England v. Social Security Administration, Commissioner

Filing 13

MEMORANDUM OPINION. Signed by Judge L Scott Coogler on 3/13/2015. (PSM)

FILED
2015 Mar-13 AM 10:00
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
JASPER DIVISION
REBECCA LEANNE ENGLAND, )
)
Plaintiff,
)
)
v.
)
)
CAROLYN W. COLVIN,
)
Commissioner of Social Security, )
)
Defendant.
)

6:14-cv-00137-LSC

MEMORANDUM OF OPINION
I.

Introduction
The plaintiff, Rebecca L. England, appeals from the decision of the

Commissioner of the Social Security Administration (“Commissioner”) denying
her application for Disability Insurance Benefits (“DIB”) and Supplemental
Security Income (“SSI”). Ms. England timely pursued and exhausted her
administrative remedies and the decision of the Commissioner is ripe for review
pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).
Ms. England was thirty-four years old at the time of the Administrative Law
Judge’s (“ALJ’s”) decision, and she has an eleventh grade education. (Tr. at 46.)
Her past work experiences include employment as a cashier and customer service
representative. (Tr. at 47-49.) Ms. England claims that she became disabled on
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October 31, 2010, due to lower back pain, bilateral foot pain with multiple calluses,
and an inability to stand for long periods of time. (Tr. at 50, 148.)
The Social Security Administration has established a five-step sequential
evaluation process for determining whether an individual is disabled and thus
eligible for DIB or SSI. See 20 C.F.R. §§ 404.1520, 416.920; see also Doughty v.
Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). The evaluator will follow the steps in
order until making a finding of either disabled or not disabled; if no finding is made,
the analysis will proceed to the next step. See 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). The first step requires the evaluator to determine whether the
plaintiff is engaged in substantial gainful activity (“SGA”).
404.1520(a)(4)(i), 416.920(a)(4)(i).

See id. §§

If the plaintiff is engaged in SGA, the

evaluator moves on to the next step.
The second step requires the evaluator to consider the combined severity of
the plaintiff’s medically determinable physical and mental impairments. See id. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). An individual impairment or combination of
impairments that is not classified as “severe” and does not satisfy the durational
requirements set forth in 20 C.F.R. §§ 404.1509 and 416.909 will result in a finding
of not disabled. See 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). The
decision depends on the medical evidence contained in the record. See Hart v.

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Finch, 440 F.2d 1340, 1341 (5th Cir. 1971) (concluding that “substantial medical
evidence in the record” adequately supported the finding that plaintiff was not
disabled).
Similarly, the third step requires the evaluator to consider whether the
plaintiff’s impairment or combination of impairments meets or is medically equal
to the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix
1. See 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the criteria of a listed
impairment and the durational requirements set forth in 20 C.F.R. §§ 404.1509
and 416.909 are satisfied, the evaluator will make a finding of disabled. 20 C.F.R.
§§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).
If the plaintiff’s impairment or combination of impairments does not meet or
medically equal a listed impairment, the evaluator must determine the plaintiff’s
residual functional capacity (“RFC”) before proceeding to the fourth step. See id.
§§ 404.1520(e), 416.920(e). The fourth step requires the evaluator to determine
whether the plaintiff has the RFC to perform the requirements of his past relevant
work.

See id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv).

If the plaintiff’s

impairment or combination of impairments does not prevent him from performing
his past relevant work, the evaluator will make a finding of not disabled. See id.

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The fifth and final step requires the evaluator to consider the plaintiff’s
RFC, age, education, and work experience in order to determine whether the
plaintiff can make an adjustment to other work. See id. §§ 404.1520(a)(4)(v),
416.920(a)(4)(v). If the plaintiff can perform other work, the evaluator will find
him not disabled. Id.; see also 20 C.F.R. §§ 404.1520(g), 416.920(g). If the plaintiff
cannot perform other work, the evaluator will find him disabled. 20 C.F.R. §§
404.1520(a)(4)(v), 404.1520(g), 416.920(a)(4)(v), 416.920(g).
Applying the sequential evaluation process, the ALJ first found that Ms.
England meets the insured status requirements of the Social Security Act through
September 30, 2013. (Tr. at 25.) He further determined that Ms. England has not
engaged in substantial gainful activity since October 31, 2010, the alleged onset date
of her disability. (Id.) According to the ALJ, Plaintiff’s obesity; mild degenerative
disc disease at the level of L2-3; bilateral foot pain with multiple calluses; and disc
protrusions at T7-8, C3-4, and C5-6

are considered “severe” based on the

requirements set forth in the regulations. (Id.) However, he found that these
impairments neither meet nor medically equal any of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 26.) After due consideration of the
record, the ALJ determined Ms. England has the RFC to perform sedentary work
as defined in 20 CFR § 404.1567(a) and § 416.967(a) except she would need the

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option of briefly standing approximately every 30 minutes in order to reposition
herself. (Tr. at 27.)
According to the ALJ, Ms. England is unable to perform any of her past
relevant work, and she is a “younger individual aged 18-44” with a “limited
education,” as those terms are defined by the regulations. (Tr. at 31.) The ALJ
determined that transferability of skills is not an issue in this case. (Id.) Because
Ms. England’s ability to perform all requirements of sedentary work has been
impeded by additional limitations, the ALJ relied on testimony from a vocational
expert (“VE”) to find that there is a significant number of jobs in the state and
national economies that she is capable of performing, such as toy stuffer, eyeglass
frames polisher, and wire wrapper. (Id.) The ALJ concluded his findings by stating
that Plaintiff “has not been under a ‘disability,’ as defined in the Social Security
Act, at any time from October 31, 2010, through the date of this decision.” (Tr. at
32.)
II.

Standard of Review
This Court’s role in reviewing claims brought under the Social Security Act

is a narrow one. The scope of its review is limited to determining (1) whether there
is substantial evidence in the record as a whole to support the findings of the
Commissioner, and (2) whether the correct legal standards were applied. See Stone

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v. Comm’r of Soc. Sec., 544 F. App’x 839, 841 (11th Cir. 2013) (citing Crawford v.
Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004)). This Court gives
deference to the factual findings of the Commissioner, provided those findings are
supported by substantial evidence, but applies close scrutiny to the legal
conclusions. See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996).
Nonetheless, this Court may not decide facts, weigh evidence, or substitute
its judgment for that of the Commissioner. Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005) (quoting Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir.
2004)).

“The substantial evidence standard permits administrative decision

makers to act with considerable latitude, and ‘the possibility of drawing two
inconsistent conclusions from the evidence does not prevent an administrative
agency’s finding from being supported by substantial evidence.’” Parker v. Bowen,
793 F.2d 1177, 1181 (11th Cir. 1986) (Gibson, J., dissenting) (quoting Consolo v. Fed.
Mar. Comm’n, 383 U.S. 607, 620 (1966)). Indeed, even if this Court finds that the
proof preponderates against the Commissioner’s decision, it must affirm if the
decision is supported by substantial evidence. Miles, 84 F.3d at 1400 (citing Martin
v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).
However, no decision is automatic, for “despite th[e] deferential standard
[for review of claims], it is imperative that th[is] Court scrutinize the record in its

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entirety to determine the reasonableness of the decision reached.” Bridges v.
Bowen, 815 F.2d 622, 624 (11th Cir. 1987) (citing Arnold v. Heckler, 732 F.2d 881,
883 (11th Cir. 1984)). Moreover, failure to apply the correct legal standards is
grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
III.

Discussion
The Court interprets Ms. England’s brief as alleging that the ALJ’s decision

should be reversed and remanded for two reasons. First, she believes that the ALJ
failed to adequately consider her subjective complaints of pain in reaching his
disability finding. (Doc. 10 at 11.) Second, Plaintiff contends that the ALJ failed to
fully consider her impairments in combination with each other, and specifically
appears to argue that the ALJ should have devoted more discussion in his opinion
to her claim that she has fibromyalgia. (Id.)
A.

Credibility Determination

Ms. England contends that the ALJ improperly evaluated her credibility in
his finding that she was not disabled. (Doc. 10 at 11.) Her specific complaints were
that she experienced severe lower back and foot pain that rendered her unable to sit
longer than 30 minutes without repositioning, stand longer than 20 minutes, or
walk longer than 5 minutes without a break. (Tr. at 51-52). She also complained of

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numbness in her left leg and foot due to her back pain and plantar warts, and of
severe headaches. (Tr. at 50-51, 53).
Subjective complaints of pain and other symptoms may establish the
presence of a disabling impairment if they are supported by medical evidence. See
Foote v. Chater, 67 F.3d 1553, 1561 (11th Cir. 1995). In order to establish disability
based on subjective complaints of pain, the claimant must provide “(1) evidence of
an underlying medical condition and either (2) objective medical evidence that
confirms the severity of the alleged pain arising from that condition or (3) that the
objectively determined medical condition is of such a severity that it can be
reasonably expected to give rise to the alleged pain.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 1991) (citing Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir.
1991)); see also Landry v. Heckler, 782 F.2d 1551, 1553 (11th Cir. 1986).
Nonetheless, the ALJ is permitted to discredit the claimant’s subjective testimony
of pain and other symptoms if he articulates explicit and adequate reasons for doing
so. Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002); see also Soc. Sec. Rul.
96-7p, 1996 WL 374186 (1996) (“[T]he adjudicator must carefully consider the
individual’s statements about symptoms with the rest of the relevant evidence in
the case record in reaching a conclusion about the credibility of the individual’s
statements.”). In making a credibility determination, an ALJ may consider the

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opinions of treating physicians and consultative examiners, as well as those of other
medical doctors. See 20 C.F.R. §§ 404.1545(a)(3), 416.945(a)(3). The credibility
determination does not need to refer to “every piece of evidence in his decision
[regarding credibility], so long as the ALJ’s decision . . . is not a broad rejection
which is not enough to enable [the district court] to conclude that [the ALJ]
considered her medical condition as a whole.” Dyer, 395 F.3d at 1210-1211.
Here, the ALJ determined that Ms. England presented evidence of medically
determinable underlying impairments that could reasonably be expected to cause
her alleged symptoms. (Tr. at 28). However, he found that the medical record did
not contain sufficient evidence that Ms. England’s allegations of disabling pain
would preclude her from the performance of sedentary work with additional
restrictions. (Id.) Substantial evidence supports the ALJ’s credibility determination
here.
First, as the ALJ noted, there are few medical records in this case. (Tr. at 28,
193-247). As such, Plaintiff failed to provide sufficient evidence to support her
subjective complaints of disabling pain and other symptoms. Even though Plaintiff
offered numerous complaints and was diagnosed with different medical conditions,
subjective complaints and diagnoses alone do not establish that she was as limited
as she claimed. See Moore v. Barnhart, 405 F.3d 1208, 1213 n.6 (11th Cir. 2005)

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(“the mere existence of these impairments does not reveal the extent to which they
limit her ability to work or undermine the ALJ’s determination in that regard”).
Secondly, and as discussed by the ALJ, the objective testing and medical data
that is in the record does not support a conclusion that Plaintiff’s condition caused
disabling limitations. (Tr. at 28-31, 193-247). See 20 C.F.R. §§ 404.1529(c)(2), (4),
416.929(c)(2),(4). For example, a consultative medical examination by Dr. Bhat on
May 12, 2011, did not reveal significant or disabling abnormalities. (Tr. at 224-228).
While he found that Plaintiff had decreased range of motion in her cervical and
lumbar spine, her muscle strength and gait were normal and her heel and toe
weight-bearing were normal. (Tr. at 224-228). X-rays of Plaintiff’s lumbar spine
showed only mild degenerative changes at the L2-L3 level with mild increase in her
lumbar lordosis. (Tr. at 231). Dr. Bhat diagnosed Plaintiff with low back pain,
obesity and bilateral foot pain with multiple calluses, but placed no restrictions on
her ability to work. (Tr. at 224-228). MRI scans of Plaintiff’s spine also failed to
support Plaintiff’s claims of disability. (Tr. at 247-249). Additionally, although
there is no evidence that Plaintiff complained of back pain or received any
treatment for back pain after 2001, she told Dr. Bhat that she had experienced back
pain for a long time and that it had worsened over the past year. (Tr. at 224-228).
Plaintiff also told Dr. Bhat that she had not been able to seek medical help because

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she had no insurance. (Tr. at 224-228). However, records from Whatley Health
Services show that she received medical treatment from January 2010 through
April of 2011, which were the months prior to Dr. Bhat’s examination. (Tr. at 205213, 224-228). These treatment records show medical treatment during that time,
but not for the problem she reported to Dr. Bhat.
Three months after seeing Dr. Bhat, Plaintiff returned to Whatley Health
Services in August 2011. (Tr. at 241). At that visit, Plaintiff reported that she had
filed for disability. (Tr. at 241). However, thereafter, she sought limited medical
attention at Whatley Health Services including one visit in each of the following
months: January 2012, February 2012 and May 2012. (Tr. at 242, 243, 246). The
records did not show disabling pain or any significant work-related limitation.
Rather, in May 2012, Plaintiff was encouraged to exercise. (Tr. at 246).
Additionally, Plaintiff’s neurosurgeon, Dr. Shenai, reviewed the evidence
and noted that Plaintiff’s thoracic spine MRI showed a tiny disc protrusion at T7-8
without any compression of the spinal cord or nerve root. (Tr. at 247-249).
Plaintiff complained to Dr. Shenai in April 2012 only of low back pain, not neck or
arm pain. (Id.) Despite some significant disc disease in Plaintiff’s neck, Dr. Shenai
found she did not have any symptoms associated with that disc disease and surgical
intervention was not warranted. (Tr. at 247-249). He referred Plaintiff for further

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pain management treatment and recommended physical therapy. (Tr. at 249).
However, Plaintiff was not restricted from work activity. (Tr. at 247-249). The
foregoing treatment history establishes that Plaintiff’s subjective complaints of pain
were not as limiting as alleged, and the ALJ properly considered Plaintiff’s
treatment history as a factor in assessing her credibility.

See 20 C.F.R. §§

404.1529(c)(3)(v), 416.929(c)(3)(v).
Further, the ALJ also properly noted Plaintiff’s activities in evaluating the
credibility of her allegations. (Tr. at 29). See 20 C.F.R. §§ 404.1529(c)(3)(i),
416.929(c)(3)(i).

In reviewing this evidence, the ALJ correctly noted that

Plaintiff’s activities are not indicative of the disabling pain and other symptoms she
alleged. For instance, Plaintiff admitted performing light household chores and
shopping. (Tr. at 29, 164-171). In addition, Plaintiff admitted that she is able to
prepare meals, wash dishes, do laundry, drive and assist and care for her son. (Tr.
at 29, 164-171). She also stated that she has no problem with paying attention and
that she can finish what she starts. (Tr. at 28, 169). As the ALJ observed, such
activities undermine her claim of disabling pain and her alleged inability to perform
any work activity. As the foregoing demonstrates, substantial evidence supports
the ALJ’s decision to discredit Plaintiff’s subject complaints of pain.
B.

Failure to Fully Consider Impairments in Combination

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Plaintiff also argues that the ALJ failed to consider her impairments in
combination and argues that the evidence was “sufficient to establish a
fibromyalgia diagnosis.” (Doc. 10 at 12.) Social Security regulations require the
ALJ to consider the combined effects of all impairments in evaluating disability:
In determining whether your physical or mental
impairment or impairments could be the basis of
eligibility under the law, we will consider the combined
effect of all of your impairments without regard to
whether any such impairment, if considered separately,
would be of sufficient severity. If we do find a medically
severe combination of impairments, the combined effect
of the impairments will be considered throughout the
disability determination process. If we do not find that
you have a medically severe combination of impairments,
we will determine that you are not disabled.
20 CFR § 404.1523.
The ALJ’s decision reveals that he properly considered Plaintiff’s
impairments in combination in rendering his findings. In fact, the ALJ specifically
referenced and analyzed the “combination” of Plaintiff’s impairments throughout
his decision. (Tr. at 24, 26, finding no. 3). The Eleventh Circuit has stated that
such statements constitute evidence that the ALJ considered the combined effects
of the claimant’s impairments. See Wilson, 284 F.3d at 1224-25.
With specific regard to Plaintiff’s complaints about fibromyalgia, the ALJ
referenced the fact that Plaintiff said she had fibromyalgia at two different points in

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his decision. (Tr. at 26, 28). First, the ALJ stated at step two that “[t]he claimant
has also alleged that she has headaches and fibromyalgia; however, there is no
objective medical evidence to support such diagnoses.” (Tr. at 26.) With no
medical evidence in support, the ALJ did not find that fibromyalgia was a “severe”
impairment. In any event, while the ALJ did not find fibromyalgia to be a “severe”
impairment (tr. at 25-26), the ALJ found in Plaintiff’s favor at step two and
proceeded with the other steps of the sequential evaluation process. (Tr. at 25-30).
See 20 C.F.R. § 404.1520(a)(4)(ii)-(v), 416.920(a)(4)(ii)-(v). Thus, “[e]ven if the
ALJ erred in not indicating whether [a condition] was a severe impairment, the
error was harmless because the ALJ concluded that [the claimant] had a severe
impairment: and that finding is all that step two requires.” Heatly v. Comm’r of Soc.
Sec. 382 F. App’x 823, 824-25 (11th Cir. 2010). “Nothing requires that the ALJ
must identify, at step two, all of the impairments that should be considered severe.
Instead, at step three, the ALJ is required to demonstrate that it has considered all
of the claimant’s impairments, whether severe or not, in combination.” Id. at 825.
Secondly, the ALJ considered Plaintiff’s statement to a physician that she
“thought she had fibromyalgia” in his assessment of her RFC. (Tr. at 28.) The
ALJ specifically noted that he considered “all symptoms” and conditions, which
would have included Plaintiff’s complaints of fibromyalgia, in the sequential

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evaluation process. (Tr. at 25-30). In short, the medical evidence failed to show
that Plaintiff’s alleged fibromyalgia caused additional limitations beyond what the
ALJ found in his RFC assessment. See Sanchez v. Comm’r of Soc. Sec., No. 12-11762,
2013 WL 490029, at *4 (11th Cir. Feb. 8, 2013) (noting even if the ALJ erred at
step two, the ALJ considered condition at other steps, the RFC finding accounted
for all of claimant’s limitations, and claimant failed to show what additional
limitations her condition caused beyond limitations manifested by her other severe
impairments). Thus, the ALJ properly assessed all of Plaintiff’s claims and medical
conditions and substantial evidence supports the RFC determination and his
conclusion that Plaintiff was not disabled.
IV.

Conclusion
Upon review of the administrative record, and considering all of Ms.

England’s arguments, the Court finds the Commissioner’s decision is supported by
substantial evidence and in accord with the applicable law. A separate order will be
entered.
DONE and ORDERED on March 13, 2015.

_____________________________
L. Scott Coogler
United States District Judge
160704

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