Woods v. Colvin
MEMORANDUM OPINION AND ORDER entered that the Commissioner's decision denying benefits should be reversed and remanded for further proceedings, as further set out. Signed by Magistrate Judge William E. Cassady on 9/24/2015. (clr)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
JOHNNY M. WOODS,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
MEMORANDUM OPINION AND ORDER
Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking
judicial review of a final decision of the Commissioner of Social Security denying his
claims for disability insurance benefits and supplemental security income. The parties
have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28
U.S.C. § 636(c), for all proceedings in this Court. (Docs. 19 & 21 (“In accordance with
the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to
have a United States Magistrate Judge conduct any and all proceedings in this case, . . .
order the entry of a final judgment, and conduct all post-judgment proceedings.”).)
Upon consideration of the administrative record, plaintiff’s brief, the Commissioner’s
brief, and the arguments of counsel at the September 23, 2015 hearing before the Court,
it is determined that the Commissioner’s decision denying benefits should be reversed
and remanded for further proceedings not inconsistent with this decision.1
Any appeal taken from this memorandum opinion and order and judgment shall
be made to the Eleventh Circuit Court of Appeals. (See Docs. 19 & 21 (“An appeal from a
judgment entered by a Magistrate Judge shall be taken directly to the United States Court of
Plaintiff alleges disability due to sciatica, mild early spondylitic disc disease at
C5-6, minimal early degenerative disc disease at L3-4 and L4-5, hernia, status-post open
reduction internal fixation at the right elbow with post-traumatic osteoarthritic changes,
post-traumatic angulation of the coccyx, and chronic pain. The Administrative Law
Judge (ALJ) made the following relevant findings:
The claimant meets the insured status requirements of the Social
Security Act through June 30, 2012.
The claimant has not engaged in substantial gainful activity since
December 1, 2011, the alleged onset date (20 C.F.R. 404.1571 et seq., and
416.971 et seq.).
The claimant has the following severe impairments: Sciatica,
mild early spondylitic disc disease at C5-6, minimal early degenerative
disc disease at L3-4 and L4-5, hernia, status-post open reduction internal
fixation at right elbow with post-traumatic osteoarthritic changes (20
C.F.R. 404.1520(c) and 416.920(c)).
The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of one of the
listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20
C.F.R. 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
After careful consideration of the entire record, the undersigned
finds that the claimant has the residual functional capacity to perform
light work as defined in 20 C.F.R. 404.1567(b) and 416.967(b) except that
he can only stand or walk for four hours in an eight-hour workday, so
he requires a sit/stand option. He cannot climb ladders, ropes, or
scaffolds. He can occasionally climb stairs, stoop, kneel, crouch, or
crawl. He cannot work at unprotected heights. He is to avoid
concentrated exposure to extreme cold, vibration, or hazards.
Appeals for this judicial circuit in the same manner as an appeal from any other judgment of
this district court.”))
In making this finding, the undersigned has considered all symptoms and
the extent to which these symptoms can reasonably be accepted as
consistent with the objective medical evidence and other evidence, based
on the requirements of 20 C.F.R. 404.1529 and 416.929 and SSRs 96-4p and
96-7p. The undersigned has also considered opinion evidence in
accordance with the requirements of 20 C.F.R. 404.1527 and 416.927 and
SSRs 96-2p, 96-5p, 96-6p and 06-3p.
In considering the claimant’s symptoms, the undersigned must follow a
two-step process in which it must first be determined whether there is an
underlying medically determinable physical or mental impairment(s)—
i.e., an impairment(s) that can be shown by medically acceptable clinical
and laboratory diagnostic techniques—that could reasonably be expected
to produce the claimant’s pain or other symptoms.
Second, once an underlying physical or mental impairment(s) that could
reasonably be expected to produce the claimant’s pain or other symptoms
has been shown, the undersigned must evaluate the intensity, persistence,
and limiting effects of the claimant’s symptoms to determine the extent to
which they limit the claimant’s functioning. For this purpose, whenever
statements about the intensity, persistence, or functionally limiting effects
of pain or other symptoms are not substantiated by objective medical
evidence, the undersigned must make a finding on the credibility of the
statements based on a consideration of the entire case record.
The claimant testified that he was born on September 2, 1965 and is 47
years old. He started the 10th grade. He worked as a ship fitter and as a
supervisor for three years. He still had to do some physical work, and had
to be on the boat. He was self-employed building homes, doing framing
work and actually completing the shell. He did some work building
modules at Northrup Grumman in 2008. He has operated a forklift. His
brother owns an electrical company, and he did some work with him.
Dr. Lawrence treated him for several years. Now he goes to the Stanton
He fell from a roof and broke his femur, ankle, and forearm on the right
side of his body. He also broke his tailbone, and it did not heal correctly.
He has recently had hernia trouble. He has [had] it for a while, but lately
he started hurting. He was a passenger in an automobile that was in an
accident, and he injured his neck.
He is married, and lives with his wife. He had a driver’s license, but has
done very little driving. He has problems with both ankles, which hurt
all the time. The severity of the pain depends on how long he stands. He
has right knee pain due to using that leg more when his left leg was
broken. His knee was never broken. He has lower back pain that goes
down his legs. He also has pain in his upper back, which affects his
shoulder. His back will go out, and he will be in bed for a week
sometimes. He has a bad disc in the upper part of [h]is back near his left
shoulder. He is left hand dominant.
He can sit, but he has to shift his position. He can sit for a couple of hours
at most, and then has to stand for about a couple of hours. He can walk
about 100 yards, and then he has to stop and rest by sitting down due to
his back and ankles hurting. He has more back pain than ankle pain.
When h[e] takes his medication, his pain level is [still] five to six out of
ten. Pain relief from his medications sometimes wears off before it is time
for his next dose, so he will take his medication earlier. He can lift twentyfive to thirty pounds.
Sometimes he will put dishes in the dishwasher. He [can] make the bed,
and use a riding lawnmower to cut the grass. He does not do the other
maintenance; his son does it. He lies down during the day a couple of
times a day for about an hour or so at a time. He tosses and turns a lot
even then. When he tosses and turns at night, he may have to get up and
sit in a chair. He has used a cane since 2005 when he fell. His medication
makes him dizzy. During the day, he will read and watch television. He
can concentrate some.
After careful consideration of the evidence, the undersigned finds that the
claimant’s medically determinable impairments could reasonably be
expected to cause some of the alleged symptoms; however, the claimant’s
statements concerning the intensity, persistence and limiting effects of
these symptoms are not fully credible, particularly to the extent that they
are inconsistent with the determined residual functional capacity. The
objective and clinical evidence does not support limitation to the degree
Pursuant to the requirements of Social Security Ruling 96-7p, in assessing
the credibility of the claimant’s statements, the undersigned has
considered factors other than the objective medical evidence alone,
including: [t]he claimant’s daily activities; the location, duration,
frequency, and intensity of the claimant’s pain or other symptoms; factors
that precipitate and aggravate the symptoms; the type, dosage,
effectiveness, and side effects of any medication the claimant takes or has
taken to alleviate pain or other symptoms; treatment, other than
medication, the claimant receives or has received for relief of pain or other
symptoms; any measures other than treatment the claimant uses or has
used to relieve pain or other symptoms; and any other factors concerning
the claimant’s functional limitations and restrictions due to pain or other
The undersigned has considered the impact of the claimant’s impairments
on both exertional and non-exertional capacities. Exertional capacity
addresses an individual’s limitations and restrictions of physical strength
and defines the individual’s remaining abilities to perform each of seven
strength demands: sitting, standing, walking, lifting, carrying, pushing,
and pulling. Nonexertional capacity considers all work-related limitations
and restrictions that do not depend on an individual’s physical strength;
i.e., all physical limitations and restrictions that are not reflected in the
seven strength demands, and mental limitations and restrictions. It
encompasses an individual’s abilities to perform postural and
manipulative maneuvers, as well as visual and communicative
limitations. In addition to these activities, non-exertional capacity
evaluation considers the ability to tolerate various environmental factors.
The undersigned finds he remains capable of performing light work as
defined in 20 C.F.R. 404.1567(b) and 416.967(b) except that he can only
stand or walk for four hours in an eight-hour workday, so he requires a
sit/stand option. He cannot climb ladders, ropes, or scaffolds. He can
occasionally climb stairs, stoop, kneel, crouch, or crawl. He cannot work at
unprotected heights. He is to avoid concentrated exposure to extreme
cold, vibration, or hazards. This residual functional capacity is supported
by the following:
A Discharge Summary from the University of South Alabama Medical
Center concerning an inpatient admission from July 25, 2005 through July
28, 2005 indicate that the claimant suffered a right pilon fracture and a
right radius and ulnar fracture after falling from a roof on July 25, 2005.
He underwent open reduction repair of both right extremity fractures,
including a right radial head replacement. He had no complications, and
was diagnosed with instructions to follow up at the Stanton Road
Orthopedic Clinic on August 8, 2005. The claimant eventually returned to
work, and worked until 2011, although he did not report earnings for all
the years he worked.
On February 10, 2009, he was placed on light duty for three days, after
which he could return to a full duty status. His right knee had been sore to
the touch, but he denied pain when examined.
His doctor, James Lawrence, M.D., noted on November 13, 2010, that he
had known the claimant for many years, but had not seen him in a while.
The claimant had some generalized pain, and still wanted to work. An
anti-nuclear antibody test and rheumatoid factor test were negative. His
knee x-rays were “relatively normal.” Lumbar x-rays showed
degenerative disc disease at L4-5 and post-traumatic angulation of the
X-rays of the claimant’s cervical spine performed on February 27, 2012,
revealed, “There is mild spondylitic disc disease at C5-6 including mild
disc space narrowing, endplate sclerosis and small anterior spondylitic
spurs. There is normal alignment. There is no prevertebral soft tissue
swelling. The atlantodental interval is normal. Impression: 1. Mild early
spondylitic disc changes C5-6. 2. No acute abnormality.”
X-rays of the lumbar spine performed the same day showed, “AP and
lateral views compared to 12/8/09. There is mild early spondylitic disc
space narrowing at L3-4 and L4-5 with endplate sclerosis and small
anterior spurs neighboring the L3-4 level. This has not significantly
changed. There is no listhesis. There are no compression deformities.
There are no acute abnormalities. Impression: Minimal early degenerative
disc disease at L3-4 and L4-5 unchanged. 2. No acute abnormality.”
Left ankle x-rays performed showed, “There is a well healed fracture
deformity of the distal tibial and fibular metaphyses. There is evidence of
previous hardware with drill holes. This is anatomically aligned. There is
no significant angulation. No acute abnormalities are noted. Impression: 1.
Well healed fractures of the distal tibial and fibular metaphyses. 2. No
Right ankle x-rays revealed, “There are 2 cannulated screws bridging a
well healed medial malleolar fracture. There are 2 anterior posterior
cannulated screws in the tibial metaphysis as well. The more proximal
screws demonstrate posterior transcortical extensions of approximately 1
cm. There is no screw fracture. No acute abnormalities are noted.
Impression: 1. Postoperative changes as described above. 2. No acute
X-rays of the right elbow indicated, “There is an olecranon compression
plate and screws in place bridging a well healed proximal ulnar fracture.
There has been resection of the radial head with radial head prosthesis in
place. There are at least moderate post traumatic osteoarthritic changes of
the elbow joint with articular surface irregularity, marginal sclerosis and
periarticular spurs. No acute abnormalities are noted. Impression: 1. Post
op changes in the proximal elbow and radius with compression plate and
screws bridging a well healed olecron process fracture with a radial head
prosthesis in place. 2. At least moderate post traumatic osteoarthritic
change of the elbow joint.” Upon review of the x-rays, Dr. Lawrence
noted, “X-rays have only shown minimal change but I am convinced this
is more severe.”
Dr. Lawrence reported on June 26, 2012, “He was denied disability and I
think I can see the reason. Imaging is just not revealing in this case. The
physical is more revealing. Physical examination: He has a positive
straight leg raising sign, a right elbow contracture and some warmth in his
ankles.” In a letter dated July 5, 2012, Dr. Lawrence wrote, “Mr. Woods is
being treated by me for severe osteoarthritis and sciatica. With regards to
the sciatica, x-ray findings have not been helpful in the diagnosis, and he
does not have health insurance that would allow us to obtain an MRI scan
of his lumbar spine to see nerve impingement. However, clinically it is
definite. His arthritis is clearly causing chronic severe pain. Your
consideration in this matter will be appreciated.”
Thoracolumbar x-rays performed on March 28, 2013 showed, “History—
[motor vehicle accident] one week prior with low back and left side pain.
There is very mild anterior spondylitic spurring at L3-4. No compression
fracture is seen. Impression: 1. Mild anterior spondylitic spurring L3-4. 2.
No acute abnormality.”
Grant Anderson, M.D., examined the claimant on May 1, 2013. Among
other things, the claimant had an easily reductible umbilical hernia.
Musculoskeletal examination showed normal range of motion, muscle
strength, and stability in all extremities with no pain on inspection. No
edema was present. Deep tendon reflexes were normal and symmetric.
Psychiatric examination indicated that he was oriented to time, place,
person, and situation. He had appropriate mood and affect. He was only
prescribed pain medication. His only musculoskeletal diagnosis was back
At the hearing, the claimant reported that his medications were Lortab
10mg, Gabapentin 300 mg, Carbamazepine 300mg, Cyclobenzaprine 5mg,
Meloxicam 15mg, Pravastatin 20mg, and Citalopram 10mg.
As for the opinion evidence, Charles K. Lee, M.D., a State agency medical
consultant, examined the record on August 22, 2012, and determined that
the claimant could lift/carry 20 pounds occasionally and 10 pounds
frequently. The claimant could stand/walk for at least 2 hours in an 8hour workday, and sit for about 6 hours in an 8-hour workday.2 The
claimant’s ability to push and/or pull including operation of foot and
hand controls was unlimited, other than as shown for lifting/carrying.
The claimant could occasionally climb ramps or stairs, but never climb
ladders, ropes, or scaffolds. He could frequently balance, but only
occasionally stoop, kneel, crouch, or crawl. He was to avoid concentrated
exposure to extreme cold, vibration, or hazards. The claimant did not have
any manipulative limitations, visual limitations, or communicative
limitations. Dr. Lee provided a discussion of his decision rationale . . .,
noting that Dr. Lawrence’s medical source statements were considered
and given only partial weight as the opinions were not totally
substantiated by the objective medical evidence. The residual functional
capacity determination is supported by Dr. Lee’s opinion.
The Physical Capacities Evaluation . . . and the Clinical Assessment of
Pain Form . . . completed by Dr. Lawrence have been considered and
accorded little weight, as they are inconsistent with Dr. Lee’s opinion and
with the objective evidence including the x-rays in Exhibits 3F and 18F
and the clinical exam findings in Exhibit 19F.
Lee also specifically noted that plaintiff’s ability to stand/walk was limited to 4
hours out of an 8-hour workday “due to post traumatic arthritis [of the] lower extremities.” (Tr.
In any case centered on an individual’s subjective complaints the issue of
credib[ility] is very important. In this case, the claimant’s allegations of
debilitating symptoms and limitations are not credible. First, the objective
evidence does not establish conditions to produce the very serious
symptoms and limitations the claimant alleged at the hearing. Second, the
relevant treating source records show that the claimant was not
complaining of the very serious symptoms he alleged at the hearing—
symptoms that the claimant testified [were] of a longstanding nature.
Viewing all the evidence together, the undersigned finds that the
claimant’s subjective allegations of serious and debilitating symptoms and
limitations cannot reasonably be accepted as consistent with the objective
medical evidence and other evidence in the case record (as required by 20
C.F.R. 404.1529 and 416.929).
Having considered the whole of the evidence, the undersigned concludes
the claimant is capable of performing work within h[is] determined
residual functional capacity.
The claimant is unable to perform any past relevant work (20
C.F.R. 404.1565 and 416.965).
The claimant was born on September 2, 1965 and was 46 years
old, which is defined as a younger individual age 18-49, on the alleged
disability onset date (20 C.F.R. 404.1563 and 416.963).
The claimant has a limited education and is able to communicate
in English (20 C.F.R. 404.1564 and 416.964).
Transferability of job skills is not material to the determination
of disability because using the Medical-Vocational Rules as a
framework supports a finding that the claimant is “not disabled,”
whether or not the claimant has transferable job skills (See SSR 82-41
and 20 C.F.R. Part 404, Subpart P, Appendix 2).
Considering the claimant’s age, education, work experience, and
residual functional capacity, there are jobs that exist in significant
numbers in the national economy that the claimant can perform (20
C.F.R. 404.1569, 404.1569(a), 416.969, and 416.969(a)).
If the claimant had the residual functional capacity to perform the full
range of light work, a finding of “not disabled” would be directed by
Medical-Vocational Rule 202.18. However, the claimant’s ability to
perform all or substantially all of the requirements of this level of work
has been impeded by additional limitations. To determine the extent to
which these limitations erode the unskilled light occupational base, the
Administrative Law Judge asked the vocational expert whether jobs exist
in the national economy for an individual with the claimant’s age,
education, work experience, and residual functional capacity. The
vocational expert testified that given all of these factors the individual
would be able to perform the requirements of representative occupations
such as mail sorter, D.O.T. 209.687-026, light, unskilled work (SVP-2), with
900,000 jobs in the national economy and 45,000 jobs in the regional
economy; parking lot attendant, D.O.T. 915.473-010, light, unskilled work
(SVP-2), with 500,000 jobs in the national economy and 25,000 jobs in the
regional economy; companion, D.O.T. 309.677-010, light, unskilled work
(SVP-2), with 850,000 jobs in the national economy and 40,000 jobs in the
[regional] economy; [and] information clerk, D.O.T. 237.367-018, light,
unskilled work (SVP-2), with 950,000 jobs in the national economy and
50,000 jobs in the regional economy.
Pursuant to SSR 00-4p, the undersigned has determined that the
vocational expert’s testimony is inconsistent with the information
contained in the Dictionary of Occupational Titles in that a sit/stand
option is not discussed in the D.O.T. However, the undersigned is
satisfied that  the vocational expert’s experience with the listed jobs is
sufficient to justify the finding that the jobs allow a sit/stand option in the
number of jobs listed.
Based on the testimony of the vocational expert, the undersigned
concludes that, considering the claimant’s age, education, work
experience, and residual functional capacity, the claimant is capable of
making a successful adjustment to other work that exists in significant
numbers in the national economy. A finding of “not disabled” is therefore
appropriate under the framework of the above-cited rule.
The claimant has not been under a disability, as defined in the
Social Security Act, from December 1, 2011, through the date of this
decision (20 C.F.R. 404.1520(g) and 416.920(g)).
(Tr. 23, 24, 25-29, 30, 31 & 31-32 (internal citations omitted; footnote added; emphasis in
original).) The Appeals Council affirmed the ALJ’s decision (Tr. 1-3) and thus, the
hearing decision became the final decision of the Commissioner of Social Security.
In all Social Security cases, an ALJ utilizes a five-step sequential evaluation
to determine whether the claimant is disabled, which considers: (1)
whether the claimant is engaged in substantial gainful activity; (2) if not,
whether the claimant has a severe impairment; (3) if so, whether the
severe impairment meets or equals an impairment in the Listing of
Impairments in the regulations; (4) if not, whether the claimant has the
RFC to perform h[is] past relevant work; and (5) if not, whether, in light of
the claimant’s RFC, age, education and work experience, there are other
jobs the claimant can perform.
Watkins v. Commissioner of Soc. Sec., 457 Fed. Appx. 868, 870 (11th Cir. Feb. 9, 2012)3 (per
curiam) (citing 20 C.F.R. §§ 404.1520(a)(4), (c)-(f), 416.920(a)(4), (c)-(f); Phillips v.
Barnhart, 357 F.3d 1232, 1237 (11th Cir. 2004)) (footnote omitted). The claimant bears the
burden, at the fourth step, of proving that he is unable to perform his previous work.
Jones v. Bowen, 810 F.2d 1001 (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. Id. at 1005. Once the
claimant establishes that he cannot perform his past relevant work, as here, it becomes
the Commissioner’s burden to prove that the claimant is capable, given his age,
education and work history, of engaging in another kind of substantial gainful
employment, which exists in the national economy. Sryock v. Heckler, 764 F.2d 834, 836
(11th Cir. 1985).
The task for the Magistrate Judge is to determine whether the Commissioner’s
decision to deny claimant benefits, on the basis that he can perform those light jobs
identified by the vocational expert, is supported by substantial evidence. Substantial
evidence is defined as more than a scintilla and means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.
“Unpublished opinions are not considered binding precedent, but they may be
cited as persuasive authority.” 11th Cir.R. 36-2.
Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971). “In determining whether
substantial evidence exists, we must view the record as a whole, taking into account
evidence favorable as well as unfavorable to the Commissioner’s] decision.” Chester v.
Bowen, 792 F.2d 129, 131 (11th Cir. 1986).4 Courts are precluded, however, from
“deciding the facts anew or re-weighing the evidence.” Davison v. Astrue, 370 Fed.
Appx. 995, 996 (11th Cir. Apr. 1, 2010) (per curiam) (citing Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005)). And, “’[e]ven if the evidence preponderates against the
Commissioner’s findings, [a court] must affirm if the decision reached is supported by
substantial evidence.’” Id. (quoting Crawford v. Commissioner of Social Security, 363 F.3d
1155, 1158-1159 (11th Cir. 2004)).
On appeal to this Court, Woods asserts two reasons why the Commissioner’s
decision to deny him benefits is in error (i.e., not supported by substantial evidence): (1)
the ALJ erred in failing to assign controlling weight to the opinions of his treating
physician, Dr. James Lawrence; and (2) the ALJ committed reversible error in
substituting the opinion of a non-examining reviewing state agency physician for the
opinion of plaintiff’s treating physician in violation of Eleventh Circuit case law under
Coleman v. Barnhart, 264 F.Supp.2d 1007, 1010-1011 (S.D. Ala. 2003) and SSR 96-6p by
finding plaintiff can perform light work. The undersigned considers these claims
together within the context of the ALJ’s RFC assessment.
Initially, the Court notes that the responsibility for making the residual
functional capacity determination rests with the ALJ. Compare 20 C.F.R. § 404.1546(c)
(“If your case is at the administrative law judge hearing level . . ., the administrative law
This Court’s review of the Commissioner’s application of legal principles,
however, is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
judge . . . is responsible for assessing your residual functional capacity.”) with, e.g.,
Packer v. Commissioner, Social Security Admin., 542 Fed. Appx. 890, 891-892 (11th Cir. Oct.
29, 2013) (per curiam) (“An RFC determination is an assessment, based on all relevant
evidence, of a claimant’s remaining ability to do work despite her impairments. There is
no rigid requirement that the ALJ specifically refer to every piece of evidence, so long as
the ALJ’s decision is not a broad rejection, i.e., where the ALJ does not provide enough
reasoning for a reviewing court to conclude that the ALJ considered the claimant’s
medical condition as a whole.” (internal citation omitted)). A plaintiff’s RFC—which
“includes physical abilities, such as sitting, standing or walking, and mental abilities,
such as the ability to understand, remember and carry out instructions or to respond
appropriately to supervision, co-workers and work pressure”—“is a[n]  assessment
of what the claimant can do in a work setting despite any mental, physical or
environmental limitations caused by the claimant’s impairments and related
symptoms.” Watkins, supra, 457 Fed. Appx. at 870 n.5 (citing 20 C.F.R. §§ 404.1545(a)-(c),
416.945(a)-(c)). Here, the ALJ’s RFC assessment consisted of the following: “After
careful consideration of the entire record, the undersigned finds that the claimant has
the residual functional capacity to perform light work as defined in 20 C.F.R.
404.1567(b) and 416.967(b) except that he can only stand or walk for four hours in an
eight-hour workday, so he requires a sit/stand option. He cannot climb ladders,
ropes, or scaffolds. He can occasionally climb stairs, stoop, kneel, crouch, or crawl.
He cannot work at unprotected heights. He is to avoid concentrated exposure to
extreme cold, vibration, or hazards.” (Tr. 25 (emphasis in original).)
To find that an ALJ’s RFC determination is supported by substantial evidence, it
must be shown that the ALJ has “’provide[d] a sufficient rationale to link’” substantial
record evidence “’to the legal conclusions reached.’” Ricks v. Astrue, 2012 WL 1020428,
*9 (M.D. Fla. Mar. 27, 2012) (quoting Russ v. Barnhart, 363 F. Supp. 2d 1345, 1347 (M.D.
Fla. 2005)); compare id. with Packer v. Astrue, 2013 WL 593497, *4 (S.D.Ala. Feb. 14, 2013)
(“’[T]he ALJ must link the RFC assessment to specific evidence in the record bearing
upon the claimant’s ability to perform the physical, mental, sensory, and other
requirements of work.’”), aff’d, 542 Fed. Appx. 890 (11th Cir. Oct. 29, 2013)5; see also
Hanna v. Astrue, 395 Fed. Appx. 634, 636 (11th Cir. Sept. 9, 2010) (per curiam) (“The ALJ
must state the grounds for his decision with clarity to enable us to conduct meaningful
review. . . . Absent such explanation, it is unclear whether substantial evidence
supported the ALJ’s findings; and the decision does not provide a meaningful basis
upon which we can review [a plaintiff’s] case.” (internal citation omitted)).6 However,
in order to find the ALJ’s RFC assessment supported by substantial evidence, it is not
In affirming the ALJ, the Eleventh Circuit rejected Packer’s substantial evidence
argument, noting, she “failed to establish that her RFC assessment was not supported by
substantial evidence” in light of the ALJ’s consideration of her credibility and the medical
evidence. Id. at 892.
It is the ALJ’s (or, in some cases, the Appeals Council’s) responsibility, not the
responsibility of the Commissioner’s counsel on appeal to this Court, to “state with clarity” the
grounds for an RFC determination. Stated differently, “linkage” may not be manufactured
speculatively by the Commissioner—using “the record as a whole”—on appeal, but rather,
must be clearly set forth in the Commissioner’s decision. See, e.g., Durham v. Astrue, 2010 WL
3825617, *3 (M.D. Ala. Sept. 24, 2010) (rejecting the Commissioner’s request to affirm an ALJ’s
decision because, according to the Commissioner, overall, the decision was “adequately
explained and supported by substantial evidence in the record”; holding that affirming that
decision would require that the court “ignor[e] what the law requires of the ALJ[; t]he court
‘must reverse [the ALJ’s decision] when the ALJ has failed to provide the reviewing court with
sufficient reasoning for determining that the proper legal analysis has been conducted’”
(quoting Hanna, 395 Fed. Appx. at 636 (internal quotation marks omitted))); see also id. at *3 n.4
(“In his brief, the Commissioner sets forth the evidence on which the ALJ could have relied . . . .
There may very well be ample reason, supported by the record, for [the ALJ’s ultimate
conclusion]. However, because the ALJ did not state his reasons, the court cannot evaluate
them for substantial evidentiary support. Here, the court does not hold that the ALJ’s ultimate
conclusion is unsupportable on the present record; the court holds only that the ALJ did not
conduct the analysis that the law requires him to conduct.” (emphasis in original)); Patterson v.
Bowen, 839 F.2d 221, 225 n.1 (4th Cir. 1988) (“We must . . . affirm the ALJ’s decision only upon
the reasons he gave.”).
necessary for the ALJ’s assessment to be supported by the assessment of an examining
or treating physician. See, e.g., Packer, supra, 2013 WL 593497, at *3 (“[N]umerous court
have upheld ALJs’ RFC determinations notwithstanding the absence of an assessment
performed by an examining or treating physician.”); McMillian v. Astrue, 2012 WL
1565624, *4 n.5 (S.D. Ala. May 1, 2012) (noting that decisions of this Court “in which a
matter is remanded to the Commissioner because the ALJ’s RFC determination was not
supported by substantial and tangible evidence still accurately reflect the view of this
Court, but not to the extent that such decisions are interpreted to require that
substantial and tangible evidence must—in all cases—include an RFC or PCE from a
physician” (internal punctuation altered and citation omitted)); but cf. Coleman v.
Barnhart, 264 F.Supp.2d 1007 (S.D. Ala. 2003).
In this case, the ALJ accorded only little weight to the RFC assessment (and pain
assessment) of plaintiff’s treating physician, Dr. James Lawrence, and, instead, relied
upon the RFC assessment completed by a non-examining, reviewing physician, Dr.
Charles K. Lee, as support for his RFC determination (compare Tr. 29 (“The residual
functional capacity determination is supported by Dr. Lee’s opinion.”) with Tr. 320-327
(Lee’s RFC assessment)). And perhaps the ALJ’s reliance upon Lee’s RFC assesent
would have sufficed had Lee properly “linked” his RFC findings/limitations to
substantial evidence in the record, as is even directed on the form he completed
(compare Tr. 322 (“Describe how the evidence substantiates your conclusions. (Cite
specific clinical and laboratory findings, observations, lay evidence, etc.).”) with Tr. 323
(“Explain how and why the evidence supports your conclusions in items 1 through
5.”)); however, all Lee did was “qualify” his answer to question 3, which asked how
long plaintiff can stand and/or walk during an 8-hour workday, by stating that
plaintiff’s standing and walking would be “limited [to] 4 hrs/8-hr workday due to post
traumatic arthritis [of the] lower extremities.” (Tr. 323.) In other words, Lee did not
“link” his noted exertional limitations—that is, his lift/carry, sit, stand/walk, and
push/pull “limitations”7—to evidence in the record, as directed (id.) and as required by
this Court, and the ALJ did not separately explain, when summarizing the evidence of
record, how the medical evidence supported each component of his RFC assessment.
Accordingly, the undersigned finds that the ALJ’s RFC assessment fails to provide an
articulated linkage to the medical evidence of record,8 and, therefore, this cause need be
remanded to the Commissioner of Social Security for further consideration not
inconsistent with this decision.
On remand, in addition to reconsidering his “physical” RFC determination, the
ALJ should explain more fully his reasons for rejecting Dr. Lawrence’s findings on the
Clinical Assessment of Pain form he completed on July 5, 2012 (Tr. 318-319). After all, as
For instance, Dr. Lee specifically found plaintiff’s ability to push and/or pull
(including operation of hand/foot controls) was “unlimited, other than [as] shown for lift[ing]
and/or carry[ing.]” (Tr. 323.) However, he fails to cite any evidence in the medical record which
supports this finding and a review of the medical evidence of record by the undersigned tends
to suggest that Dr. Lawrence’s findings that plaintiff cannot use his arms/hands and legs/feet
for pushing and pulling arm or leg controls (see Tr. 316) actually are supported by the record
inasmuch as x-rays of the right elbow reveal “[a]t least moderate post traumatic osteoarthritic
change of the elbow joint” (Tr. 286 (emphasis supplied)) and examination findings reveal
“contracture” (that is, a shrinkage or shortening) of the right elbow (Tr. 315 & 279),
warmth/swelling in the ankles (Tr. 315), positive straight leg raising sign (Tr. 315), and muscle
spasms (Tr. 275).
The linkage requirement is simply another way to say that, in order for this
Court to find that an RFC determination is supported by substantial evidence, ALJs must “show
their work” or, said somewhat differently, show how they applied and analyzed the evidence to
determine a plaintiff’s RFC. See, e.g., Hanna, 395 Fed. Appx. at 636 (an ALJ’s “decision [must]
provide a meaningful basis upon which we can review [a plaintiff’s] case”); Ricks, 2012 WL
1020428, at *9 (an ALJ must “explain the basis for his decision”); Packer, 542 Fed.Appx. at 891892 (an ALJ must “provide enough reasoning for a reviewing court to conclude that the ALJ
considered the claimant’s medical condition as a whole” (emphasis added)). Thus, by failing
to “show his work,” the ALJ has not provided the required “linkage” between the record
evidence and his RFC determination necessary to facilitate this Court’s meaningful review of
even the ALJ recognized (Tr. 30), this is a classic “pain” case, and the majority of the
evidence of record certainly reflects that plaintiff experiences chronic pain (Tr. 270-271,
275-280, 287-288, 315, 317, 343-345, 353, 355, 359-360, 364, 368, 372 & 375). Here, the ALJ
“lumped together” his decision to give little weight to Lawrence’s “CAP” with his
decision to give little weight to Lawrence’s PCE, noting both were “inconsistent with
Dr. Lee’s opinion and with the objective medical evidence including the x-rays in
Exhibits 3F and 18F and the clinical exam findings in Exhibit 19F.” (Tr. 29.)9 Reliance on
Dr. Lee’s opinion, however, amounts to only so much circular reasoning since it is Lee’s
apparent belief that the CAP is not substantiated by the objective evidence (see Tr. 326),
The law in this Circuit is clear that an ALJ “’must specify what weight is given to
a treating physician’s opinion and any reason for giving it no weight, and failure to do so is
reversible error.’” Nyberg v. Commissioner of Social Security, 179 Fed.Appx. 589, 590-591 (11th Cir.
May 2, 2006) (unpublished), quoting MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986)
(other citations omitted). In other words, “the ALJ must give the opinion of the treating
physician ‘substantial or considerable weight unless “good cause” is shown to the contrary.’”
Williams v. Astrue, 2014 WL 185258, *6 (N.D. Ala. Jan. 15, 2014), quoting Phillips v. Barnhart, 357
F.3d 1232, 1240 (11th Cir. 2004) (other citation omitted); see Nyberg, supra, 179 Fed.Appx. at 591
(citing to same language from Crawford v. Commissioner of Social Security, 363 F.3d 1155, 1159
(11th Cir. 2004)).
Good cause is shown 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.” Phillips v. Barnhart, 357 F.3d 1232, 1241
(11th Cir. 2004). Where the ALJ articulate[s] specific reasons for failing to
give the opinion of a treating physician controlling weight, and those
reasons are supported by substantial evidence, there is no reversible
error. Moore [v. Barnhart], 405 F.3d [1208,] 1212 [(11th Cir. 2005)].
Gilabert v. Commissioner of Soc. Sec., 396 Fed.Appx. 652, 655 (11th Cir. Sept. 21, 2010) (per
curiam). Most relevant to this case, an ALJ’s articulation of reasons for rejecting a treating
source’s pain assessment must be supported by substantial evidence. Compare id. (“Where the
ALJ articulated specific reasons for failing to give the opinion of a treating physician controlling
weight, and those reasons are supported by substantial evidence, there is no reversible error. In
this case, therefore, the critical question is whether substantial evidence supports the ALJ’s
articulated reasons for rejecting Thebaud’s RFC.”) (citing Moore v. Barnhart, 405 F.3d 1208, 1212
(11th Cir. 2005)) with D’Andrea v. Commissioner of Social Security Admin., 389 Fed.Appx. 944, 947948 (11th Cir. Jul. 28, 2010) (per curiam) (same).
evidence to which Lee makes no specific reference in this portion of his decision (see id.).
Moreover, the ALJ’s reliance on the x-ray findings and the clinical exam findings of Dr.
Grant Anderson ignores not only Anderson’s consistent assessment that he was treating
Woods for chronic back pain (see Tr. 359-377) and the doctor’s plan to refer plaintiff to a
pain specialist upon the establishment of disability and entitlement to insurance (Tr.
364) but, more importantly, Dr. Lawrence’s clinical findings—most notably, positive
straight leg raising sign, a right elbow contracture, warmth/swelling in the ankles,
muscle spasms—and specific opinion that if there was insurance to obtain an MRI of the
lumbar spine that test would confirm his clinical findings that there is nerve
impingement causing plaintiff’s chronic severe pain (Tr. 317). In other words, because
there is no question but that plaintiff experiences chronic pain, it was necessary for the
ALJ to explain in greater detail why the clinical findings noted by Dr. Lawrence—which
were not rejected by the ALJ—would not cause pain which would distract plaintiff from
adequately performing daily activities or work, that physical activity would not greatly
increase plaintiff’s pain to the point it would cause distraction from task or total
abandonment of task, and that the pain and/or medication side effects could not be
expected to be severe and limit effectiveness due to distraction, inattention or
The ALJ performed no analysis (see Tr. 29-30) directed to the pain/side effects
finding by Dr. Lawrence; instead, he simply listed plaintiff’s medications (see Tr. 29 (“At the
hearing, the claimant reported that his medications were Lortab 10mg, Gabapentin 300mg,
Carbamazepine 300mg, Cyclobenzaprine 5mg, Meloxicam 15mg, Pravastatin 20mg, and
Citalopram 10mg.”). It is not difficult to discern that Lortab 10, which is indicated for the
treatment of moderate to moderately severe pain, may impair the physical and/or mental
http://www.medicineonline.com/drugs/1/1238/LORTAB-10-500 (last visited September 24,
2015, 9:59 a.m.); Gabapentin, which is indicated for the management of postherpetic neuralgia
in adults, causes somnolence and dizziness, such that patients are warned to refrain from
driving or operating complex machinery until they have gained enough experience on the drug
In light of the foregoing, it is ORDERED that the decision of the Commissioner
of Social Security denying plaintiff benefits be reversed and remanded pursuant to
sentence four of 42 U.S.C. § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct. 2157,
115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this decision. The
remand pursuant to sentence four of § 405(g) makes the plaintiff a prevailing party for
purposes of the Equal Access to Justice Act, 28 U.S.C. § 2412, Shalala v. Schaefer, 509 U.S.
292, 113 S.Ct. 2625, 125 L.Ed.2d 239 (1993), and terminates this Court’s jurisdiction over
DONE and ORDERED this the 24th day of September, 2015.
s/WILLIAM E. CASSADY
UNITED STATES MAGISTRATE JUDGE
http://www.drugs.com/pro/gabapentin.html (last visited September 14, 2015, 10:02 a.m.);
Carbamazepine, which is indicated for the treatment of nerve pain, can cause dizziness and
drowsiness and impair thinking and reactions such that people who take it should take caution
http://www.drugs.com/carbamezepine.html (last visited September 24, 2015, 10:05 a.m.);
Cyclobenzaprine, a muscle relaxant indicated for the treatment of skeletal muscle conditions
such as pain, can cause dizziness, drowsiness, concentration problems and impair thinking and
reactions such that those who take it should take caution if they drive or do anything requiring
alertness, http://www.drugs.com/cyclobenzaprine.html (last visited September 24, 2015, 10:06
a.m.); and Meloxicam, an anti-inflammatory indicated for the treatment of pain or inflammation
http://www.drugs.com/meloxicam.html (last visited September 24, 2015, 10:07 a.m.). In light
of the fact that plaintiff is taking five drugs for the treatment of his pain, which could certainly
account for plaintiff being “queasy-headed . . . most of the day” and uncomfortable “behind the
wheel” (Tr. 49), the Court is uncertain how Dr. Lawrence was “off base” in noting that
plaintiff’s “[p]ain and/or drug side effects can be expected to be severe and to limit
effectiveness due to distraction, inattention, drowsiness, etc.” (Tr. 319.) The ALJ will have the
opportunity to further explain his rejection of Dr. Lawrence’s opinion in this regard on remand.
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