October 15, 2012, the claimant was admitted to Mountain View Treatment Center for Major
Depression. He was discharged on October 22, 2012, after he reported that he was feeling better
and was no longer having suicidal thoughts. (R. 286-294).
The claimant completed a Function Report on February 28, 2012. The claimant reported
that he watched TV, did housework, and cooked. He reported that he was able to care for
himself, do laundry and yard work, care for his dog, vacuum, pay bills, count change, handle a
savings account, use a checkbook/money orders, go to the grocery store, and drive. The claimant
reported that he did not need a reminder or assistance to complete any of these tasks. (R. 187202).
On March 3, 2013, at the request of the claimant’s lawyers, Dr. Ismail completed a
supplemental questionnaire in which he reported that the claimant had moderate restrictions of
activities of daily living; moderate degree of difficulty in maintaining social functioning;
moderate estimated deficiencies of concentration, persistence, or pace resulting in frequent
failure to complete tasks in a timely manner; marked estimated impairment of ability to respond
to customary work pressures; moderate ability to understand, carry out, and remember
instructions in a work setting (on a sustained basis in a routine work setting); moderate ability to
respond appropriately to supervision in a work setting (on a sustained basis in a routine work
setting); moderate ability to respond appropriately to co-workers in a work setting (on a sustained
basis in a routine work setting); moderate ability to perform simple tasks in a work setting (on a
sustained basis in a routine work setting); and moderate ability to perform repetitive tasks in a
work setting (on a sustained basis in a routine work setting). Dr. Ismail wrote that these
limitations could be expected to last longer than twelve months. Finally, Dr. Ismail noted that he
had not obtained a psychological evaluation, and that the patient needed a psychological
evaluation. (R. 339).
VI. ALJ HEARING
After the Commissioner denied the claimant’s request for supplemental security income,
the claimant requested and received a hearing before an ALJ on February 28, 2013. The ALJ
started the hearing by inquiring about the claimant’s use of pain medication. In response to the
ALJ’s questions, the claimant admitted that he took more than his prescribed dosage at times, but
asserted that he only took larger doses in response to continued pain and his perceived tolerance
to the medication. The claimant also testified that he and his wife had separated because of his
use of pain medications; however, they had not yet divorced. He then testified that he no longer
took pain medications because he would rather suffer through the pain than take the medication
again. Additionally, claimant testified that he no longer visited the doctor who prescribed the
medication for his shoulder, because the doctor put him on the medications that “ruined [his]
life.” (R. 43-45).
The ALJ then questioned the claimant as to why he never took advantage of the
vocational rehabilitation that he was entitled to as part of a his worker’s compensation
settlement. In response, the claimant testified that he did not try vocational therapy because he
felt that he was incapable of holding down a job because of his pain and mental state. When
asked why his physical examination conducted at GrandView in October of 2012 indicated the
claimant’s movement and capabilities were normal, the claimant responded that he did not
remember the physicians at GrandView conducting a physical examination. (R. 45-46).
Next, the claimant testified about his daily activities. He testified that he lived by himself,
did his own laundry, and cooks his meals daily mostly via microwave. He also testified that he
could keep track of his bills, but that his daughters helped him pay for his food and utility bills.
The claimant stated that most days he would “mainly just sit and watch TV and try to deal with
[his] pain and depression.” (R. 46-48).
The claimant’s attorney then questioned the claimant. The claimant testified that he was
still depressed because his wife had left him, he was not able to work, he did not have a job, and
he was in constant pain. In response to his attorney’s questions about his physical abilities, the
claimant said that he was able to lift a gallon of tea from the refrigerator, but that it caused him
pain, and that he would have trouble lifting anything heavier than a gallon. He testified that he
was able to sit for thirty to forty minutes at a time and could “mosey” around for about thirty
minutes or walk about a city block at a normal pace before having to sit down. He then said that
his pain forced him to lie down for two-and-a-half to three hours in an eight hour period. (R. 5153).
Finally, the vocational expert, Jewel E.B. Euto, Ph. D., testified about the claimant’s
ability to retain a job. Dr. Euto noted that the claimant was a fifty-one-year-old man with a
twelfth grade education and past relevant work experience as a dye machine operator. The ALJ
then posed four hypothetical situations. (R. 54).
In the first hypothetical, the ALJ assumed a claimant, Mr. Alpha, with the actual
claimant’s same education, training, and work experience. The hypothetical claimant was limited
to a maximum of light range of work as that term is defined under the regulations, and was
further limited to frequent postural maneuvers except no climbing of ropes, ladders or scaffolds;
only occasional overhead reaching of the left upper extremity; had to avoid concentrated hot or
cold temperature extremes, extreme wetness, humidity or vibrations; and avoid dangerous
moving, unguarded, machinery, heights and large bodies of water. The ALJ then asked whether
the claimant was able to perform any of his past relevant work. Dr. Euto responded that he was
not. When asked if any other jobs existed in the national or regional economies that Mr. Alpha
could perform, Dr. Euto testified that Mr. Alpha could find work as an information clerk with
12,100 positions in Alabama and 937,000 nationally; a bench assembler, with 2,300 positions in
Alabama and 235,900 nationally; or an egg breaker (a person who holds tools and assists
assembly line workers) with 16,300 positions in Alabama and 420,000 nationally. (R. 55-56).
The ALJ then proposed a second hypothetical in which the hypothetical claimant, Mr.
Beta, had the same limitations as Mr. Alpha, except that Mr. Beta had to have the option to sit or
stand during the workday one or two minutes every hour or so. When asked if the claimant could
find jobs in the regional or national economy with these limitations, Dr. Euto responded that the
claimant could find work in the three positions previously discussed; however, the available jobs
in these positions was decreased by about 25% because of the additional limitations. (R. 56).
In a third hypothetical, the ALJ asked Dr. Euto to assume a claimant, Mr. Charlie, who
was identical to Mr. Beta, except that he was limited to unskilled work where he could
understand, remember, and carry out simple instructions and tasks; have casual, non-intensive
interactions with co-workers and the general public; have infrequent and well-explained
workplace changes; and was able to concentrate and remain on tasks for two hours at a time
sufficient to complete an eight-hour workday. When asked if the claimant could find any jobs in
the regional or national economy under these limitations, Dr. Euto testified that the previously
mentioned jobs as a bench assembler and an egg breaker would remain, but reduced by 25%, and
that the job as an information clerk would change to a small parts assembler, light with 2,250
jobs in Alabama and 235,000 nationally. (R. 56-57).
Finally, in a fourth hypothetical, the ALJ assumed another hypothetical claimant, Mr.
Delta, who had the same limitations as Mr. Charlie, except that he was expected to consistently
miss work on two or more days per month. When asked if Mr. Delta could perform any work in
the regional or national economy, Dr. Euto testified that he could not because the excessive
absenteeism would preclude all work activity.
The claimant’s attorney concluded the hearing by asking Dr. Euto if any of the previous
hypothetical claimants could find jobs in the regional or national economy if his pain caused him
to lie down two-and-a-half hours a day at times and places he could not predict in advance. Dr.
Euto testified that none of the hypothetical claimants could find work with that limitation. (R. 5758).
VII. ALJ OPINION
On May 15, 2013, the ALJ issued a decision finding that the claimant was not disabled
under the Social Security Act. (R. 34). First, the ALJ found that the claimant met the insured
status requirements of the Social Security Act through December 31, 2014. Next, she found that
the claimant had not engaged in substantial gainful activity since June 22, 2011, the alleged onset
of his disability. (R. 22). The ALJ then found that the claimant’s degenerative disc disease, Major
Depression, and anxiety qualified as a severe impairment. The ALJ concluded, however, that the
claimant did not have an impairment or combination of impairments that met or medically
equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix
Specifically, the ALJ found that the severity of the claimant’s mental impairment did not
satisfy the criteria of “paragraph B,” which requires at least two of the following: marked
restrictions of daily living; marked difficulties in maintaining social functioning; marked
difficulties in maintaining concentration, persistence, or pace; or repeated episodes of
decompensation, each of extended duration. (R. 26-27).
In activities of daily living, the ALJ found the claimant had mild restrictions, and she
cited the fact that the claimant lived by himself, had no problems with his personal care; took
care of his pet; prepared his own meals on a daily basis; and performed household chores such as
laundry and vacuuming. The ALJ found the claimant to have moderate difficulties in social
functioning, citing the claimant’s tendency towards suicidal and homicidal ideations as well as
the claimant’s stressful family issues and conflicts. The ALJ found the claimant to have mild
difficulties regarding concentration, persistence, or pace and supported her findings by citing the
claimant’s ability to pay bills, count change, handle a savings account, use a checkbook/money
orders, drive a car, go out alone, shop in stores for food and other household items, read, and
watch TV. The ALJ also noted that the claimant did not need a reminder or help to run errands.
Finally, the ALJ found that the claimant had not experienced any extended episodes of
decompensation. (R. 27).
The ALJ found that the claimant did not meet “paragraph C” requirements because the
record does not show a medically documented history of decompensation; an inability to adjust
to an increase in mental demands; or an inability to function outside of a highly supportive living
arrangement. (R. 27-28).
Next, the ALJ determined the claimant’s Residual Functioning Capacity (RFC). She
found that the claimant could perform less than the full range of light work as defined in 20
C.F.R. § 404.1567(b) with the following limitations: can frequently balance, stoop, kneel,
crouch, crawl, and climb ramps and stairs; can never climb ropes, ladders, or scaffolds, and must
have an option to sit and/or stand during the workday for one to two minutes every hour or so;
can occasionally perform overhead reaching with his left upper extremity; should avoid
concentrated hot and cold temperature extremes, extreme wetness, humidity, and vibration;
should avoid being around dangerous, moving, unguarded machinery, unprotected heights, and
large bodies of water; can tolerate jobs that involve infrequent and well-explained workplace
changes; must have casual and non-intensive interaction with co-workers and the general public;
and can concentrate and remain on tasks for two hours at a time, sufficient to complete an eighthour workday. The ALJ came to this decision after she examined the entire record and
determined that “the claimant’s medically determinable impairments could reasonably be
expected to cause the alleged symptoms, but, the claimant’s statements concerning the intensity,
persistence, and limiting effects of these symptoms [were] not entirely credible.” (R. 28-29).
To support her conclusion about the claimant’s credibility, the ALJ first found that,
although the claimant has received various treatments, he received only conservative treatment
and the treatment successfully controlled his symptoms. She noted that visits to the Pain &
Wound Care Center demonstrated the claimant had pain at only a five to six on a scale of ten and
that physical exams revealed mildly decreased cervical and lumbar range of motion, with all
other tests showing normal results. The ALJ noted that the claimant refused to do any heel-toe
walking and squatting and offered voluntary rigidity during the examination. She also noted that
the claimant asked for prescription pain medication during the examination. The ALJ mentioned
that the claimant denied having any complaints of pain at routine visits on August 6, 2012 and
October 3, 2012. The ALJ also noted that the claimant denied having any pain when he was
admitted to Dekalb Medical Center on October 15, 2012. (R. 29-31).
The ALJ found that while the claimant’s depression and anxiety symptoms appeared to be
genuine, the claimant had received conservative treatment, and that the treatment had
successfully controlled his symptoms. The ALJ noted a visit to the Mountainview Treatment
Center in which the claimant’s concentration was normal, his recent, remote, and immediate
memory was intact, and his intellectual functioning was probably in the average range.
The ALJ then found that the claimant’s alleged limitations on his daily activities could
not be “verified with any reasonable degree of certainty,” and contributing the degree of the
claimant’s limitations to his medical condition, as opposed to other factors, would be difficult
given the “relatively weak medical evidence and other factors discussed in the decision.” The
ALJ stated that one would expect to see some indication of restrictions placed on claimant,
considering his allegations of disabling pain, but that Dr. Ismail’s treatment notes for this time
period did not indicate that he placed any restrictions on the claimant. Noting the claimant’s
ability to perform regular functions such as preparing meals, doing household chores, and paying
bills, the ALJ found that the claimant’s daily activities suggested he was not disabled.
Finally, the ALJ discounted the opinions of the medical professionals who examined the
claimant. First, the ALJ gave little weight to the assessments of the State Agency medical
consultant and disability examiner, because they did not examine or treat the claimant or have an
opportunity to review the medical evidence submitted at the hearing level.
The ALJ gave “some weight” to the April 2012 physical assessment by the claimant’s
treating physician, Dr. Ismail, because his assessment was consistent with the claimant’s history
of treatment. However, the ALJ pointed out that, although the claimant complained of pain in
multiple areas, he was not seeing any other physicians or taking any other pain medication at the
time of the assessment. The ALJ gave “little weight” to Dr. Ismail’s March 2013 assessments of
the claimant’s physical and mental limitations and allegations of pain. The ALJ found that, even
though Dr. Ismail was a treating physician, his assessments were inconsistent with his own
treatment records. The ALJ found the record to be inconsistent because in his assessment Dr.
Ismail reported that the claimant had significant limitations but the record contained no mention
or evidence of these limitations. (R. 32).
After assessing the claimant’s RFC, the ALJ found that the claimant was unable to
perform his past relevant work as a dye machine operator because that job was medium in
exertional level and semi-skilled. Noting the testimony of the vocational expert, the ALJ found
that jobs existed in significant numbers in the national and regional economy that the claimant
could perform, specifically, a bench assembler with 2,300 jobs in Alabama and 235,900 jobs
nationally; an egg breaker with 16,300 jobs in Alabama and 420,000 nationally, and a small parts
assembler with 2,250 jobs in Alabama and 235,000 nationally. (R. 34).
I. The ALJ gave proper weight to the treating physician’s opinion.
The claimant argues that the ALJ erred by failing to give proper weight to Dr. Ismail’s
opinion. The court disagrees and finds that substantial evidence existed to discredit Dr. Ismail’s
The testimony of a treating physician must be given substantial or considerable weight
unless “good cause” is shown to the contrary. Crawford v. Commissioner, 363 F.3d 1155, 1159
(11th Cir. 2004); see also Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). However, a
treating physician’s report may be discounted when it is not accompanied by objective medical
evidence, is wholly conclusory, or is contradicted by other medical evidence in the record.
Crawford, 363 F.3d at 1159. Where the ALJ articulated specific reasons for failing to give the
opinion of a treating physician controlling weight and those reasons are supported by substantial
evidence, she commits no reversible error. Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir.
The ALJ articulated specific reasons for failing to give the opinion of Dr. Ismail
controlling weight. The ALJ stated that she gave Dr. Ismail’s March 2013 assessment “little
weight” because it was inconsistent with the doctor’s own treatment record. When discussing Dr.
Ismail’s treatment notes, the ALJ noted that, from April 30, 2012 through October 3, 2012, Dr.
Ismail treated the claimant for a variety of complaints. The ALJ stated that one would expect to
see some indication of restrictions placed on the claimant, considering his allegations of
disabling pain, but that Dr. Ismail’s treatment notes for this time period did not indicate that he
placed any restrictions on the claimant. The ALJ also considered that, at a routine follow-up visit
on August 6, 2012, the claimant denied having any complaints of pain. The ALJ mentioned that,
at another appointment with Dr. Ismail on October 3, 2012, the claimant again denied any
complaints of pain. Finally, the ALJ noted that, at the time of Dr. Ismail’s April 2012 assessment,
the claimant was not receiving medical attention or taking medication for any of his alleged
physical impairments. (R. 29- 33).
Based on the explicit reasoning of the ALJ, this court finds that the ALJ applied the
proper legal standard when discrediting Dr. Ismail’s testimony and that substantial evidence
supports her finding.
II. The ALJ’s RFC assessment is supported by substantial evidence in the record.
The claimant argues that the ALJ’s RFC assessment was incorrect where the ALJ found
the claimant was capable of performing jobs at an exertional level of “less than light work.” The
claimant claims that a “sedentary” exertional level would be more appropriate. However, this
court finds that ALJ did not err because substantial evidence supports her RFC assessment.
When determining the claimant’s functional limitation, the ALJ must consider all of the
relevant evidence, including medical records and reports of daily activities. SSR 96–8p.
Sedentary work involves lifting a maximum of ten pounds; occasionally carrying light items; and
occasionally walking and standing. 20 C.F.R. § 404.1567(a), [20 C.F.R. § 416.967(a)] Light
work involves lifting a maximum of twenty pounds; carrying ten pounds often; a good deal of
walking; or sitting while operating arm and leg controls. 20 C.F.R. § 404.1567(b), [20 C.F.R.
The ALJ relied on the medical records when making the RFC assessment. The ALJ said
that the weak medical evidence made it difficult to verify the limitations that the claimant
reported. In supporting this opinion, the ALJ noted that the treatment for the claimant’s back pain
was conservative. The ALJ pointed out that the claimant reported only moderate back pain to his
doctors and said that medication treated his back pain effectively. The ALJ also stated that,
besides a mildly decreased range of motion in his lumbar spine, the claimant’s range of motion,
strength, and gait were all normal. The ALJ pointed out that no evidence in the record suggests
that the claimant’s doctors placed any restrictions on the claimant. Based on the medical
evidence, the ALJ did not find support that the claimant was limited to a sedentary exertional
The ALJ found that the claimant’s self report of his physical abilities indicated that he
was able to do work at a light exertional level. The ALJ noted that the claimant said he is able to
do housework; cook; take care of his dog; drive; and go to the store without assistance. Because
the claimant’s physical abilities did not limit his daily activities, the ALJ did not find evidence to
suggest the claimant was unable to complete work at a light exertional level.
Regarding the claimant’s mental health, the ALJ noted the claimant’s self assessment that
he was able to groom and care for himself; remember to take his medication; and pay his bills.
The ALJ pointed out that the claimant reported regularly spending time with others and talking
about current events. The ALJ noted the claimant’s testimony that he did not have any problems
getting along with neighbors, family, friends, or others. Based on this self report, the ALJ found
that the claimant’s mental health did limit his work abilities but did not preclude him from work
entirely because he is able to care for himself and interact with other people. (R. 32-33).
The ALJ properly applied the law in making her RFC assessment. The ALJ is required to
consider all of the relevant evidence. SSR 96–8p. In reaching her conclusion, the ALJ considered
the medical evidence in the treatment records; the claimant’s self assessment of his daily
activities; the claimant’s testimony; and the treating physician’s opinion. Ultimately the ALJ
discredited the treating physician’s testimony, but, as the court explained above, this decision
was substantially supported by the record. Therefore, the ALJ did consider all of the relevant
evidence. By considering all of the evidence, the ALJ properly applied the law.
The claimant argues that the ALJ should have found the claimant to be limited to a
sedentary work level and that, if he was, the MVR guidelines would direct a finding of disabled.
But, this court has affirmed the ALJ’s RFC assessment. Based on the ALJ’s assessment, the
MVR guidelines did not direct a finding. When the MVR does not direct a finding, the ALJ can
rely on the Vocational Expert’s testimony, which the ALJ did in this case. See S.S.R. 83-12.
Based on the Vocational Expert’s testimony, the ALJ found that the claimant is able to perform
jobs which exist in significant numbers in the regional economy. Therefore, substantial evidence
supported the ALJ’s finding that the claimant was not disabled.
For the reasons as stated, this court concludes that the decision of the Commissioner is
supported by substantial evidence and is to be AFFIRMED.
A separate order will be entered in accordance with this Memorandum Opinion.
DONE and ORDERED this 17th day of February, 2015.
KARON OWEN BOWDRE
CHIEF UNITED STATES DISTRICT JUDGE
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?