Henderson v. Social Security Administration, Commissioner

Filing 20

MEMORANDUM OPINION. Signed by Magistrate Judge Staci G Cornelius on 4/24/19. (MRR, )

FILED
2019 Apr-24 PM 04:24
U.S. DISTRICT COURT
N.D. OF ALABAMA

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

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Case No.: 5:18-cv-00134-SGC

MEMORANDUM OPINION1
The plaintiff, Larry M. Henderson, appeals from the decision of the
Commissioner of the Social Security Administration (the “Commissioner”)
denying his applications for Disability Insurance Benefits (“DIB”) and
Supplemental Security Income (“SSI”). Henderson timely pursued and exhausted
his administrative remedies, and the Commissioner’s decision is ripe for review
pursuant to 42 U.S.C §§ 405(g) and 1383(c)(3). For the reasons discussed below,
the Commissioner’s decision is due to be reversed and remanded.
I. Procedural History
Henderson has a high school education and has previously worked as a
sandblaster and a cook. (Tr. at 84-85, 228). In his applications for DIB and SSI,

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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. 18).

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Henderson alleged he became disabled on October 1, 2014, as a result of
motorcycle accident injuries and a steel rod in his leg. (Id. at 227). After his
claims were denied, Henderson requested a hearing before an administrative law
judge (“ALJ”). (Id. at 128). Following a hearing, the ALJ denied Henderson’s
claims. (Id. at 10-17). Henderson was fifty-three years old when the ALJ issued
his decision. (Id. at 17, 102). After the Appeals Council denied review of the
ALJ’s decision (id. at 1-3), 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,
Henderson commenced this action. (Doc. 1). 2
II. Statutory and Regulatory Framework
To establish 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),
1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). Furthermore, a DIB
claimant must show he was disabled between his alleged initial onset date and his
date last insured. Mason v. Comm’r of Soc. Sec., 430 F. App’x 830, 831 (11th Cir.
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The Appeals Council granted Henderson an extension of time to commence a civil action
seeking review of the Commissioner’s decision. (Tr. at 22).

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2011) (citing Moore v. Barnhart, 405 F.3d 1209, 1211 (11th Cir. 2005); Demandre
v. Califano, 591 F.2d 1088, 1090 (5th Cir. 1979)).

The Social Security

Administration (“SSA”) employs a five-step sequential analysis to determine an
individual’s eligibility for disability benefits.

20 C.F.R. §§ 404.1520(a)(4),

416.920(a)(4).
First, the Commissioner must determine whether the claimant is engaged in
“substantial gainful activity.” Id. at §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If the
claimant is engaged in substantial gainful activity, the Commissioner will find the
claimant is not disabled. Id. at §§ 404.1520(a)(4)(i) and (b), 416.920(a)(4)(i) and
(b). At the first step, the ALJ determined Henderson met the Social Security
Administration’s insured status requirements through June 30, 2015, and has not
engaged in substantial gainful activity since his alleged onset date of October 1,
2014. (Tr. at 12).
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), 416.920(a)(4)(ii).

If the claimant does not have a severe

impairment or combination of impairments, the Commissioner will find the
claimant is not disabled. Id. at §§ 404.1520(a)(4)(ii) and (c), 416.920(a)(4)(ii) and
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(c). At the second step, the ALJ determined Henderson has the following severe
impairments: osteoarthritis and the residual effects of a leg fracture. (Tr. at 12).
If the claimant has a severe impairment or combination of impairments, the
Commissioner must then determine whether the impairment or combination of
impairments 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), 416.920(a)(4)(iii). If the
claimant’s impairment or combination of impairments meets or equals one of the
Listings, the Commissioner will find the claimant is disabled.

Id. at §§

404.1520(a)(4)(iii) and (d), 416.920(a)(4)(iii) and (d). At the third step, the ALJ
determined Henderson does not have an impairment or combination of
impairments that meets or medically equals the severity of one of the Listings. (Tr.
at 12-13).
If the claimant’s impairment or combination of impairments 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), 416.920(e). At the fourth step, the Commissioner will
compare an 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),
416.920(a)(4)(iv) and (e). If the claimant is capable of performing his past relevant
work, the Commissioner will find the claimant is not disabled.
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Id. at §§

404.1520(a)(4)(iv), 416.920(a)(4)(iv).
Before proceeding to the fourth step, the ALJ determined Henderson has the
RFC to perform a full range of light work.3 (Tr. at 13-15). At the fourth step, the
ALJ determined Henderson is not able to perform his past relevant work. (Id. at
15-16).
If the claimant is unable to perform his 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), 416.920(a)(4)(v) and (g)(1). If the claimant is
capable of performing other work, the Commissioner will find the claimant is not
disabled. Id. at §§ 404.1520(a)(4)(v) and (g)(1), 416.920(a)(4)(v) and (g)(1). If
the claimant is not capable of performing other work, the Commissioner will find
the claimant is disabled. Id. at §§ 404.1520(a)(4)(v) and (g)(1), 416.920(a)(4)(v)
and (g)(1).
At the fifth step, considering Henderson’s age, education, work experience,
and RFC, the ALJ determined there are jobs that exist in significant numbers in the
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Light work “involves lifting no more than 20 pounds at a time with frequent lifting or carrying
of objects weighing up to 10 pounds” and may require “a good deal of walking or standing . . . or
. . . involve[] sitting most of the time with some pushing and pulling of arm or leg controls.” 20
C.F.R. §§ 404.1567(b) and 416.967(b). A claimant must be able to do substantially all of these
activities to be considered capable of performing a full range of light work. Id. at §§
404.1567(b) and 416.967(b).

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national economy that Henderson can perform and that Medical-Vocational Rule
202.14 directed a finding of “not disabled.” (Tr. at 16). Therefore, the ALJ
concluded Brown is not disabled. (Id. at 16-17).
III. Standard of Review
Review of the Commissioner’s decision is limited to a determination of
whether that decision is supported by substantial evidence and whether the
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 if 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.
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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
mandates reversal.” Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir.
1991).
IV. Discussion
On appeal, Henderson argues the ALJ improperly discredited his testimony
regarding his pain and other subjective symptoms. (Doc. 14).
A claimant may establish disability through testimony of pain or other
subjective symptoms. Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 1991).
To do so, he must satisfy the three-part “pain standard,” by showing (1) evidence
of an underlying medical condition and either (2) objective medical evidence that
confirms the severity of the alleged pain or other subjective symptoms arising from
that condition or (3) that the objectively determined medical condition is of such a
severity that it can reasonably be expected to give rise to the alleged pain or other
subjective symptoms. Id.; see also Taylor v. Acting Comm’r of Soc. Sec. Admin.,
2019 WL 581548, at *2 (11th Cir. 2019) (citing Dyer, 395 F.3d at 1210); 20 C.F.R.
§ 416.929; SSR 16-3p. A claimant’s subjective testimony supported by medical
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evidence that satisfies the pain standard is sufficient to support a finding of
disability. Brown, 921 F.2d at 1236 (citing Hale v. Bowen, 831 F.2d 1007, 1011
(11th Cir. 1987); MacGregor v. Bowen, 786 F.2d 1050, 1054 (11th Cir. 1986);
Landry v. Heckler, 782 F.2d 1551, 1552 (11th Cir. 1986)). An ALJ may discredit a
claimant’s testimony regarding his pain or other subjective symptoms provided he
clearly articulates explicit and adequate reasons for doing so. Brown, 921 F.2d at
1236; Taylor, 2019 WL 581548, at *2 (citing Dyer, 395 F.3d at 1210).
In a pain questionnaire and function report submitted with his DIB and SSI
applications, Henderson indicated he has difficulty walking, can only walk ten feet
before he has to rest for between fifteen and twenty minutes, and uses a wheelchair
and a walker. (Id. at 240-49). During the hearing before the ALJ, Henderson
testified he can walk no more than half of a city block before he has to stop and
rest, has difficulty squatting, cannot kneel or crawl, and can carry no more than
two or three pounds for one-third of a day. (Id. at 88-91). He testified that on an
average day his leg pain is a seven out of ten on an ascending pain scale. (Id. at
88). He testified that on a bad day the pain is a ten and he has between three and
five bad days per month. (Id.).
The ALJ determined Henderson’s medically determinable impairments
could reasonably be expected to produce his alleged symptoms but that
Henderson’s statements concerning the intensity, persistence, and limiting effects
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of the symptoms are not entirely consistent with the medical and other evidence.
(Id. at 15).

The ALJ articulated three reasons for discrediting Henderson’s

statements regarding his symptoms: (1) Henderson’s medical records, which lack
corroborating medical opinions, do not substantiate his complaints, (2)
Henderson’s daily activities are not as limited as would be expected for someone
with disabling symptoms and limitations, and (3) there is evidence Henderson
stopped working for reasons not related to his alleged impairments. (Id.).
Henderson challenges the ALJ’s credibility determination on a variety of
grounds. Implied in one of those grounds is the argument that the record does
contain medical opinions and the ALJ erred in failing to state and explain the
weight given to those opinions. (Doc. 14 at 19-21).
“Medical opinions are statements from physicians and psychologists or other
acceptable medical sources that reflect judgments about the nature and severity of
[a claimant’s] impairment(s), including [a claimant’s] symptoms, diagnosis and
prognosis, what [a claimant] can still do despite impairment(s), and [a claimant’s]
physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(1), 416.927(a)(1); see
also Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011)
(holding treating physician’s treatment notes, which included description of
claimant’s symptoms, a diagnosis, and a judgment about the severity of claimant’s
impairments, were medical opinions to which the ALJ was required to assign a
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particular weight and explain reasons for doing so). 4
An ALJ must state with particularity the weight given to medical opinions
and the reasons for doing so. Winschel, 631 F.3d at 1179 (citing Sharfarz v.
Bowen, 825 F.2d 278, 279 (11th Cir. 1987)). Moreover, an ALJ must give the
medical opinions of treating physicians “substantial or considerable weight,”
absent clearly articulated good cause. Id. (internal quotation marks omitted). An
ALJ’s failure to clearly articulate the weight assigned to a medical opinion is an
error that requires reversal and remand. See McClurkin v. Soc. Sec. Admin., 625 F.
App’x 960, 962 (11th Cir. 2015) (“In the absence of [a clear articulation of the
weight given different medical opinions], it is impossible for a reviewing court to
determine whether the ultimate decision on the merits of the claim is rational and
supported by substantial evidence[,]” and “ ‘we will decline to affirm simply
because some rationale might have supported the ALJ’s conclusion.’” (quoting
Winschel, 631 F.3d at 1179)).
Here, the ALJ stated there was no opinion evidence for consideration. (Tr.
at 15). Contrary to the ALJ’s assertion, the record does contain opinion evidence.
The ALJ did discuss records of Dr. Mark Leberte, an orthopedic surgeon who
treated Henderson’s lower right extremity fracture, and seems to have given
4

Sections 404.1527 and 416.927 apply to claims filed before March 27, 2017. See §§ 404.1527
and 416.927; see also 82 Fed. Reg. 5844-01 (Jan. 18, 2017) (noting revisions to rules regarding
evaluation of medical evidence are effective as of March 27, 2017); 82 Fed. Reg. 15132-01
(same). Henderson filed his claims on March 2, 2015. (Tr. at 100-101).

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considerable weight to his most recent record from January 2016, noting his
physical examination of Henderson revealed adequate range of motion in the
ankle, a callus formation at the fracture site, and no tenderness and that imaging
showed good healing of the fracture. (Id. at 14-15, 457). However, the ALJ did
not discuss or state the particular weight given to other medical opinions contained
in the record.

For example, in an August 2015 radiology report, Dr. E.L.

Mollohan, whose practice provided pain management treatment to Henderson
between August 2015 and June 2016, interpreted imaging of Henderson’s lower
right extremity to show severe osteoarthritis of the right ankle joint. (Id. at 521).
Other of Dr. Mollohan’s records include a diagnosis of chronic pain and document
limited range of motion in Henderson’s right ankle and knee. (Id. at 534, 536).
The ALJ’s failure to state and explain the weight given to the medical
opinions contained in the record, based on an incorrect determination there was no
opinion evidence to consider, is in and of itself an error that requires reversal and
remand to the Commissioner for further consideration. See McClurkin, 625 F.
App’x at 962. 5 Moreover, because this error infected the ALJ’s evaluation of
Henderson’s testimony regarding his symptoms, the ALJ’s decision to discredit
that testimony is not supported by substantial evidence.

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Given this error warrants reversal and remand to the Commissioner for further consideration, it
is not necessary to address Henderson’s remaining assignments of error.

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V.

Conclusion
Having reviewed the administrative record and considered all of the

arguments presented by the parties, the undersigned find the Commissioner’s
decision is not in accordance with applicable law or supported by substantial
evidence. Therefore, the decision is due to be reversed and remanded for further
consideration. A separate order will be entered.
DONE this 24th day of April, 2019.

______________________________
STACI G. CORNELIUS
U.S. MAGISTRATE JUDGE

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