Nelms v. Colvin
Order entered that the decision of the Commissioner of Social Security denying Plaintiff's claim for a period of disability, disability insurance benefits, and supplemental security income be AFFIRMED. Signed by Magistrate Judge Sonja F. Bivins on 3/26/2015. (mjn)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
MONEKE LATASHA NELMS,
CAROLYN W. COLVIN,
Commissioner of Social Security,*
CIVIL ACTION NO. 14-00018-B
brings this action seeking judicial review of a final decision
of the Commissioner of Social Security denying her claim for a
supplemental security income under Titles II and XVI of the
Social Security Act, 42 U.S.C. §§ 401, et seq., and 1381, et
On October 15, 2014, the parties waived oral argument, and
on October 21, 2014, they
consented to have the undersigned
conduct any and all proceedings in this case.
(Docs. 16, 18).
Thus, the action was referred to the undersigned to conduct all
proceedings and order the entry of judgment in accordance with
28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73.
memoranda of the parties, it is hereby ORDERED that the decision
of the Commissioner be AFFIRMED.
Plaintiff filed an application for a period of disability,
disability insurance benefits and supplemental security income
on March 3, 2011. 1
Plaintiff alleged that she had
been disabled since November 10, 2010, due to a “slipped disc in
back[;] right leg is numb[;] [and] diabetic.” (Id. at 172, 175).
Plaintiff’s applications were denied, and upon timely request,
she was granted an administrative hearing before Administrative
Law Judge Kim McClain-Leazure (hereinafter “ALJ”) on May 11,
(Id. at 30).
Plaintiff attended the hearing with her
counsel and provided testimony related to her claims.
A vocational expert (“VE”) also appeared at the hearing
and provided testimony.
(Id. at 45).
On July 16, 2012, the ALJ
issued an unfavorable decision finding that Plaintiff is not
(Id. at 23).
The Appeals Council denied Plaintiff’s
request for review on November 20, 2013.
(Id. at 1).
ALJ’s decision dated July 16, 2012, became the final decision of
timely filed the present civil action.
agree that this case is now ripe for judicial review and is
Plaintiff filed a prior claim on April 3, 2009, which was
denied and was pending at the Appeals Council level at the time
that she filed the instant claim. (Tr. 174).
properly before this Court pursuant to 42 U.S.C. §§ 405(g) and
Issue on Appeal
Whether the ALJ erred in giving “little
weight” to the opinions of Plaintiff’s
III. Factual Background
Plaintiff was born on March 4, 1980, and was thirty-two
years of age at the time of her administrative hearing on May
30, 33, 172).
She completed the twelfth grade
(Id. at 33, 176).
Plaintiff testified that she suffers from diabetes, 2 high
blood pressure, 3 back pain, and right leg numbness.
(Id. at 35-
She described her pain as constant, and she rated it as a
seven on a ten-point pain scale.
(Id. at 36-37).
Plaintiff testified that her blood sugar, on average, tends to
run “around 280,” but it has shot up as high as 498 and dropped
as low as 40. (Tr. 39). A normal fasting blood glucose target
range for an individual without diabetes is 70-100 mg/dL (3.95.6 mmol/L).
The American Diabetes Association recommends a
fasting plasma glucose level of 70–130 mg/dL (3.9-7.2 mmol/L)
and after meals less than 180 mg/dL (10 mmol/L). See
Plaintiff testified that her high blood pressure is fairly well
controlled with medication. (Tr. 40).
(Id. at 36, 42).
She has also had repeated epidurals
for pain, but they only made her condition worse.
(Id. at 42).
Plaintiff testified that she cannot work because of her
(Id. at 35-36, 42).
According to Plaintiff, she spends the
majority of her day lying down.
(Id. at 37).
She takes care of
her four-year old daughter alone, except that her mother comes
over and helps approximately three days a week.
(Id. at 37-38).
She can shop, but she has to do it quickly.
(Id. at 41).
Plaintiff testified that she cannot clean, sweep, mop, bathe her
child, or put on her child’s clothes.
(Id. at 38).
Standard of Review
In reviewing claims brought under the Act, this Court’s
supported by substantial evidence and 2) whether the correct
legal standards were applied.
1520, 1529 (11th Cir. 1990).
Martin v. Sullivan, 894 F.2d
A court may not decide the facts
anew, reweigh the evidence, or substitute its judgment for that
Plaintiff listed her medications as Glipizide (for diabetes),
Integra Plus (for low iron), Percocet (for pain), and Xanax (for
panic attacks). (Tr. 199).
This Court’s review of the Commissioner’s application of legal
principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th
of the Commissioner.
Sewell v. Bowen, 792 F.2d 1065, 1067 (11th
affirmed if they are based upon substantial evidence.
Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v.
substantial evidence is defined as “more than a scintilla, but
evidence as a reasonable person would accept as adequate to
evidence exists, a court must view the record as a whole, taking
into account evidence favorable, as well as unfavorable, to the
Chester v. Bowen, 792 F. 2d 129, 131
(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4
(S.D. Ala. June 14, 1999).
An individual who applies for Social Security disability
Disability is defined as 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 12
determining if a claimant has proven his disability. 6
§§ 404.1520, 416.920.
In the case sub judice, the ALJ determined that Plaintiff
has not engaged in substantial gainful activity since November
10, 2010, the alleged onset date, and that she has the severe
impairments of disorders of the back, diabetes, hypertension,
The claimant must first prove that he or she has not engaged in
substantial gainful activity.
The second step requires the
claimant to prove that he or she has a severe impairment or
combination of impairments. If, at the third step, the claimant
proves that the impairment or combination of impairments meets
automatically found disabled regardless of age, education, or
If the claimant cannot prevail at the third
step, he or she must proceed to the fourth step where the
claimant must prove an inability to perform their past relevant
work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In
evaluating whether the claimant has met this burden, the
examiner must consider the following four factors: (1) objective
medical facts and clinical findings; (2) diagnoses of examining
physicians; (3) evidence of pain; and (4) the claimant’s age,
education and work history.
Once a claimant meets this
burden, it becomes the Commissioner’s burden to prove at the
fifth step that the claimant is capable of engaging in another
claimant’s residual functional capacity, age, education, and
Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir.
1985). If the Commissioner can demonstrate that there are such
jobs the claimant can perform, the claimant must prove inability
to perform those jobs in order to be found disabled. Jones v.
Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v.
Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.
Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).
further found that Plaintiff does not have an impairment or
combination of impairments that meets or medically equals any of
the listed impairments contained in 20 C.F.R. Part 404, Subpart
P, Appendix 1.
(Id. at 18).
functional capacity (hereinafter “RFC”) to perform a full range
of light work.
The ALJ also determined that while
Plaintiff’s medically determinable impairments could reasonably
concerning the intensity, persistence and limiting effects of
the alleged symptoms were not credible to the extent that they
were inconsistent with the RFC.
(Id. at 19).
However, utilizing the testimony of a VE, the ALJ concluded that
residual functional capacity for a full range of light work, a
(Id. at 22).
The ALJ concluded that
disorder were non-severe.
challenged these findings.
Plaintiff’s headaches and anxiety
Plaintiff has not
Plaintiff’s testimony as follows:
The representative’s theory indicates the
claimant is disabled due to back problems,
osteoarthritis with some anxiety.
hearing, claimant testified she has not
November 10, 2010. The claimant testified
she is unable to work due to “slipped disc,”
right leg numbness, and diabetes, which she
states includes sugar readings that are both
high and low, and hand cramps.
testified that her pain averages seven on a
scale of 1-10, and stated she frequently has
to lie down because of pain, but gets up to
take her medicine.
The claimant testified
she has a four-year old daughter to care
for, but indicates her mother assists in
reportedly has “bad days” three times a
week, despite medication.
that her diabetes escalates out of control,
about five times a week.
She indicated her
hypertension is controlled with medication,
but escalates on “bad days” due to pain.
She described cramping in her hands and
legs, which she relieves by shaking them
constantly to prevent pain and stiffness.
The claimant reported she is unable to run
errands on “bad days.”
She also reported
having undergone at least 25 epidurals in
the past by a pain management (sic), which
only made her pain worse.
stated that a doctor wanted to perform back
surgery, but she decided against surgery
because of her daughter’s young age.
Yearwood before she started seeing Dr.
Barnes, and explained she had difficulty
getting appointments to see Dr. Barnes. . .
In discussing the relevant medical evidence, the ALJ stated
Turning to the medical evidence, records
from Barnes Family Medical reflect a visit
on February 23, 2010, with the claimant
requesting pain medication for back pain and
Barnes, M.D., prescribed Celestone, Toradol
injections, Percocet, and Xanax.
complaints of pain in the right leg, back,
arm and right shoulder.
However, she was
seen lifting and holding her daughter on her
right side and was noted as easily weighing
20 pounds (Exhibit B5F). Outpatient records
treatment for bilateral lower leg pain on
January 5, 2011 after the claimant explained
that a metal shelf had fallen, striking her
legs and feet. However, on examination,
there was no evidence of bruising, swelling,
or redness noted. On January 25, 2011,
returned to the hospital and was diagnosed
with chronic low back pain; however, a
lumbar MRI showed only mild degenerative
Claimant was prescribed Prednisone 10 mg and
Mobic 25 mg (Exhibit B4F).
returned to Dr. Barnes on March 21, 2011,
with persistent pain, including abdominal
complaints. He referenced the earlier MRI,
and diagnosed cervical spine disc disease,
presented to Barnes Medical Center on June
6, 2011, complaining of back pain, left hand
right leg pain, but denied injury.
practitioner noted there was evidence of
cause for the claimant’s hand pain. All
vital signs were stable, and claimant was
advised to continue on current medicines
(Exhibit B10F). On January 30, 2012, she
returned to Barnes Family Medical with
additional pain complaints, but indicated
her pain level overall was 5/10.
claimant was administered a B12 and a
Toradol injection for pain (Exhibit B11F).
A follow up visit the following month for
back and leg pain referenced emergency
hospital treatment for a fractured right
On March 8, 2012, the claimant
presented to Barnes Family Medical, with
complaints of pain and myalgias involving
moving furniture around a lot at home, and
that her shoulder had been bothering her for
the last few days. On examination, the
claimant exhibited painful range of motion
of the left shoulder, but there was no
evidence of popping, crepitus, heat, redness
or swelling. The claimant was prescribed
Prednisone for seven days, and Flexeril 10
mg. She was given refills of Percocet, and
Xanax, and told to return in one to three
months, or as necessary (Exhibit B11F).
Although diagnostic imaging in January 2011
showed facet joint hypertrophy at L4-5 and
L5-S-1, those findings were mild in severity
(Exhibit B4F). Since then, the claimant has
not been observed to have ongoing neurologic
deficits in the upper or lower extremities,
such as reflex and sensory abnormalities,
decreased muscle strength.
is no indication of joint deformities, gait
documented in the record.
As for the claimant’s alleged diabetes and
hypertension, an assessment of July 14, 2010
claimant was started on medication for
elevated blood pressure without hypertension
(Exhibit B5F). On February 21, 2011, Dr.
Barnes diagnosed benign hypertension in
The claimant indicated her
blood sugar had been dropping; but on
examination, there was no indication of
fever, chills, sweats, nausea or vomiting;
all of which are character symptoms (Exhibit
Shortly thereafter, the claimant
began having recurring abdominal pain.
Barnes noted on March 21, 2011, that the
claimant was a diabetic hypertensive and
responsible for the recurring abdominal
claimant’s medicines were adjusted several
times over the course of treatment with Dr.
established treating relationship
excessive use of Goody powders along with
her prescribed medicines, which ultimately
lead (sic) to noncompliance as contributing
to the claimant’s
abdominal and related
symptoms (Exhibit B11F). Dr. Barnes’ nurse
November 28, 2011, that the claimant’s
vital signs were stable, including a blood
pressure of 120/70 (Exhibit B10F).
February 21, 2012, the claimant’s vital
signs were again stable, and her blood
pressure was 130/70 (Exhibit B11F).
damage causing a significant functional
impairment failed to respond appropriately
consistently shown that treatment for the
impairments has been effective when properly
acknowledged at the hearing, that while her
diabetes, treated by Dr. Yearwood remains
controlled with medication.
Although the claimant testified that Dr.
Yearwood is her current treating physician,
the record is void of evidence until April
24, 2012, when Amrita Yearwood, M.D., a
primary care physician, advised she had
treated the claimant for several years.
hypertension, uncontrolled type II diabetes,
and back pain, Dr. Yearwood opined that,
“due to her multiple medical problems, Ms.
Nelms is unable to work” (Exhibit B13F). On
May 11, 2012, Dr. Yearwood completed a
Physical Capacities Evaluation, indicating
that during an 8-hour workday, the claimant
can lift/carry 5 pounds occasionally to 1
She can sit, stand, walk
for a total of two hours out of eight.
movements with arms and/or
legs; can climb, balance, and can perform
gross and fine manipulations, and operate
Dr. Yearwood opined that,
on rare occasions, the claimant could bend,
stoop, reach in all directions, and work
allergies, dust, etc.
She indicated the
claimant could never work with or around
She would likely miss
more than four days per month from work
because of impairments or treatment.
Clinical Pain Assessment indicates that the
claimant’s pain is severe enough to cause
distraction of daily activities or work,
indicated that medication side effect were
severe enough to limit effectiveness due to
distraction, inattention, drowsiness, etc.
consisting of routine physical examinations
and medication adjustments and refills, the
allegations are not fully credible.
claimant testified that her medicines make
her drowsy and sleepy[;] however, these
complaints are not substantiated in the
Rather, the current
medications fail to support any disabling
I find the claimant is not
credible at all, as she basically does as
she pleases; then complains to doctors about
her back, which does not seem to stop her
from doing all kinds of activities, such as
moving furniture “a lot” (Exhibit B11F).
Evidence from Evergreen Medical Center,
including emergency room records in January
complaints (Exhibit B4F), but includes no
records from Dr. Yearwood, albeit her report
of April 24, 2012, states she had treated
Overall, medical evidence
from Dr. Barnes, the established primary
physician from April 2010 through February
2011, consistently references the claimant’s
complaints of back pain, but totally, the
assessments that showed little more than
generalized myalgias, benign hypertension,
and diabetes, capable of being managed
conservatively (Exhibits BSF, B10F, BllF).
assigned by Dr. Yearwood, she notes the
claimant is able to climb ladders and stairs
one-third of a workday, yet indicates the
claimant can only stand for two hours and
can sit for two hours; and can rarely be
exposed to environmental factors (Exhibit
Nevertheless, in considering Dr. Yearwood’s
opinion that the claimant is unable to work
(Exhibit B13F); even if her records were
substantial evidence of record.
unfortunate in that Dr. Yearwood failed to
provide any basis to support the assigned
limitations, particularly since her records,
which includes a brief one-page report at
assessments, consisting of two-pages at
Exhibit B13F, certainly do not support her
opinion, which is given little weight.
Although Dr. Barnes has not offered a
specific opinion regarding the claimant’s
functional limitations, his statements merit
Based on Dr. Barnes’
longstanding treating relationship with the
claimant; and his familiarity (along with
that of his nurse practitioner) with the
Claimant’s overall medical condition and
limitations, based on his clinical findings;
notes, are all factors that give weight to
his opinion statements, which also supports
the residual functional capacity finding.
capacity assessment is supported by the
preponderance of the most credible objective
evidence of record, including the claimant’s
conservative treatment history and physician
record in this case and the issue on appeal.
Whether the ALJ erred in giving “little
weight” to the opinions of Plaintiff’s
substituting her own opinion for that of the treating physician,
Amrita Yearwood, M.D., without following proper legal standards
and without support of substantial evidence for her opposite
(Doc. 13 at 3).
The Commissioner counters that
As discussed herein, the record shows that the ALJ gave “little
weight” to the opinions of Dr. Yearwood set forth in the April
24, 2012 letter opining that Plaintiff “is unable to work” and
in the May 2012 Physical Capacities Evaluation (“PCE”) and
Clinical Assessment of Pain (“CAP”) forms.
(Tr. 22, 342, 34748).
the ALJ had good cause to reject Dr. Yearwood’s opinions because
they are wholly unsupported and inconsistent with the record
evidence in this case and that the ALJ’s determination that
Plaintiff is not disabled is supported by substantial evidence.
(Doc. 14 at 3-4).
Having carefully reviewed the record, the
Court agrees with Defendant that Plaintiff’s claim is without
Generally speaking, “[i]f a treating physician’s opinion on
the nature and severity of a claimant’s impairments is wellsupported
diagnostic techniques, and is not inconsistent with the other
controlling weight.” 9
Roth v. Astrue, 249 Fed. Appx. 167, 168
(11th Cir. 2007) (citing 20 C.F.R. § 404.1527(d)(2)).
requisite ‘good cause’ for discounting a treating physician’s
opinion may exist where the opinion is not supported by the
“Controlling weight” is defined as a medical opinion from a
treating source that must be adopted. See SSR 96–2P, 1996 SSR
LEXIS 9, *3, 1996 WL 374188, *1 (1996).
evidence, or where the evidence supports a contrary finding.”
3155570, *3 (M.D. Ala. 2012).
“Good cause may also exist where
a doctor’s opinions are merely conclusory, inconsistent with the
doctor’s medical records, or unsupported by objective medical
“[T]he weight afforded a treating doctor’s
opinion must be specified along with ‘any reason for giving it
no weight, and failure to do so is reversible error.’”
v. Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1
(M.D. Fla. 2009); see also Phillips v.
Barnhart, 357 F.3d 1232,
1241 (11th Cir. 2004) (“When electing to disregard the opinion
of a treating physician, the ALJ must clearly articulate [his or
Plaintiff on November 10, 2010, in the hospital emergency room
when Plaintiff sought treatment for uncontrolled hypertension,
low back pain, and right leg pain.
(Id. at 248, 252).
Yearwood discharged Plaintiff approximately one hour later in
stable condition with Clonidine (for high blood pressure) and
Lortab (for pain).
(Id. at 248, 253).
The record next shows
that Dr. Yearwood treated Plaintiff on five occasions in 2012
various complaints including hypertension, diabetes, back pain,
cough, congestion, bronchitis, and medication refills. 10
347-48, 364, 367-69, 379-80).
After an office visit on April
drafted a letter for Plaintiff on April 24, 2012, addressed “to
whom it may concern,” in which Dr. Yearwood opined that “due to
(Id. at 342, 380).
Approximately two weeks later, on
Evaluation (“PCE”) form in which she opined that Plaintiff could
frequently, that she could sit for only two hours in an eighthour day, and that she could stand/walk for only two hours in an
completed a Clinical Assessment of Pain (“CAP”) form in which
she stated that Plaintiff’s pain is “present to such an extent
On April 1, 2012, Dr. Yearwood treated Plaintiff in the
emergency room for back pain and elevated diabetes and
discharged her approximately one and a half hours later with
Lortab and instructions to follow up with her family physician.
(Tr. 364-65). Three days later, on April 4, 2012, Dr. Yearwood
admitted Plaintiff to the hospital for two days for treatment of
bronchitis. (Id. at 368-70).
The letter, in full, consisted of five sentences and stated:
“Moneke Nelms has been a patient of mine for several years. She
has hypertension and uncontrolled type II Diabetes.
She has a
history of back pain, having had many epidurals done to relieve
Due to her multiple medical problems, Ms. Nelms is
unable to work. If you have any questions, or if you need any
additional information, please contact my office.” (Tr. 342).
activities;” that physical activity will “greatly” increase the
pain “to such an extent as to cause distraction from tasks or
total abandonment of task[s];” and that “drug side effects can
Having reviewed the record at length, the Court finds, as the
ALJ found, that Dr. Yearwood’s opinions are not supported by the
First, as the ALJ articulated, there is absolutely nothing
in Dr. Yearwood’s treatment records to support the debilitating
limitations assigned to Plaintiff in the April 24, 2012 letter
and back pain.
(Id. at 248, 364, 367, 380, 379).
In addition to being inconsistent with her own treatment
findings and opinions of Plaintiff’s other treating physician,
treated Plaintiff from 2008 to 2012 for diabetes, hypertension,
treatment of Plaintiff’s medical conditions with medications.
(Id. at 265, 272-94, 336-39).
Nothing in Dr. Barnes’ treatment
notes reflects that Plaintiff’s medical conditions resulted in
2011, Dr. Barnes assessed Plaintiff with “benign hypertension,
osteoarthritis, generalized myalgias, and diabetes,” for which
he simply adjusted her medications.
(Id. at 272).
impairment caused by Plaintiff’s hypertension12 or diabetes.
As for Plaintiff’s back pain, on June 9, 2009, Dr. Barnes’
prescribed pain medication.
(Id. at 280).
Barnes frequently noted that Plaintiff requested refills on her
As noted previously, at her hearing, Plaintiff acknowledged
that her hypertension is controlled with medication. (Tr. 40).
On May 6, 2008, Dr. Barnes stated that he saw no reason to
keep Plaintiff on any pain medication and that he would “give
her [an] anti-inflammatory or something to that effect.”
285). On August 3, 2009, Dr. Barnes’ nurse practitioner noted
that Plaintiff “went to the ER over the weekend with leg pain
but they just gave her a Toradol shot and she didn’t get any
pain medicine so I told her she shouldn’t have needed any as it
is still early for her last pain medication.” (Id. at 290). On
January 25, 2010, Dr. Barnes stated, “Dr. Rainer [has]
recommended no further therapy.
He’s not really sure what’s
going to help her out. Now I want to put her on some Mobic and
before I could even get the words out of my mouth she claimed it
wouldn’t work so I don’t think she’s interested in getting any
kind of help or anything like that.
Unfortunately she has
succumbed to taking the narcotic analgesics. She’s here early.”
(Id. at 292).
On June 21, 2010, Dr. Barnes stated, “She needs
her pain medicine refilled. She is about 4 days early. I have
daughter’s young age.
(Id. at 43).
However, on March 18, 2009,
Dr. Barnes noted that Plaintiff wanted to be put in the hospital
for her back pain, but he “[saw] no medical reason to do that.”
(Id. at 282).
Dr. Barnes stated, “[h]er MRI Scan 14 didn’t show
much of anything so putting her in the hospital is certainly not
even a remote option.”
On July 6, 2009, Dr. Barnes
further noted that Plaintiff had “no back pain with straight leg
swelling or edema.”
(Id. at 290).
On February 23, 2010, Dr.
told her that she is not to come in early.
days or not at all.” (Id. at 294).
It is going to be 30
On July 2, 2008, Dr. Barnes noted, “This patient comes in with
right hip pain. I’m not really sure what’s going on. We did a
scan on her.
On October 27, 2009,
Dr. Clay Rainer, M.D., the orthopedist to whom Dr. Barnes had
referred Plaintiff, noted that Plaintiff’s June 2008 MRI showed
“minimal facet degeneration at L4-5 and L5-S1.”
(Id. at 220)
Almost three years later, on January 25,
2011, an MRI of Plaintiff’s lumbar spine again showed “mild
degenerative facet hypertrophy at L4-5 and L5-S1.” (Id. at 270)
“basically released” her.
(Id. at 277).
Thus, as the ALJ
treatment notes, Dr. Yearwood’s opinions are inconsistent with
the treatment notes of Dr. Barnes and Dr. Rainer and the MRI’s
taken in June 2008 and January 2011.16
Last, as the ALJ articulated, the record shows that Dr.
Plaintiff’s activities of daily living.
Dr. Barnes observed on
back, arm, and shoulder pain, she was able to lift and hold her
daughter who “[was] probably a good 20 lbs. easily.”
At the hearing, Plaintiff testified that she alone cares
for her four-year-old daughter, with the exception of help from
her mother approximately three days a week.
(Id. at 38).
Also, on March 8, 2012, Plaintiff reported to Dr. Barnes’ nurse
practitioner that her left shoulder was bothering her because
As noted, Dr. Rainer found on October 27, 2009 that Plaintiff
had only “minimal facet degeneration at L4-5 and L5-S1.”
220). Dr. Barnes’ treatment notes on January 25, 2010, reflect
that “Dr. Rainer [has] recommended no further therapy. He’s not
really sure what’s going to help her out.” (Id. at 292).
Dr. Yearwood’s opinions are also inconsistent with the
treatment notes of Dr. Stephen West, M.D., one of Dr. Barnes’
partners, who on March 11, 2009, noted that Plaintiff “wanted me
to write her a letter so that she could get out of community
service but I refused to.
There is nothing that she has that
would prevent her from doing it.
She can do all her community
service. (Tr. 282).
she had been “mov[ing] furniture around a lot at home.”
opinions, as discussed herein, particularly her opinion in the
PCE form that Plaintiff could only occasionally lift five pounds
and frequently lift one pound.
(Id. at 347).
Based on the foregoing evidence, the Court finds that Dr.
Yearwood’s opinions set forth in the April 24, 2012 letter and
the May 2012 PCE and CAP forms are inconsistent with the record
substantial medical evidence in this case supports the ALJ’s
finding that Plaintiff can perform a full range of light work. 17
The Court also rejects Plaintiff’s argument that the ALJ’s
determination is not supported by substantial evidence because,
without Dr. Yearwood’s opinions, the record contains no opinion
from a consultative examiner or other medical expert as to
Plaintiff’s RFC. (Doc. 13 at 8). To the contrary, the ALJ has
the discretion to order a consultative examination where the
record establishes that such is necessary to enable the ALJ to
render a decision. Holladay v. Bowen, 848 F.2d 1206, 1210 (11th
The ALJ is not required to order a consultative
examination where the record contains sufficient evidence to
permit the ALJ’s RFC determination.
Ingram v. Commissioner of
Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (“The
administrative law judge has a duty to develop the record where
appropriate but is not required to order a consultative
examination as long as the record contains sufficient evidence
Likewise, “[t]he ALJ’s RFC assessment may be
supported by substantial evidence, even in the absence of an
opinion from an examining medical source about Plaintiff’s
functional capacity.” Saunders v. Astrue, 2012 U.S. Dist. LEXIS
39571, *10, 2012 WL 997222, *4 n.5 (M.D. Ala. March 23, 2012)
(citing Green v. Soc. Sec. Admin., 223 Fed. Appx. 915, 923 (11th
Therefore, Plaintiff’s claim is without merit.
consideration of the administrative record and memoranda of the
Commissioner of Social Security denying Plaintiff’s claim for a
supplemental security income be AFFIRMED.
DONE this 26th day of March 2015.
/s/ SONJA F. BIVINS
UNITED STATES MAGISTRATE JUDGE
Cir. 2007) (unpublished)); see also Packer v. Astrue, 2013 U.S.
Dist. LEXIS 20580, *7, 2013 WL 593497, *2 (S.D. Ala. February
14, 2013) (the fact that no treating or examining medical source
submitted a physical capacities evaluation “does not, in and of
itself, mean that there is no medical evidence, much less no
‘substantial evidence,’ to support the ALJ’s decision.”). Thus,
Plaintiff’s contention that the absence of a physical RFC
evaluation by a medical source means that the ALJ’s RFC
assessment is not based on substantial evidence is simply
incorrect. Moreover, as noted supra, the record contains
substantial evidence, including the treatment records of Dr.
Barnes, from which the ALJ was able to render a decision.
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