Baldwin v. Social Security Administration, Commissioner

Filing 15

MEMORANDUM OPINION. Signed by Magistrate Judge Staci G Cornelius on 9/28/18. (MRR, )

FILED
2018 Sep-28 PM 02:03
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
NORTHEASTERN DIVISION
BRENDA BALDWIN,
Plaintiff,
v.
SOCIAL SECURITY
ADMINISTRATION, Commissioner,
Defendant.

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Case No.: 5:17-cv-00512-SGC

MEMORANDUM OPINION1
The plaintiff, Brenda Baldwin, appeals from the decision of the
Commissioner of the Social Security Administration (the “Commissioner”)
denying her application for Disability Insurance Benefits (“DIB”). Baldwin timely
pursued and exhausted her administrative remedies, and the Commissioner’s
decision is ripe for review pursuant to 42 U.S.C. § 405(g). For the reasons
discussed below, the Commissioner’s decision is due to be affirmed.
I. Procedural History
Baldwin did not complete high school or obtain a GED. (Tr. at 41). Her last
job was working for the Jefferson County, Alabama Department of Roads and
Transportation as a dump truck driver and equipment operator. (Id. at 42, 68-70).

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The parties have consented to the exercise of full dispositive jurisdiction by a magistrate judge
pursuant to 28 U.S.C. § 636(c). (Doc. 12).

In her application for DIB, she claimed she became disabled on September 3,
2014, due to back problems; fibromyalgia; arthritis in her hands, shoulders, and left
knee; carpel tunnel syndrome in both hands; plantar fasciitis; and restless leg
syndrome. (Id. at 87-88). After her claims were denied, Baldwin requested a
hearing before an administrative law judge (“ALJ”). (Id. at 108). Following a
hearing, the ALJ denied Baldwin’s claim. (Id. at 24-32.). Baldwin was 48 years
old when the ALJ issued her decision. (Id. at 26). After the Appeals Council
declined to review the ALJ’s decision (Id. at 3-5), that decision became the final
decision of the Commissioner, see Frye v. Massanari, 209 F. Supp. 2d 1246, 1251
(N.D. Ala. 2001) (citing Falge v. Apfel, 150 F.3d 1320, 1322 (11th Cir. 1998)).
Thereafter, Baldwin initiated this action. (Doc. 1).
II. Statutory and Regulatory Framework
To establish her eligibility for disability benefits, a claimant must show “the
inability 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. §§ 416(i)(1)(A), 423(d)(1)(A); see also 20
C.F.R. § 404.1505(a). Furthermore, a claimant must show that she was disabled
between her alleged initial onset date and her date last insured. Mason v. Comm’r
of Soc. Sec., 430 F. App’x 830, 831 (11th Cir. 2011) (citing Moore v. Barnhart,
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405 F.3d 1209, 1211 (11th Cir. 2005); Demandre v. Califano, 591 F.2d 1088, 1090
(5th Cir. 1979)).

The Social Security Administration employs a five-step

sequential analysis to determine an individual’s eligibility for disability benefits.
20 C.F.R. § 404.1520(a)(4).
First, the Commissioner must determine whether the claimant is engaged in
“substantial gainful activity.” Id. at § 404.1520(a)(4)(i). “Under the first step, the
claimant has the burden to show that she is not currently engaged in substantial
gainful activity.” Reynolds-Buckley v. Comm’r of Soc. Sec., 457 F. App’x 862,
863 (11th Cir. 2012). If the claimant is engaged in substantial gainful activity, the
Commissioner will determine the claimant is not disabled.

20 C.F.R. §

404.1520(a)(4)(i) and (b). At the first step, the ALJ determined Baldwin met the
insured status requirements of the Social Security Act through December 31, 2018,
and has not engaged in substantial gainful activity since her alleged onset date of
September 3, 2014. (Tr. at 26).
If the claimant is not engaged in substantial gainful activity, the
Commissioner must next determine whether the claimant suffers from a severe
physical or mental impairment or combination of impairments that has lasted or is
expected to last for a continuous period of at least twelve months. 20 C.F.R. §
404.1520(a)(4)(ii). An impairment “must result from anatomical, physiological, or
psychological abnormalities which can be shown by medically acceptable clinical
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and laboratory diagnostic techniques.” Id. at § 404.1508. Furthermore, it “must be
established by medical evidence consisting of signs, symptoms, and laboratory
findings, not only by [the claimant’s] statement of symptoms.” Id.; see also 42
U.S.C. § 423(d)(3).

An impairment is severe if it “significantly limits [the

claimant’s] physical or mental ability to do basic work activities . . . .” 20 C.F.R. §
404.1520(c).2 “[A]n impairment can be considered as not severe only if it is a
slight abnormality which has such a minimal effect on the individual that it would
not be expected to interfere with the individual’s ability to work, irrespective of
age, education, or work experience.” Brady v. Heckler, 724 F.2d 914, 920 (11th
Cir. 1984); see also 20 C.F.R. § 404.1521(a). A claimant may be found disabled
based on a combination of impairments, even though none of her individual
impairments alone is disabling. 20 C.F.R. § 404.1523. The claimant bears the
burden of providing medical evidence demonstrating an impairment and its
severity. Id. at § 404.1512(a) and (c). If the claimant does not have a severe

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Basic work activities include:
(1) [p]hysical functions such as walking, standing, sitting, lifting, pushing,
pulling, reaching, carrying, or handling; (2) [c]apacities for seeking, hearing, and
speaking; (3) [u]nderstanding, carrying out, and remembering simple instructions;
(4) [u]se of judgment; (5) [r]esponding appropriately to supervision, co-workers
and usual work situations; and (6) [d]ealing with changes in a routine work
setting.

20 C.F.R. § 404.1521(b).

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impairment or combination of impairments, the Commissioner will determine the
claimant is not disabled. Id. at § 404.1520(a)(4)(ii) and (c).
At the second step, the ALJ determined Baldwin has the following severe
impairments: degenerative disc disease and osteoarthritis of the cervical and
lumbar spine, sciatic joint disease, degenerative joint disease of the right shoulder,
tendinitis of the right shoulder rotator cuff, a partial tear of the right shoulder status
post-arthroscopic repair, bilateral plantar fasciitis status post-bilateral percutaneous
plantar fasciotomies, status post-left gastrocnemius recession with residual sural
neuropraxia, fibromyalgia, and obesity. (Tr. at 26).
If the claimant has a severe impairment or combination of impairments, the
Commissioner must then determine whether the impairment meets or equals one of
the “Listings” found in 20 C.F.R. Part 404, Subpart P, Appendix 1. 20 C.F.R. §
404.1520(a)(4)(iii); see also id. at § 404.1525-26. The claimant bears the burden
of proving her impairment meets or equals one of the Listings. Reynolds-Buckley,
457 F. App’x at 863. If the claimant’s impairment meets or equals one of the
Listings, the Commissioner will determine the claimant is disabled. 20 C.F.R §
404.1520(a)(4)(iii) and (d). At the third step, the ALJ determined Baldwin does
not have an impairment or combination of impairments that meet or medically
equal the severity of one of the Listings. (Tr. at 28).

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If the claimant’s impairment does not meet or equal one of the Listings, the
Commissioner must determine the claimant’s residual functional capacity (“RFC”)
before proceeding to the fourth step. 20 C.F.R. § 404.1520(e); see also id. at §
404.1545. A claimant’s RFC is the most he can do despite his impairment. See id.
at § 404.1545(a)(1). At the fourth step, the Commissioner will compare her
assessment of the claimant’s RFC with the physical and mental demands of the
claimant’s past relevant work. Id. at §§ 404.1520(a)(4)(iv) and (e), 404.1560(b).
“Past relevant work is work that [the claimant] [has] done within the past 15 years,
that was substantial gainful activity, and that lasted long enough for [the claimant]
to learn to do it.” Id. § 404.1560(b)(1). The claimant bears the burden of proving
that her impairment prevents her from performing her past relevant work.
Reynolds-Buckley, 457 F. App’x at 863. If the claimant is capable of performing
her past relevant work, the Commissioner will determine the claimant is not
disabled. 20 C.F.R. §§ 404.1520(a)(4)(iv), 404.1560(b)(3).
Before proceeding to the fourth step, the ALJ determined Baldwin has the
RFC to perform a limited range of light work. (Tr. at 28).3 At the fourth step, the

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The ALJ determined Baldwin can occasionally lift and/or carry up to twenty pounds; she can
frequently lift and/or carry ten pounds; she can stand and/or walk in combination for at least six
hours during an eight-hour workday, with normal breaks; she requires the need to alternate
sitting and standing in thirty-minute to one-hour increments; she can occasionally climb ramps
and stairs; she should never climb ladders, ropes, or scaffolds; she can frequently balance; she
can occasionally stoop; she can never kneel, crouch, or crawl; she would need to use her right
upper extremity to perform overhead work activities and reach above the shoulder level; she can
occasionally perform push-pull movements with her right upper extremity limited to the shoulder

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ALJ determined Baldwin is not capable of performing any of her past relevant
work. (Id. at 31).
If the claimant is unable to perform her past relevant work, the
Commissioner must finally determine whether the claimant is capable of
performing other work that exists in substantial numbers in the national economy
in light of the claimant’s RFC, age, education, and work experience. 20 C.F.R. §§
404.1520(a)(4)(v) and (g)(1), 404.1560(c)(1).

If the claimant is capable of

performing other work, the Commissioner will determine the claimant is not
disabled. Id. at § 404.1520(a)(4)(v) and (g)(1). If the claimant is not capable of
performing other work, the Commissioner will determine the claimant is disabled.
Id.
At the fifth step, considering Baldwin’s age, education, work experience,
and RFC, the ALJ determined Baldwin can perform jobs that exist in significant
numbers in the national economy, such as those of inspector, hand packager, and
sorter. (Tr. at 32). Therefore, the ALJ concluded Baldwin is not disabled. (Id.).
III. Standard of Review
Review of the Commissioner’s decision is limited to a determination
whether that decision is supported by substantial evidence and whether the

level; she should avoid concentrated exposure to extreme heat, extreme cold, wetness, humidity,
and vibration; and she should avoid exposure to industrial hazards, including working at
unprotected heights and in close proximity to moving dangerous machinery. (Tr. at 28).

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Commissioner applied correct legal standards. Crawford v. Comm’r of Soc. Sec.,
363 F.3d 1155, 1158 (11th Cir. 2004).

A district court must review the

Commissioner’s findings of fact with deference and may not reconsider the facts,
reevaluate the evidence, or substitute its judgment for that of the Commissioner.
Ingram v. Comm’r of Soc. Sec. Admin., 496 F.3d 1253, 1260 (11th Cir. 2007);
Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Rather, a district court
must “scrutinize the record as a whole to determine whether the decision reached is
reasonable and supported by substantial evidence.” Bloodsworth v. Heckler, 703
F.2d 1233, 1239 (11th Cir. 1983) (internal citations omitted).

Substantial

evidence is “such relevant evidence as a reasonable person would accept as
adequate to support a conclusion.” Id. It is “more than a scintilla, but less than a
preponderance.” Id. A district court must uphold factual findings supported by
substantial evidence, even if the preponderance of the evidence is against those
findings. Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996) (citing Martin v.
Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).
A district court reviews the Commissioner’s legal conclusions de novo.
Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). “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

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mandates reversal.” Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir.
1991).
IV. Discussion
On appeal, Baldwin argues (1) the ALJ’s determination Baldwin has the
RFC to perform sedentary work 4 is not supported by substantial evidence, (2) the
ALJ failed to show good cause for dismissing the opinion and treatment records of
Dr. Lorn Miller, and (3) the ALJ failed to assign any weight to the opinions of Dr.
J. Ty Blackwell. (Doc. 13 at 17-32).
A. RFC Assessment
Baldwin has a well-documented history of lower back pain. In 2011, she
was referred to Dr. Miller by her primary care physician, Dr. Blackwell, for a
neurological evaluation and lower back pain consultation. (Tr. at 518). During her
first appointment with Dr. Miller, Baldwin reported her lower back pain began in
2007 and that in the past Lortab had made it tolerable and enabled her to continue
working. (Id.). Dr. Miller gave Baldwin prescriptions for Lortab and Cymbalta.
(Id. at 523).

Dr. Miller continued to treat Baldwin for lower back pain and

fibromyalgia until September 2014. (Id. at 272-327, 518-24). Baldwin’s last
appointment with Dr. Miller was on September 22, 2014. (Id. at 324, 421). On
that date, Baldwin reported to Dr. Miller her lower back pain was stable and she
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In fact, the ALJ determined Baldwin has the RFC to perform a limited range of light work. (Tr.
at 28).

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felt prescription pain medication controlled that pain well. (Id. at 324). She
further reported she felt prescription pain medication controlled her fibromyalgia
pain and allowed her to continue her daily chores and activities. (Id.). Moreover,
between April 17, 2012, and December 16, 2014, Baldwin saw Dr. Blackwell
twelve times, and during each visit reported her lower back pain and fibromyalgia
pain were stable with pain medication prescribed by Dr. Miller. (Id. at 245, 248,
251, 256, 257, 258, 261, 264, 267, 379, 382, 387). Between January 20, 2015, and
May 20, 2015, Baldwin was under the care of various medical professionals at a
pain management center for her lower back pain, as well as pain in her neck. (Id.
at 441-66). At each visit, she reported she was happy with her current pain
regimen and/or that she experienced forty- to fifty-percent relief with prescription
pain medication. (Id. at 441, 442, 446, 451, 460). A Magnetic Resonance Imaging
(MRI) scan performed on January 28, 2015, revealed mild degenerative changes of
the lumbar and cervical spine. (Id. at 451, 455-59).
During an appointment with Dr. Blackwell on January 21, 2013, Baldwin
complained of pain in her right shoulder that materialized four weeks prior. (Id. at
379). Between May 29, 2013, and December 16, 2014, Baldwin reported to Dr.
Blackwell that her shoulder pain was stable. (Id. at 258, 261, 264, 267, 382, 387).
On June 26, 2015, following an MRI, Dr. David Dueland diagnosed Baldwin with
a partial tear of the right shoulder rotator cuff, biceps tendinitis, and degenerative
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joint disease of the acromioclavicular joint. (Id. at 478, 488). On July 16, 2015,
Dr. Dueland performed several surgical procedures related to these diagnoses. (Id.
at 485). Dr. Dueland referred Baldwin to physical therapy following her shoulder
surgery. (Id. at 468). A therapy progress note dated August 18, 2015, recorded
that Baldwin did not report pain in her right upper extremity, that she was
progressing well, and that her range of motion was within functional limits. (Id. at
469). At a follow-up visit with Dr. Dueland on August 20, 2015, Baldwin reported
she was doing well and had no complaints. (Id. at 482).
Between March 14, 2014, and November 20, 2014, Baldwin underwent
four surgical procedures to relieve symptoms of bi-lateral plantar fasciitis and an
equinus contracture of the left foot. (Id. at 332, 340, 350, 527). On January 16,
2015, at a follow-up visit with one of the surgeons who performed these
procedures, Baldwin reported that while she was experiencing some numbness in
her leg and foot, her pain had significantly improved. (Id. at 529). The ALJ noted
that at the hearing, Baldwin indicated she did not wear inserts or orthotics, which
additionally led the ALJ to conclude Baldwin’s foot problems had improved. (Id.
at 30).
Finally, the ALJ found that Baldwin’s daily activities were inconsistent with
disabling symptoms and limitations. (Id. at 30-31). The ALJ noted Baldwin
reported she is able to care for herself, drive, attend church once per week and
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small groups twice per week, and shop online. (Id. at 31). The record generally
supports the determination Baldwin is able to perform these activities to some
extent. (Id. at 46, 204-05, 370).
The foregoing constitutes substantial evidence supporting the ALJ’s
determination Baldwin is able to perform a limited range of light work.
B. Weight Assigned to Dr. Miller’s Opinions
An ALJ may disregard a treating physician’s opinion if he articulates good
cause for doing so. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th
Cir. 2011). “Good cause exists ‘when the: (1) treating physician’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.’”

Id. (quoting Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir.

2004)); see also Crawford, 363 F.3d at 1159 (holding ALJ properly discounted
treating physician’s opinion claimant was disabled because, amongst other things,
that opinion appeared to be based primarily on claimant’s subjective complaints of
pain). An opinion as to whether a claimant is able to work is not a medical
opinion, even if offered by a treating source, but rather a dispositive finding for the
ALJ to make. 20 C.F.R. § 404.1527(e)(1); Kelly v. Comm’r of Soc. Sec., 401 F.
App’x 403, 407 (11th Cir. 2010). It is entitled to no special significance.
C.F.R. § 404.1527(e)(3); Kelly, 401 F. App’x at 407.
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On December 22, 2015, Dr. Miller completed a functional capacity
assessment for Baldwin, noting limitations at variance with some of those found by
the ALJ and further opining Baldwin would be expected to miss one hundred or
more full or partial days of work each year on account of her impairments. (Id. at
402-04). On this date, he also gave a sworn statement opining Baldwin is no
longer able to do any kind of work. (Id. at 430-31). The ALJ assigned limited
weight to Dr. Miller’s opinion regarding Baldwin’s RFC because it was rendered
within a period of weeks following Baldwin’s last surgery and, thus, before
Baldwin had sufficient time to recover. (Id. at 30). In fact, Dr. Miller completed
the functional capacity assessment for Baldwin and gave his sworn statement
approximately five months following Baldwin’s last surgery. (Id. at 324, 404, 406,
421). However, he had not examined Baldwin since September 22, 2014, more
than a year before offering his opinion regarding her limitations. (Id. at 324, 421).
In the intervening time, Baldwin underwent a foot and shoulder surgery. (Id. at
405, 527). The medical evidence indicates those surgeries were successful in
alleviating the problems Baldwin was experiencing with her foot and shoulder.
(Id. at 482, 469, 529). Accordingly, although the ALJ was mistaken as to the
timing of Dr. Miller’s opinion regarding Baldwin’s RFC, the rationale underlying
her assignment of limited weight to that opinion – that Dr. Miller did not have
knowledge of Baldwin’s current, post-operative condition – holds. That rationale
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constitutes good cause for the ALJ’s assignation of limited weight to Dr. Miller’s
opinion of Baldwin’s RFC. See Hunter v. Comm’r of Soc. Sec., 651 F. App’x 958,
962 (11th Cir. 2016) (holding ALJ articulated good cause for assigning little
weight to treating physician’s opinion where, inter alia, claimant had not seen
treating physician for seven years before opinion rendered).

Moreover, Dr.

Miller’s opinion that Baldwin cannot work is not entitled to special significance.
See 20 C.F.R. § 404.1527(e)(1) & (3); Kelly, 401 F. App’x at 407; HeppellLibsansky v. Comm’r of Soc. Sec., 170 F. App’x 693, 698 (11th Cir. 2006) (holding
ALJ did not err by declining to accord controlling weight to treating physician’s
statement he doubted claimant would ever be able to return to gainful employment
because such statement is a dispositive finding left to ALJ, not a medical opinion).
C. Failure to Assign Weight to Dr. Blackwell’s Opinions
“The ALJ must state with particularity the weight given to different medical
opinions and the reasons for doing so.” Forrester v. Comm’r of Soc. Sec., 455 F.
App’x 899, 902 (11th Cir. 2012) (citing Sharfarz v. Bowen, 825 F.2d 278, 279
(11th Cir. 1987)). Ordinarily, an ALJ’s failure to do so is reversible error. Tillman
v. Comm’r, Soc. Sec. Admin., 559 F. App’x 975 (11th Cir. 2014); see also Caldwell
v. Barnhart, 261 F. App’x 188, 190 (11th Cir. 2008).

“When, however, an

incorrect application of the regulations results in harmless error because the correct
application would not contradict the ALJ’s ultimate findings, the ALJ’s decision
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will stand.” Caldwell, 261 F. App’x at 190; see also Tillman, 558 F. App’x at 975.
Because, as discussed above, Dr. Blackwell’s treatment records are consistent with
the ALJ’s determination of Baldwin’s RFC, her failure to assign specific weight to
Dr. Blackwell’s opinions was harmless error. See Caldwell, 261 F. App’x at 190
(holding ALJ’s failure to state weight accorded medical opinions was harmless
error because those opinions did not contradict ALJ’s findings or change result).
V. Conclusion
Having reviewed the administrative record and considered all of the
arguments presented by the parties, the undersigned finds the Commissioner’s
decision is supported by substantial evidence and in accordance with applicable
law. Therefore, that decision is due to be AFFIRMED. A separate order will be
entered.
DONE this 28th day of September, 2018.

______________________________
STACI G. CORNELIUS
U.S. MAGISTRATE JUDGE

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