Mclaren v. Social Security Administration, Commissioner

Filing 15

MEMORANDUM OPINION. Signed by Judge L Scott Coogler on 8/14/2017. (KAM, )

FILED
2017 Aug-14 PM 04:48
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
JASPER DIVISION
ROBERT MACLAREN,
Plaintiff,
vs.
NANCY BERRYHILL,
Commissioner of Social Security,
Defendant.

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6:16-CV-1271-LSC

MEMORANDUM OF OPINION
I.

Introduction
The plaintiff, Robert Maclaren, appeals from the decision of the

Commissioner of the Social Security Administration (“Commissioner”) denying
his application for Supplemental Security Income (“SSI”) and Disability Insurance
Benefits (“DIB”). Mr. Maclaren timely pursued and exhausted his administrative
remedies and the decision of the Commissioner is ripe for review pursuant to 42
U.S.C. §§ 405(g), 1383(c)(3).
Mr. Maclaren was forty-three years old at the time of the Administrative
Law Judge’s (“ALJ’s”) decision, and he has an eleventh grade education and a
GED. (Tr. at 50.) His past work experiences include employment as chiller

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operator, poultry hanger, metal hanger in the manufactured home industry, over
the road truck driver, window installer in the manufactured building industry,
cabinet and trim installer in manufactured buildings, electronics technician in the
military, table saw operator, pizza baker, and manager trainee in a restaurant. (Tr.
at 51-53.) Mr. Maclaren claims that he became disabled on August 16, 2013, due to
neck and back injury and arthritis. (Tr. at 54-55.)
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”). See Id. §§
404.1520(a)(4)(i), 416.920(a)(4)(i). If the plaintiff is not 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

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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.
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

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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.
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 found that Mr.
Maclaren meets the non-disability requirements for a period of disability and DIB
and was insured through the date of his decision. (Tr. at 31.) He further determined
that Mr. Maclaren has not engaged in SGA since the alleged onset of his disability.
(Id.) According to the ALJ, Plaintiff’s degenerative disc disease of the cervical
spine with chronic cervicalgia; degenerative disc disease of the lumbar spine with
chronic lumbago; and degenerative joint disease of the right shoulder are
considered “severe” based on the requirements set forth in the regulations. (Id.)
However, the judge found that these impairments neither meet nor are the medical

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equivalent of any of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (Tr. at 32.) The ALJ then determined that the plaintiff has the RFC to
perform sedentary work with significant postural and environmental restrictions;
he can occasionally balance, stoop, kneel, or crouch; he can occasionally climb
ramps and stairs; however, he is precluded from climbing ladders, ropes, or
scaffolds; he is precluded from doing work that involves crawling, unprotected
heights, and concentrated exposure to extreme heat and cold; he is limited to only
occasional reaching/lifting with his non-dominant right upper extremity. (Tr. at
33.)
According to the ALJ, Mr. Maclaren is unable to perform any of his past
relevant work. (Tr. at 36.) He is a “younger individual” and “has at least a high
school education” as those terms are defined by the regulations. (Id.) Because
Plaintiff cannot perform the full range of sedentary work, the ALJ enlisted a
vocational expert (“VE”) and used Medical-Vocational Rule 201.28 as a guideline
for finding that there are a significant number of jobs in the national economy that
he is capable of performing, such as a spotter table worker, a check weigher, and a
non-production assembler. (Tr. at 37.) The ALJ concluded his findings by stating
that Plaintiff “was not under a ‘disability,’ as defined in the Social Security Act, at
any time through the date of this decision.” (Id.)

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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
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

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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
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
Mr. Maclaren contends that the ALJ’s decision should be reversed and

remanded for two reasons. First, the plaintiff believes the ALJ improperly
evaluated his subjective complaints. Second, the plaintiff contends that the Appeals
Council erred by not considering MRI results submitted several months after the
hearing decision.
A.

Evaluation of Subjective Complaints

The plaintiff asserts that the ALJ did not properly evaluate his subjective
complaints with respect to the ALJ’s consideration of his 2009 spinal MRI results.
A disabling impairment can be established via subjective testimony of pain and

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other symptoms when it is supported by medical evidence. See Foote v. Chater, 67
F.3d 1553, 1561 (11th Cir. 1995). To establish a disability based on subjective
symptoms and pain “[t]he pain standard requires, (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, 395 F.3d at 1210 (citing Holt v.
Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991)).
When the severity of symptoms is not supported by objective medical
evidence, the intensity and persistence of alleged symptoms must be evaluated. See
20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1); Wilson v. Barnhart, 284 F.3d 1219,
1225-26 (11th Cir. 2002). During assessment, the ALJ considers the plaintiff’s
testimony and any inconsistencies between the testimony of symptoms and any
other evidence. 20 C.F.R. §§ 404.1529(c)(3)-(4), 416.929(c)(3)-(4). 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. See generally
Wilson, 284 F.3d at 1225; see also Social Security Ruling (“SSR”) 96-7p, 1996 WL
374186 (“[T]he adjudicator must carefully consider the individual’s statements
about symptoms with the rest of the relevant evidence in the case record in

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reaching a conclusion about the credibility of the individual’s statements.”),
superseded by SSR 16-3p.
The Eleventh Circuit does not require explicit findings regarding credibility
but “the implication must be obvious to the reviewing court.” Dyer, 395 F.3d at
1210 (quoting Foote, 67 F.3d at 1562). “[P]articular phrases or formulations” do not
have to be cited in an ALJ’s credibility determination, but it cannot be a broad
rejection because this is “not enough to enable [the Court] to conclude that [the
ALJ] considered the medical condition as a whole.” (Id.)
In this case, Plaintiff claimed to have disabling back and neck injuries. (Tr. at
172.) The existence of injuries is confirmed in the record, specifically by two 2009
MRI reports of the lumbar spine and cervical spine respectively. (Tr. at 242-43.)
However, while Plaintiff’s MRI results document minimal, mild, and moderate
findings and establish the existence of spinal impairments, “it is well established
that it is the functional limitations from an impairment, and not the diagnosis of an
impairment, that [are] determinative in an evaluation of disability.” Hollman v.
Astrue, 2010 WL 3361970, at *3 (M.D. Fla. Aug. 25, 2010); see also Moore v.
Barnhart, 405 F.3d 1208, 1213 n.6 (11th Cir. 2005) (“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”); McCruter v. Bowen, 791 F.2d

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1544, 1547 (11th Cir. 1986) (“[T]he ‘severity’ of a medically ascertained disability
must be measured in terms of its effect upon ability to work, and not simply in
terms of deviation from purely medical standards of bodily perfection or
normality.”).
The relatively scant medical evidence in this case does not support a finding
that Plaintiff’s impairments were more limiting than the ALJ found. As the ALJ
noted, the plaintiff’s back pain was treated conservatively with pain medication
during the relevant period. (Tr. at 57, 246.) Plaintiff received only two epidural
injections as treatment for his neck and shoulder pain during the relevant time
period. (Tr. at 213, 215.) Though Plaintiff alleges that he is still in pain, and that the
epidural shots wear off after a few days, there is no objective medical evidence to
corroborate these assertions. (Tr. at 35.) As the ALJ pointed out, physical
examination findings after Plaintiff claims his disability began generally indicated
tender lumbar paraspinal muscles with no joint swelling or abnormality, no joint
instability, and normal range of motion throughout. (Tr. at 35, 248, 258). The
Commissioner’s regulations provide that clinical findings such as reduced joint
motion, muscle spasm, sensory deficit, and motor disruption are “useful
indicator[s] to assist [the ALJ] in making reasonable conclusions about the intensity
and persistence of [a claimant’s] symptoms and the effect those symptoms, such as

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pain, may have on [his or her] ability to work.” 20 C.F.R. §§ 404.1529(c)(2),
416.929(c)(2). Findings such as these “tend to lend credibility to an individual’s
allegations about pain or other symptoms and their functional effects.” SSR 96-7p,
1996 WL 347186, superseded by SSR 16-3p. Plaintiff’s medical records during the
relevant period, however, do not document any such findings. (Tr. at 246-48, 25658). Indeed, treatment notes dated August 15, 2013, the day before Plaintiff alleges
he became disabled, do not indicate that Plaintiff complained of back or neck pain,
and no musculoskeletal or neurological findings were recorded. (Tr. at 136, 143,
218-19).
In any event, the ALJ did not find that Plaintiff was completely pain free or
dismiss all of his subjective complaints of pain. Rather, he found the complaints
supported to the extent they were consistent with the plaintiff’s ability to perform a
reduced range of sedentary work. See Tr. at 35 (“I have given the claimant the
benefit of doubt and more than fully accounted for his credible symptoms and
limitations by limiting him to sedentary work with significant postural and
environmental restrictions. I have accounted for his right shoulder by limiting him
to occasional overhead reaching/lifting on the right.”).
Considering the foregoing, the Court discerns no error in the ALJ’s
credibility finding.

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B.

Additional Evidence Submitted to Appeals Council

With few exceptions, a social security disability claimant is entitled to
present new evidence at each stage of the administrative process. The Social
Security Appeals Council must consider new, material and chronologically relevant
evidence and must review the case if the ALJ’s action, findings, or conclusion is
contrary to the weight of the evidence currently of record. Ingram v. Commissioner,
496 F.3d 1253, 1258 (11th Cir. 2007). When reviewing the Commissioner’s
decision to deny Social Security benefits, “[A] federal district court must consider
evidence not submitted to the administrative law judge but considered by the
Appeals Council.” Id. Specifically, when the Appeals Council denies review of
newly submitted evidence, a reviewing court must determine “whether the new
evidence renders the denial of benefits,” and ultimately the ALJ’s decision,
erroneous and unsupported by substantial evidence. Id. at 1261-63.
In this case, the ALJ’s decision denying Plaintiff disability benefits was
entered on April 8, 2015. Plaintiff sought review of the decision by the Appeals
Council, submitting an MRI report dated September 3, 2015, as additional
evidence. The Appeals Council denied Plaintiff’s request for review of the ALJ’s
decision. (Tr. at 2.) The Appeals Council determined that the MRI report

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pertained to a different time period and did not affect the validity of the ALJ’s
findings. (Id.)
The September 3, 2015, MRI report compared Plaintiff’s then-current
condition to his condition noted in a 2009 MRI Report. (Tr. at 9.) Specifically, the
September 3, 2015, MRI report notes:
Findings:
Comparison 5/27/2009. Numbering will assume 5 lumbar type
vertebral bodies as on the previous examination. Using this
numbering system, axial images begin in the L1 vertebral body.
L1-L2: A mixture of chronic and more acute appearing reactive
endplate changes are present anteriorly, more than on the previous
examination. A diffuse bulge osteophyte complex and minimal
retrolisthesis contribute to mild thecal sac narrowing, similar in
magnitude compared to the previous examination. Mild right
foraminal narrowing.
L2-L3: Mild edematous reactive endplate changes are new at the left
side of the L3 upper endplate. A small diffuse disc bulge is present.
Small superimposed right paracentral protrusion is new. There is
mild thecal sac narrowing. There is mild bilateral foraminal
narrowing. Mild facet DJD.
L3-L4: Small diffuse bulge mildly narrows the thecal sac. The disc
bulge is slightly smaller in a craniocaudad dimension than on the
previous examination. Mild facet DJD. There is mild—moderate left
foraminal narrowing.
L4-L5: Small diffuse bulge mildly narrows the thecal sac, slightly
worse on the left than the right. The disc bulge has a slightly different
configuration than on the previous, but the overall magnitude of
thecal sac narrowing is similar. Currently the disc bulge apex in the
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let paracentral region lies near the origin of the left L5 nerve from the
thecal sac. There is moderate bilateral foraminal narrowing.
Foraminal narrowing is similar compared to the previous.
L5S1: Minimal facet DJD. Small left bulge causes mild narrowing.
Impression:
Disc and facet degenerative changes with thecal sac and foraminal
narrowing as described above.
(Id.)
Because Plaintiff has not established that the September 3, 2015, MRI report
constitutes new, chronologically relevant, and material evidence, the Appeals
Council was not required to consider it. As an initial matter, although the Appeals
Council did not provide a more thorough analysis regarding its decision, it is not
required to provide a detailed discussion of new evidence when denying a request
for review. Mitchell v. Comm’r of Soc. Sec., 771 F.3d 780, 784 (11th Cir. 2014).
Further, even assuming the MRI evidence is new and chronologically relevant, it is
not “material.” See Falge v. Apfel, 150 F.3d 1320, 1323 (11th Cir. 1998) (explaining
that “material evidence” is “such that a reasonable possibility exists that the new
evidence would change the administrative result.”). The new MRI report does not
demonstrate that Plaintiff has more restrictive functional limitations than those
found by the ALJ. See Moore, 405 F.3d at 1213 n.6 (“The mere existence of []
impairments does not reveal the extent to which they limit [one’s] ability to work
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or undermine the ALJ’s determination in that regard.”); McCruter, 791 F.2d at
1547 (“[T]he ‘severity’ of a medically ascertained disability must be measured in
terms of its effect upon ability to work, and not simply in terms of deviation from
purely medical standards of bodily perfection or normality.”). The Appeals
Council did not err in refusing to review the ALJ’s decision.
IV.

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

Maclaren’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 August 14, 2017.

_____________________________
L. Scott Coogler
United States District Judge
160704

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