Carney v. Berryhill

Filing 27

MEMORANDUM OPINION AND ORDER entered 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), for further proceedings not inconsistent with this decision. Signed by Magistrate Judge P. Bradley Murray on 3/7/2018. (eec)

IN  THE  UNITED  STATES  DISTRICT  COURT  
FOR  THE  SOUTHERN  DISTRICT  OF  ALABAMA  
SOUTHERN  DIVISION  

STEPHANIE  T.  CARNEY,  

:  

Plaintiff,  

:  

vs.    

:  

NANCY  A.  BERRYHILL,    

:  
Acting  Commissioner  of  Social  Security,  

:  

Defendant.    

CA  17-­0070-­MU  

 MEMORANDUM  OPINION  AND  ORDER  
Plaintiff  brings  this  action,  pursuant  to  42  U.S.C.  §  405(g),  seeking  judicial  review  

of  a  final  decision  of  the  Commissioner  of  Social  Security  denying  her  claim  for  a  period  
of   disability   and   disability   insurance   benefits.   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.  23  &  24  (“In  accordance  with  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,  and  the  Commissioner’s  brief,1  it  is  determined  
that   the   Commissioner’s   decision   denying   benefits   should   be   reversed   and   remanded  
for  further  proceedings  not  inconsistent  with  this  decision.2      

1

2

The  parties  in  this  case  waived  oral  argument.  (Doc.  22;;  see  also  Doc.  25.)  

Any  appeal  taken  from  this  memorandum  opinion  and   order  and  judgment  shall  
be   made   to   the   Eleventh   Circuit   Court   of   Appeals.   (See   Docs.   23   &   24   (“An   appeal   from   a  
judgment   entered   by   a   magistrate   judge   shall   be   taken   directly   to   the   United   States   court   of  

(Continued)

I.  Procedural  Background  
Plaintiff   filed   an   application   for   a   period   of   disability   and   disability   insurance  
benefits   on   December   27,   2013,   alleging   disability   beginning   on   September   30,   2013.  
(See   Tr.   124-­25.)   Carney’s   claim   was   initially   denied   on   March   6,   2014   (Tr.   73)   and,  
following   Plaintiff’s   April   3,   2014   request   for   a   hearing   before   an   Administrative   Law  
Judge   (“ALJ”)   (see   Tr.   82-­83),   a   hearing   was   conducted   before   an   ALJ   on   June   17,  
2015   (Tr.   37-­61).   On   December   24,   2015,   the   ALJ   issued   a   decision   finding   that   the  
claimant   was   not   disabled   and,   therefore,   not   entitled   to   disability   insurance   benefits.  
(Tr.   21-­33.)   More   specifically,   the   ALJ   proceeded   to   the   fourth   step   of   the   five-­step  
sequential   evaluation   process   and   determined   that   Carney   retains   the   residual  
functional   capacity   to   perform   a   range   of   light   work   and   her   past   relevant   work   as   a  
caterer  helper  (Tr.  32;;  see  also  Tr.  30).  On  February  22,  2016,  the  Plaintiff  appealed  the  
ALJ’s  unfavorable  decision  to  the  Appeals  Council  (Tr.  15);;  the  Appeals  Council  denied  
Carney’s  request  for  review  on  December  12,  2016  (Tr.  1-­3).  Thus,  the  hearing  decision  
became  the  final  decision  of  the  Commissioner  of  Social  Security.  
Plaintiff   alleges   disability   due   obesity,   diabetes   mellitus   (type   II),   questionable  
history   of   fibromyalgia,   questionable   history   of   restless   leg   syndrome,   hypertension,  
history   of   diabetic   ketoacidosis,   questionable   history   of   acute   sinusitis   and   bronchitis,  
and   depression.   The   Administrative   Law   Judge   (ALJ)   made   the   following   relevant  
findings:  

appeals  for  this  judicial  circuit  in  the  same  manner  as  an  appeal  from  any  other  judgment  of  this  
district  court.”))  

2

2.  
The   claimant   has   not   engaged   in   substantial   gainful   activity  
since  September  30,  2013,  the  alleged  onset  date  (20  CFR  404.1571  et  
seq.).  

The   claimant   has   the   following   combinations   of   impairments   that   is  
severe  (20  CFR  404.1520(c)):  obesity;;  diabetes  mellitus  type  II,  controlled  
with  compliance;;  questionable  history  of  fibromyalgia;;  questionable  history  
of   restless   leg   syndrome[];;   hypertension;;   history   of   diabetic   ketoacidosis,  
acute;;   and   questionable   history   of   acute   sinusitis   and   bronchitis.  
Individually,  these  impairments  are  slight  abnormalities  that  individually  do  
not  cause  greater  than  slight  limitation  in  the  claimant’s  capacity  for  work  
activity.   Therefore[,]   they   are   not   severe;;   however[,]   as   noted   herein,   the  
undersigned   considered   the   impairments   collectively   in   assessing   the  
residual  functional  capacity.    

In   application   documents[,]   the   claimant[,]   a   forty-­eight[-­]year[-­]old   female  
with   a   general   equivalent   diploma   (GED)[,]   initially   alleged   her   ability   to  
work   is   limited   by   diabetes,   diabetic   neuropathy,   depression,   leg   pain,  
migraines,  memory  problem,  blurred  vision,  pain  in  arms,  and  numbness.  
She   reported   her   height   as   5’5”   and   her   weight   as   171   pounds.   She  
reported   she   stopped   working   on   August   5,   2010,   because   the   business  
closed;;   however,   on   September   30,   2013,   she   reported   her   conditions  
became  severe  enough  to  keep  her  from  working.  

She  reported  her  impairments  affect  her  ability  to  lift,  squat,  bend,  stand,  
reach,   walk,   kneel,   stair   climb,   see,   memorize,   complete   tasks,  
concentrate,   understand,   follow   directions,   and   use   her   hands.   However,  
she   reported   she   can   attend   to   her   personal   needs   independently.   She  
reported   she   can   prepare   meals   and   perform   light   cleaning   and   laundry  
duties.   She   reported   she   shops   in   stores   and   can   handle   financial  
obligations.  She  reported  she  enjoys  watching  television  and  she  spends  
time   with   others.   On   appeal,   she   reported   her   neuropathy   has   gotten  
worse  and  she  now  has  leg  pain,  numbness,  and  migraines.  She  reported  
everything   has   gotten   worse   including   her   depression.   She   reported   this  
change  took  place  in  2013.  

At   the   hearing[,]   when   questioned   by   the   undersigned[,]   the   claimant  
testified  she  cannot  perform  any  work  activity  that  requires  sitting  because  
she  can  only  sit  for  minutes  at  a  time  due  to  pain.  She  testified  she  has  to  
stand  up,  walk  around,  and  sometimes  lay  down.  She  testified  she  uses  a  
heating  pad  for  pain  and  cannot  sit  for  hours  at  a  time  without  severe  pain  
from  neuropathy  and  fibromyalgia.  She  testified  she  takes  Neurontin  three  
times   a   day,   Tramadol   for   pain,   and   Celexa   for   depression   and   anxiety.  
She  testified  she  has  not  worked  since  2010  and  she  last  worked  at  a  dry  
cleaner.  

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When   questioned   by   her   representative[,]   she   testified   she   receives  
treatment   at   The   Clinic   PC.   She   testified   she   has   been   diagnosed   with  
diabetes   mellitus   II,   uncontrolled,   peripheral   neuropathy,   and   back   pain.  
She  testified  her  treating  physician  referred  her  to  mental  health  and  also  
prescribes  her  depression  medication  as  well  as  Neurontin  and  Tramadol.  
She  testified  she  cannot  function  without  taking  the  Neurontin;;  however,  it  
causes  dizziness  and  lightheadedness.  She  testified  the  only  side  effect  of  
the   Tramadol   is   she   cannot   operate   any   vehicle.   She   testified   she   takes  
the   Tramadol   every   six   hours.   She   testified   she   has   chronic   lower   back  
pain   daily   and   needs   assistance   with   personal   hygiene.   She   testified   her  
husband  provides  assistance  and  her  daughter-­in-­law  helps  out  a  lot.  She  
testified  her  husband  cooks,  but  she  can  prepare  simple  meals.    

In  regards  to  her  diabetes  mellitus  type  II,  controlled  with  compliance,  the  
claimant   testified   she   was   diagnosed   with   uncontrolled   diabetes   mellitus  
type  II  and  she  has  painful  neuropathy.  The  evidence  does  document[]  a  
diagnosis   if   diabetes   mellitus   type   II;;   however,   when   she   presented   to  
Meridian   Medical   Associates   on   December   19,   2013,   it   was   noted   her  
diabetes   had   been   under   good   control.   Although   her   examination  
indicated   decreased   pinprick   and   light   touch   in   a   stocking   distribution,  
reflexes   were   depressed,   but   symmetrical,   and   Romberg’s   was   slightly  
positive  for  swaying  away.  It  further  indicated  she  had  normal  gait  and  her  
cranial  nerves  were  intact  with  5/5  motor  strength.  She  was  assessed  with  
painful  peripheral  neuropathy,  possible  element  of  restless  leg  syndrome,  
and   history   of   diabetes.   She   was   given   a   trial   of   Neurontin   and   it   was  
recommended   she   follow   up   in   a   couple   of   months.   The   evidence  
indicates   she   returned   to   Meridian   Medical   Associates   in   February   2014  
and   reported   the   Neurontin   was   helping   some,   but   [she]   was   still   having  
pain   when   squatting.   Her   Neurontin   was   increased   and   it   was  
recommended  she  follow  up  in  three  months.  

On   March   3,   2014,   she   returned   to   The   Clinic   PC   for   follow   up   and  
medication  refills.  It  was  noted  she  did  not  have  any  verbal  complaints  and  
again   her   diabetes   w[as]   documented   as   controlled.   Her   physical  
examination   was   unremarkable   and   dietary   modification   was  
recommended.  It  was  a  year  later[,]  on  March  2,  2015,  when  she  returned  
to  The  Clinic  PC  for  medication  refills.  It  was  noted  she  was  doing  better  
and  her  examination  was  normal.  

Although[]  the  claimant  has  been  diagnosed  with  diabetes  mellitus  type  II,  
the   evidence   documents   several   instances   where   her   diabetes   was  
controlled.  Her  physical  examinations  have  been  unremarkable  and  there  
is   no   evidence   of   cerebrovascular   accidents,   renal   failure,   polydipsia,   or  
polyuria,   generally   associated   with   uncontrolled   diabetes   mellitus,   which  
certainly  suggests  the  impairment[]  is  well  controlled.  If  the  claimant  were  
to   remain   compliant   with   all   treatment   recommendations,   dietary  
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modifications,  exercise,  and  medications[,]  her  diabetes  would  continue  to  
be  controlled.  Therefore,  the  evidence  does  not  show  this  impairment  has  
significantly  limited  or  is  likely  to  significantly  limit  the  claimant’s  ability  to  
do  basic  work  activities.  

In   regards   to   her   questionable   history   of   reckless   leg   syndrome,   the  
evidence   indicates   she   presented   to   The   Clinic   PC   in   October   2013   with  
fatigue  and  pain  in  her  legs  that  hurts  when  walking  up  steps.  On  review  of  
systems[,]   she   denied   any   musculoskeletal   problems   as   well   as  
neurological   problems.   Her   physical   examination   was   normal   with   no  
deformities,   cyanosis,   or   edema   of   the   extremities.   There   was   no  
decreased   range   of   motion   in   her   joints.   There   was   no   sensation   to   pain  
and   touch   and   she   had   normal   pinprick.   Her   deep   tendon   reflexes   were  
normal   in   the   upper   and   lower   extremities   and   her   cranial   nerves   were  
normal.   At   that   time[,]   she   was   assessed   with   fatigue;;   however,   in  
December  2013  she  presented  to  Meridian  Medical  Associates  with  pain,  
numbness,   and   tingling   in   her   lower   extremities   and   was   diagnosed   with  
possible   element   of   reckless   leg   syndrome.   The   evidence   documents  
unremarkable  examinations  with  no  deformities,  cyanosis,  or  edema  of  the  
extremities.   She   has   normal   gait   and   station   as   well   as   normal   range   of  
motion  of  her  joints  with  no  neurological  deficits.  Furthermore,  there  is  no  
follow  up  treatment  for  this  impairment  and  the  claimant  d[id]  not  mention  
this  impairment  at  the  hearing.  Therefore,  the  evidence  does  not  show  this  
impairment   has   significantly   limited   or   is   likely   to   significantly   limit   the  
claimant’s  ability  to  do  basic  work  activities.  

In   regards   to   her   questionable   history   of   fibromyalgia[,]   the   evidence  
documents   a   diagnosis   of   fibromyalgia;;   however,   there   are   no   follow   up  
appointments   for   this   impairment.   The   evidence   does   not   document   any  
widespread   pain   in   the   joints,   muscles,   tendons,   or   nearby   soft   tissues  
associated  with  fibromyalgia.  Nor  does  the  evidence  document  at  least  11  
positive   tender   points   found   bilaterally   both   above   and   below   the   waist.  
Furthermore,  there  are  no  objective  tests  or  signs  to  confirm  the  severity  
of  any  observable  problem  of  fibromyalgia.  Therefore,  the  evidence  does  
not  document  any  objective  findings  for  this  impairment  nor  does  it  show  
this  impairment  has  significantly  limited  or  is  likely  to  significantly  limit  the  
claimant’s  ability  to  do  basic  work  activities.  

In   regards   to   her   hypertension,   the   claimant   did   not   mention   this  
impairment   at   the   hearing.   She   has   very   limited   treatment   for   this  
impairment,   yet   the   evidence   documents   a   diagnosis   of   hypertension.  
However,  there  are  several  examinations  that  have  documented  her  blood  
pressure   as   normal   and   her   heart   as   having   regular   rate   and   rhythm.  
Furthermore,  there  is  no  evidence  she  has  suffered  any  renal  damage  or  
cardiovascular   accident   generally   associated   with   prolonged  
uncontrollable   hypertension.   The   undersigned   notes   the   evidence   does  
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not  show  this  impairment  has  significantly  limited  or  is  likely  to  significantly  
limit  the  claimant’s  ability  to  do  basic  work  activities.    

In   regards   to   her   history   of   diabetic   ketoacidosis,   acute,   the   evidence  
documents  [that]  she  presented  to  The  Clinic  PC  on  March  30,  2015,  with  
complaints  of  vomiting,  sweating,  and  fatigue[].  Her  examination  indicated  
she   was   well   appearing,   well-­nourished   [and]   in   no   distress.   She   was  
oriented  times  three  and  her  mood  and  affect  was  normal.  Examination  of  
her  abdomen  and  extremities  w[as]  unremarkable;;  however,  it  was  noted  
since   she   has   [had]   ketoacidosis   before   it   was   recommended   she   go   to  
the   emergency   room,   but   she   refused.   She   was   encouraged   to   continue  
her   current   medication[s]   and   dietary   modification[s].   Approximately[]   a  
month   later[,]   on   April   26,   2015,   she   presented   to   Anderson   Regional  
Medical  Hospital  and  was  admitted  for  diabetic  ketoacidosis.  It  was  noted  
she   was   vomiting   and   severely   dehydrated;;   therefore,   she   was   placed   in  
intensive  care  and  started  on  normal  saline  and  an  insulin  drip.  Within  two  
days   she   was   gradually   weaned   off   the   insulin   drip   and   became   stable  
enough   to   be   discharged.   She   was   discharged   in   stable   condition   with  
instructions   to   follow   up   with   her   treating   physician   in   a   week.   She  
followed  up  at  The  Clinic  PC  on  June  10,  2015,  and  her  examination  was  
unremarkable.   She   was   assessed   with   fatigue,   pain   in   back,   depression,  
and  anxiety.    

Although[]   the   claimant   was   hospitalized   for   the   above   impairment,   the  
evidence   indicates   it   was   recommended   she   go   to   the   emergency   room  
one  month  prior,  yet  she  refused.  She  was  stable  within  two  days  and  did  
not  follow  up  for  almost  two  months.  As  stated  above[,]  her  diabetes  has  
been  controlled  with  medication  and  if  she  were  to  remain  compliant  with  
all  treatment  recommendations[,]  including  dietary  modifications,  exercise,  
and   medications[,]   there   is   no   reason   to   believe   she   would   have   any  
further   acute   diabetic   ketoacidosis.   In   fact,   the   evidence   documents   she  
was   last   ketoacidosis   in   2000,   which   clearly   suggests   her   acute   diabetic  
ketoacidosis  is  well  controlled.  

With   her   questionable   history   of   acute   sinusitis   and   bronchitis,   the  
evidence  documents  she  presented  to  The  Clinic  PC  in  January  2013  with  
complaints  of  a  sore  throat,  bilateral  ear  pain,  weakness/fatigue,  hurting  all  
over,   neck   pain,   and   cough.   Her   examination   indicated   her   lungs   were  
clear   and   her   eyes,   ears,   nose,   and   throat   were   normal.   She   was  
assessed   with   sinusitis,   acute[,]   and   treated   with   medication   [].   She  
returned  in  October  2013  with  a  sore  throat  and  again  she  was  diagnosed  
with   sinusitis,   acute.   On   April   22,   2015,   she   returned   to   The   Clinic   PC  
reporting   cough   and   congestion   and   hurting   in   her   chest   at   times.   She  
reported   chronic   leg   pain   and   headaches.   Her   physical   examination  
indicated   she   was   well   appearing,   well-­nourished   [and]   in   no   acute  
distress.  She  was  oriented  times  three  with  normal  mood  and  affect.  Her  
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lungs   were   clear   to   auscultation   and   percussion   and   her   extremities   did  
not   exhibit   any   deformities,   cyanosis,   or   edema.   She   was   assessed   with  
acute   sinusitis,   acute   bronchitis,   pain   in   back,   and   depression.   There   is  
nothing   to   show   the   claimant   required   any   medications   on   a   continuous  
basis   or   corticosteroids   for   this   impairment.   Furthermore,   there   is   no  
indication   the   claimant’s   acute   sinusitis   and   bronchitis   caused   long-­term  
complications   such   as   severe   shortness   of   breath,   chronic   obstructive  
pulmonary  disease,  or  respiratory  failure.  

The   claimant’s   medically   determinable   mental   impairments   of   depressive  
disorder,   not   otherwise   specified[,]   and   anxiety,   considered   singly   and   in  
combination,   do   not   cause   more   than   minimal   limitation   in   the   claimant’s  
ability  to  perform  basic  mental  activities  and  are  therefore  non-­severe.  

In   making   this   finding,   the   undersigned   has   considered   the   four   broad  
functional   areas   set   out   in   the   disability   regulations   for   evaluating   mental  
disorders  and  in  section  12.00C  of  the  Listing  of  Impairments.  These  four  
broad  functional  areas  are  known  as  the  “paragraph  B”  criteria.  

The   first   functional   area   is   activities   of   daily   living.   In   this   area,   the  
claimant  has  no  limitation.  The  claimant  is  mentally  able  to  initiate,  sustain,  
and  complete  activities  such  as  attending  to  her  personal  care,  preparing  
meals,   shopping,   driving,   managing   finances,   and   [is]   independent  
direction  or  supervision.  

The   next   functional   area   is   social   functioning.   In   this   area,   the   claimant  
has   no   limitation.   The   claimant   can   communicate   clearly,   demonstrate  
cooperative  behaviors,  initiate  and  sustain  social  contacts  and  participate  
in  group  activities.    

The   third   functional   area   is   concentration,   persistence   or   pace.   In   this  
area,   the   claimant   has   mild   limitation.   The   claimant   can   certainly   sustain  
the   focused   attention   and   concentration   necessary   to   permit   the   timely  
and   appropriate   completion   of   tasks   commonly   found   in   routine   and  
repetitive  work  settings.  However,  the  record  also  reveals  that  the  claimant  
obtained  a  GED.  Thereafter[,]  she  performed  semiskilled  work  as  a  caterer  
helper  in  a  family[-­]owned  business.  That  business  apparently  folded.  The  
record   strongly   suggests   that   had   the   business   [not   folded]   the   claimant  
would   have   continued   in   that   business.   The   record   does   not   allow   for   a  
finding  of  greater  than  mild  limitation  in  this  domain.  

The  fourth  functional  area  is  episodes  of  decompensation.  In  this  area,  the  
claimant   has   experienced   no   episodes   of   decompensation   which   have  
been  of  extended  duration.  

7

Because  the  claimant’s  medically  determinable  mental  impairments  cause  
no  more  than  “mild”  limitations  in  any  of  the  first  three  functional  areas  and  
“no”   episodes   of   decompensation   which   would   have   been   of   extended  
duration  in  the  fourth  area,  they  are  non-­severe.  

The   limitations   identified   in   the   “paragraph   B”   criteria   are   not   a   residual  
functional  capacity  assessment  but  are  used  to  rate  the  severity  of  mental  
impairments   at   steps   2   and   3   of   the   sequential   evaluation   process.   The  
mental   residual   functional   capacity   assessment   used   at   steps   4   and   5   of  
the  sequential  evaluation  process  requires  a  more  detailed  assessment  by  
itemizing   various   functions   contained   in   broad   categories   found   in  
paragraph  B  of  the  adult  mental  disorders  listings  in  12.00  of  the  Listing  of  
Impairments.   Therefore,   the   following   residual   functional   capacity  
assessment  reflects  the  degree  of  limitation  the  undersigned  has  found  in  
the  “paragraph  B”  mental  function  analysis.    

In  addition,  the  evidence  documents  on  February  18,  2014,  [the  claimant]  
attended   a   consultative   examination   conducted   by   Nina   Tocci,   PhD,   at  
which   time   she   was   diagnosed   with   depressive   disorder,   not   otherwise  
specified[,]   and   [given   a]   global   assessment   functioning   score   of   60.  
During   the   mental   status   evaluation,   the   claimant’s   posture   and   gait   was  
normal   and   her   motor   activity   was   unremarkable.   She   spoke   without   an  
impediment   and   her   affect   was   appropriate,   normal,   and   stable.   She  
described   her   mood   as   “okay/fair”.   She   was   oriented   to   time,   place,  
person,   and   situation   and   she   demonstrated   good   attention   and  
concentration.   She   demonstrated   good   fund   of   information   and  
comprehension   and   her   abstract   was   intact.   She   demonstrated   thought  
content  appropriate  to  mood  and  circumstances  and  goal-­directed  thought  
[and]   organization.   Dr.   Tocci   noted   the   claimant   appeared   to   be  
functioning   within   the   average   range   of   intellectual   ability   and   she   can  
make   informed   personal   and   financial   decisions.   Dr.   Tocci   opined   the  
claimant  has  the  ability  to  learn,  perform,  and  complete  job  tasks,  but  her  
concentration,   pace,   and   persiste[nce]   could   be   distracted   and   result   in  
imprecise  product  []  secondary  to  pain.  The  undersigned  does  not  concur  
with  this  opinion  because  it  is  inconsistent  with  the  evidence  as  a  whole.    

On   March   5,   2014,   Donald   Hinton,   Ph.D.,   a   State   Agency   medical  
consultant,   completed   a   Psychiatric   Review   Technique   Form   assessing  
the  claimant’s  mental  impairment.  Dr.  Hinton  opined  the  claimant  has  mild  
limitation   in   restriction   of   activities   of   daily   living,   mild   limitations   in  
maintaining   social   functioning,   and   moderate   limitations   in   difficulties   in  
maintaining   concentration,   persistence   or   pace.   He   found   no   episodes   of  
decompensation,  each  of  extended  duration.  

Dr.   Hinton   also   completed   a   Mental   Residual   Functional   Capacity  
Assessment   indicating   no   more   than   moderate   limitations   in   any   areas.  
8

Specifically,  Dr.  Hinton  opined  the  claimant  has  the  ability  to  understand,  
remember,   and   carry   out   many   short   and   simple   instructions.   He   opined  
the   claimant   can   attend   and   concentrate   for   two-­hour   periods.   He   lastly  
opined   work   setting   changes   should   be   minimal,   gradual,   and   fully  
explained  and  she  may  require  assistance  with  goal  setting.  

On   May   7,   2015,   she   presented   to   West   Alabama   Mental   Health   Center  
reporting   problems   with   depression   for   a   long   time.   After   a   screening  
assessment   intake[,]   she   was   assessed   with   major   depression   and  
recommended  [to]  return  in  two  weeks.  She  returned  on  May  29,  2015,  for  
individual   counseling   and   it   was   noted   her   affect   was   normal   and   her  
mood   was   anxious   and   depressed.   She   was   oriented   to   person,   place,  
time,   and   situation   and   her   motor   activity   was   calm.   She   reported   poor  
sleep  and  fair  appetite  and  it  was  recommended  she  return  in  two  weeks.  
The   evidence   does   not   indicate   the   claimant   followed   up   for   individual  
counseling,  which  clearly  suggests  her  impairment  is  under  control.  

On   June   12,   2015,   the   claimant’s   therapist   completed   a   Medical   Source  
Statement  (Mental)  on  behalf  of  the  claimant.  She  opined  the  claimant  has  
marked  limitations  in  her  ability  to  understand  and  remember  short  simple  
instructions,  understand  and  remember  detailed  instructions,  and  carry  out  
detailed  instructions.  She  opined  [claimant]  has  moderate  limitations  in  her  
ability[ies]   to   carry   out   short,   simple   instructions   and   make   judgments   on  
simple[,]  work-­related  decisions.  She  also  opined  the  claimant  is  markedly  
limited   to   interaction   with   the   public,   supervisors,   and   coworkers   and  
markedly  limited  [in]  responding  appropriately  to  work  pressures  in  a  usual  
work   setting   and   responding   appropriately   to   changes   in   a   routine   work  
setting.   The   undersigned   does   not   concur   with   this   opinion   because   it   is  
inconsistent  with  the  evidence  as  a  whole.    

Despite  the  fact[  that]  the  evidence  documents  a  diagnosis  of  depression  
and   the   record   indicates   some   treatment[     ],   the   treatment   has   been  
essentially  routine  and/or  conservative  in  nature  with  only  two  total  visits.  
Interestingly,  her  treating  physician  prescribes  her  depression  medication;;  
however,   examination[s]   of   her   mental   state   have   been   documented   as  
alert,  awake,  and  oriented  times  three  with  normal  mood  and  affect.  More  
importantly,   the   evidence   documents   she   has   denied   any   psychiatric  
problems.   What   is   more,   when   admitted   for   diabetic   ketoacidosis[,]   her  
mental   state   was   absent   any   depression   and   anxiety   and   she   was   alert  
and   oriented   times   three   with   normal   affect.   Furthermore,   the   evidence  
does  not  document  any  inpatient  hospitalizations  for  this  impairment  and[,  
as  stated  above[,]  she  only  has  two  visits  with  a  mental  health  facility.  In  
addition,   she   testified   she   discontinued   prior   mental   health   treatment   in  
2001,   but   reported   she   stopped   working   in   2010.   The   fact[]   she   has   not  
had  any  treatment  for  depression  in  fourteen  years,  but  continued  to  work,  

9

clearly   suggests   the   impairment   is   under   control[]   and   would   not   prevent  
work  activity.    

The   record   also   mentions   migraines;;   memory   problems;;   pain   and  
numb[ness]   in   arms;;   blurred   vision;;   and   back   problems.   Despite   multiple  
subsequent   physical   examinations   and   assessments,   there   is   no  
additional   mention   or   confirmation   for   the   impairments.   Although[]   the  
evidence   documents   reported   back   problems   throughout   the   record[,]   []  
there  are  no  laboratory  findings  to  suggest  the  severity  of  the  impairment.  
In  fact,  the  evidence  documents  she  had  normal  gait  and  station  with  full  
range   of   motion   of   all   joints.   The   undersigned   believes   these   conditions  
are  not  medically  determin[able]  and  do[]  not  affect  the  claimant’s  ability  to  
work.      

3.  
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   CFR   Part   404,   Subpart   P,   Appendix   1   (20  
CFR    404.1520(d),  404.1525  and  404.1526).  

.  
.  
.  

4.  
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   CFR   404.1567(b)  
except   she   can   stand   and/or   walk   at   least   two   hours   without  
interruption  and  six  hours  over  the  course  of  an  eight-­hour  workday.  
She   can   sit   at   least   two   hours   without   interruption   and   a   total   of   at  
least  six  hours  over  the  course  of  an  eight-­hour  workday.  She  cannot  
climb  ropes,  poles  or  scaffolds.  She  can  occasionally  climb  ladders,  
ramps,   and   stairs.   She   can   frequently   balance,   stoop,   kneel   and  
crouch.   She   can   occasionally   crawl.   She   can   frequently   use   her  
lower   extremities   for   pushing,   pulling   and   the   operation   of   foot  
controls.   She   can   occasionally   work   in   humidity,   wetness   and  
extreme   temperatures.   The   claimant   can   occasionally   [be   exposed  
to]   dusts,   gases,   odors   and   fumes.   The   claimant   can   occasionally  
work   in   poorly   ventilated   areas.   The   claimant   cannot   work   at  
unprotected   heights.   The   claimant   can   occasionally   work   while  
exposed   to   operating   hazardous   machinery.   The   claimant   can  
frequently   work   while   exposed   to   vibration.   The   claimant   can  
occasionally  operate  motorized  vehicles.    

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  CFR  404.1529  and  SSRs  96-­4p  and  96-­7p.  The  
10

undersigned  has  also  considered  opinion  evidence  in  accordance  with  the  
requirements  of  20  CFR  404.1527  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.  

After  careful  consideration  of  the  evidence,  the  undersigned  finds  that  the  
claimant’s   medically   determinable   impairments   could   reasonably   be  
expected   to   cause   the   alleged   symptoms;;   however,   the   claimant’s  
statements   concerning   the   intensity,   persistence   and   limiting   effects   of  
these  symptoms  are  not  entirely  credible  for  the  reasons  explained  in  this  
decision.  

With   regards   to   the   claimant’s   physical   limitations,   no   treating   physician  
has   offered   an   opinion   sufficient   upon   which   to   assess   the   claimant’s  
residual   functional   capacity.   However,   the   undersigned   notes   that   the  
above  limitations  are  consistent  with  and  supported  by  records  and  reports  
obtained  from  the  claimant’s  treating  physicians  and  with  the  evidence  as  
a   whole.   Therefore,   the   undersigned   finds   that   the   above   residual  
functional   capacity   assessment   is   supported   by   objective   treatment  
evidence,  treatment  records,  and  the  record  as  a  whole.  

In  addition,  the  undersigned  gives  some  weight  to  the  opinion  of  the  State  
agency   psychological   consultant[,]   Dr.   Robert   Hinton.   Although[]   the  
functional   limitations   given   by   Dr.   Hinton   differ   slightly   from   those   in   the  
residual   functional   capacity   assessment,   the   undersigned   finds   Dr.  
Hinton’s   opinion,   indicating   the   claimant   is   not   disabled   based   on   any  
mental   impairment,   is   generally   credible   and   consistent   with   the   medical  
evidence  of  record.  

11

In  addition,  the  undersigned  has  considered  the  opinion  of  Dr.  Tocci,  the  
mental   consultative   examiner.   Dr.   Tocci   assessed   the   claimant   with  
depressive   disorder,   not   otherwise   specified[,]   and   a   global   assessment  
functioning  score  (GAF)  of  60.  She  opined  the  claimant  has  the  ability  to  
learn,   perform,   and   complete   job   tasks,   but   her   concentration,   pace   and  
persiste[nce]   could   be   distracted   and   result   in   imprecise   product  
secondary   to   pain.   The   undersigned   notes   Dr.   Tocci’s   opinion   and  
assessments   are   inconsistent   with   records   and   reports   and   with   the  
evidence  as  a  whole.  There  is  no  documentation  in  the  record  to  support  
the   claimant   has   a   moderate   limitation   or   that   her   depression   is   at   all  
severe.   In   fact,   there   are   only   two   mental   health   visits   and   no   inpatient  
mental  hospitalizations.  Dr.  Tocci  did  not  report  any  signs  or  symptoms  for  
pain   and[,]   as   stated   above[,]   the   claimant’s   mental   examinations   have  
been   unremarkable.   Furthermore,   the   evidence   documents   the   claimant  
stopped   working   due   to   the   business   closing   and   not   because   of   the  
allegedly   disabling   impairment.   There   is   no   evidence   of   a   significant  
deterioration  in  the  claimant’s  mental  condition  since  the  business  closed;;  
therefore,  the  claimant’s  impairment  would  not  prevent  the  performance  of  
any   job,   since   it   was   being   performed   adequately   at   the   time.   Therefore,  
pursuant  to  20  CFR  404.1527(d)(1)  [],  the  undersigned  gives  little  weight  
to  the  opinion  of  Dr.  Tocci.  

The   undersigned   gives   little   weight   to   the   Medical   Source   Statement  
(Mental)   completed   by   Jennifer   Embrey,   a   Licensed   Professional  
Counselor.   Ms.   Embrey   opined   the   claimant   has   moderate   to   marked  
limitations   in   each   domain.   However,   the   evidence   documents   the  
claimant   was   treated   at   West   Alabama   Mental   Health   two   times   and   her  
affect  was  noted  as  normal  and  she  was  oriented  times  four.  Besides  her  
reports  of  poor  sleep  and  fair  appetite,  it  was  noted  her  motor  activity  was  
calm   and   she   denied   suicidal   and   homicidal   ideation.   The   undersigned  
notes   Ms.   Embrey’s   treating   relationship   with   the   claimant   is   quite   brief  
and   without   substantial   support   from   the   other   evidence   of   record,   which  
obviously  renders  her  opinion  less  persuasive.  Therefore,  the  undersigned  
gives  little  weight  to  the  opinion  of  Ms.  Embrey.  

The   undersigned   has   considered   the   opinion   of   Dr.   Manning   and   has  
given   it   little   weight.   Dr.   Manning   opined   the   claimant   is   unable   to   work  
because   of   her   diabetes   and   is   experiencing   a   lot   of   high   readings   with  
alternating  low  sugars.  Normally  a  treating  physician  would  be  given  great  
weight,  but  not  if  the  opinion  is  inconsistent  with  her  treating  notes  and  the  
evidence   of   record.   The   evidence   documents   controlled   diabetes   as   well  
as   unremarkable   physical   examinations.   Even   Dr.   Manning’s   records   do  
not  reflect  objective  findings  consistent  with  her  opinion.  Her  most  recent  
records   show   the   claimant   as   well   appearing,   well-­nourished[,   and]   in   no  
distress.  There  were  no  complications  related  to  uncontrolled  diabetes  and  
her  physical  examination  was  unremarkable.  Thus,  the  undersigned  ha[s]  
12

given   this   opinion   little   weight   and   great   probative   value   to   treatment  
records  as  a  whole.  

In  sum,  the  above  residual  functional  capacity  assessment  is  supported  by  
the   available   objective   evidence[/]treatment   records,   the   claimant’s  
activities,   the   available   acceptable   medical   sources   referred   to   herein,   to  
the  extent  such  [i]s  consistent  with  Finding  of  Fact  Number  5.    

5.  
The  claimant  is  capable  of  performing  past  relevant  work  as  a  
caterer  helper.  This  work  does  not  require  the  performance  of  work-­
related   activities   precluded   by   the   claimant’s   residual   functional  
capacity  (20  CFR  404.1565).  

The  vocational  expert  testified  that  the  claimant  has  past  relevant  work  as  
a   Caterer   Helper   (light,   semiskilled,   DOT   Number   319.677-­010)   and   a  
Machine   Presser   (medium,   unskilled,   DOT   Number   363.682-­018).   The  
vocational  expert  was  instructed  to  assume  a  hypothetical  individual  of  the  
claimant’s   age,   education,   past   relevant   work   experience,   and   who   has  
the  residual  functional  capacity  set  out  above.  The  vocational  expert  was  
then   queried   as   to   whether   such   an   individual   would   be   able   to   perform  
the   claimant’s   past   work.   The   vocational   expert   answered   that   such   a  
hypothetical   individual   would   still   be   able   to   perform   the   claimant’s   past  
relevant  work  as  a  Caterer  Helper.    

20   CFR   404.1520(e)   .   .   .   provide[s]   that   an   individual   will   be   found   “not  
disabled”   when   it   is   determined   that   a   claimant   retains   the   residual  
functional   capacity   to   perform   past   relevant   work.   This   includes  
performance   of   the   actual   functional   demands   and   duties   of   a   particular  
past  relevant  job  or  the  functional  demands  and  duties  of  the  occupation  
as   generally   required   by   employers   throughout   the   national   economy.  
Given  the  claimant’s  residual  functional  capacity,  and  the  testimony  of  the  
vocational  expert,  the  undersigned  finds  that  the  claimant  is  able  to  return  
to  her  past  relevant  work  as  a  Caterer  Helper,  and  she  is[,]  therefore,  “not  
disabled.”  In  comparing  the  claimant’s  residual  functional  capacity  with  the  
physical  and  mental  demands  of  this  work,  the  undersigned  finds  that  the  
claimant   is   able   to   perform   it   as   actually   and   generally   performed,  
pursuant  to  Social  Security  Ruling  82-­62.  

6.  
The  claimant  has  not  been  under  a  disability,  as  defined  in  the  
Social   Security   Act,   from   September   30,   2013,   through   the   date   of  
this  decision  (20  CFR  404.1520(f)).      

(Tr.  23-­29  &  30-­33  (internal  citations  and  footnote  omitted;;  emphasis  in  original)).      

13

II.  Standard  of  Review  and  Claims  on  Appeal  
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   Social   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  she  is  unable  to  perform  
her   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.  Although  “a  claimant  bears  the  burden  of  demonstrating  an  inability  to  return  
to   her   past   relevant   work,   the   [Commissioner   of   Social   Security]   has   an   obligation   to  
develop   a   full   and   fair   record.”   Schnorr   v.   Bowen,   816   F.2d   578,   581   (11th   Cir.   1987)  
(citations  omitted).  If  a  plaintiff  proves  that  she  cannot  do  her  past  relevant  work,  it  then  
becomes   the   Commissioner’s   burden—at   the   fifth   step—to   prove   that   the   plaintiff   is  
capable—given   her   age,   education,   and   work   history—of   engaging   in   another   kind   of  
substantial  gainful  employment  that  exists  in  the  national  economy.  Phillips,  supra,  357  
3

“Unpublished   opinions   are   not   considered   binding   precedent,   but   they   may   be  
cited  as  persuasive  authority.”  11th  Cir.R.  36-­2.  

14

F.3d   at   1237;;   Jones   v.   Apfel,   190   F.3d   1224,   1228   (11th   Cir.   1999),   cert.   denied,   529  
U.S.  1089,  120  S.Ct.  1723,  146  L.Ed.2d  644  (2000);;  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  she  can  perform  her  past  relevant  
work  as  a  caterer  helper  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.   Richardson   v.   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  Sec.,  363  F.3d  1155,  1158-­
1159  (11th  Cir.  2004)).  
On   appeal   to   this   Court,   Carney   asserts   two   reasons   the   Commissioner’s  
decision  to  deny  her  benefits  is  in  error  (i.e.,  not  supported  by  substantial  evidence):  (1)  

4

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).  

15

the   ALJ   erred   in   finding   she   has   no   severe   mental   impairment   and   finding   that   she  
retains  the  mental  residual  functional  capacity  to  perform  semi-­skilled  work;;  and  (2)  the  
ALJ  erred  in  finding  that  she  has  the  residual  functional  capacity  to  perform  light  work.  
Because  the  undersigned  finds  that  the  ALJ  erred  to  reversal  with  respect  to  Plaintiff’s  
first   assignment   of   error,   the   Court   has   no   reason   to   address   Carney’s   second  
assignment   of   error.   See   Pendley   v.   Heckler,   767   F.2d   1561,   1563   (11th   Cir.   1985)  
(“Because   the   ‘misuse   of   the   expert’s   testimony   alone   warrants   reversal,’   we   do   not  
consider  the  appellant’s  other  claims.”).
A   severe   impairment   is   an   impairment   or   combination   of   impairments   that  
significantly  limits  the  claimant’s  physical  or  mental  ability  to  do  basic  work  activities.  20  
C.F.R.   §   404.1520(c).   The   Commissioner’s   regulations   define   basic   work   activities   as  
the   abilities   and   aptitudes   to   do   most   jobs   and   in   analyzing   step   two   of   the   sequential  
evaluation   process,   the   Commissioner   considers   a   claimant’s   “(1)   Physical   functions  
such   as   walking,   standing,   sitting,   lifting,   pushing,   pulling,   reaching,   carrying,   or  
handling;;  (2)  Capacities  for  seeing,  hearing,  and  speaking;;  (3)  Understanding,  carrying  
out,   and   remembering   simple   instructions;;   (4)   Use   of   judgment;;   (5)   Responding  
appropriately  to  supervision,  co-­workers  and  usual  work  situations;;  and  (6)  Dealing  with  
changes   in   a   routine   work   setting.”   20   C.F.R.   §   404.1522(b).   “Step   two   is   a   threshold  
inquiry.”  McDaniel  v.  Bowen,  800  F.2d  1026,  1031  (11th  Cir.  1986).  Only  claims  based  
on  the  most  trivial  impairments  may  be  rejected,  and  an  impairment  is  not  severe  only  if  
the  abnormality  is  so  slight  and  its  effect  so  minimal  that  it  would  clearly  not  be  expected  
to   interfere   with   the   individual’s   ability   to   work.   Id.   A   claimant   need   only   demonstrate  
that  her  impairment  is  not  so  slight  and  its  effect  not  so  minimal.  Id.  

16

When   evaluating   whether   a   claimant   suffers   from   a   severe   mental   impairment,  
the   Commissioner   considers   how   the   impairment   impacts   the   following   four   broad  
functional   areas:   (1)   activities   of   daily   living;;   (2)   social   functioning;;   (3)   concentration,  
persistence,   and   pace;;5   and   (4)   episodes   of   decompensation.   20   C.F.R.   §  
404.1520a(c)(3).  Where  the  degree  of  limitation  is  rated  as  “none”  or  “mild”  in  the  first  
three   functional   areas,   and   as   “none”   in   the   fourth   functional   area,   the   Commissioner  
will   generally   conclude   that   the   claimant   does   not   suffer   from   a   severe   mental  
impairment.  20  C.F.R.  §  404.1520a(d)(1).  
In  this  case,  the  ALJ  concluded  that  Carney’s  depression  and  anxiety  were  non-­
severe  after  concluding  that  the  degree  of  functional  limitation  in  the  first  three  functional  
areas  was  “mild”  (or  that  there  were  no  limitations)  and  that  there  were  no  episodes  of  
decompensation.  (Tr.  27-­28.)  In  particular,  the  ALJ  found  that  Carney  had  mild  limitation  
in  the  area  of  concentration,  persistence,  and  pace  because  after  obtaining  a  GED  she  
performed  semiskilled  work  as  a  caterer  helper  in  a  family-­owned  business  and  that  had  
the   business   not   folded,   “[t]he   record   strongly   suggests   .   .   .   the   claimant   would   have  
continued   in   that   business.”   (Tr.   27.)   This   finding   is   not   supported   by   substantial  
evidence   inasmuch   as   the   record   is   clear   that   this   family-­owned   business   closed   in  
2010  (Tr.  45),  approximately  three  years  before  Carney’s  alleged  disability  onset  date  of  
September  30,  2013  (see  Tr.  23)  and  approximately  four  to  five  years  prior  to  examining  
or   reviewing   mental   health   professionals   indicated   that   Carney   had   difficulties   in  
5

“Concentration,   persistence,   or   pace   refers   to   the   claimant’s   ability   to   sustain  
focused   attention   and   concentration   sufficiently   long   enough   to   permit   h[er]   to   timely   and  
appropriately   complete   tasks   that   are   commonly   found   in   work   settings.”   Jacobs   v.  
Commissioner   of   Social   Security,   520   Fed.Appx.   948,   950     (11th   Cir.   Jun.   6,   2013)   (citation  
omitted).  

17

maintaining   concentration,   persistence,   and   pace   because   of   her   mental   impairments  
(compare   Tr.   66   &   69   with   Tr.   239).6   Accordingly,   whether   Carney   would   have   been  
capable   of   continuing   in   the   family-­owned   catering   business   in   20107   simply   has   no  
import  with  respect  to  whether  Carney  had  limitations  in  concentration,  persistence  and  
pace,   and   consequently   a   severe   mental   impairment,   on   or   after   her   alleged   onset  
disability   date   of   September   30,   2013,   and   certainly   not   on   March   5,   2014,   when   the  
reviewing  physician,  Dr.  Donald  E.  Hinton,  completed  a  Psychiatric  Review  Technique  
indicating  that  Carney  suffers  from  a  severe  affective  disorder  on  account  of  moderate  
difficulties   in   maintaining   concentration,   persistence,   and   pace   (Tr.   66)   and   thereafter,  
completed   a   “[n]ecessary”   mental   RFC   assessment   (see   Tr.   69-­70   (RFC   assessment  
concluded   that   Carney   has   sustained   concentration   and   persistence   limitations   in   that  
her   ability   to   maintain   attention   and   concentration   for   extended   periods   is   moderately  
limited,  such  that  she  can  attend  and  concentrate  for  two-­hour  periods,  and  her  ability  to  
carry   out   detailed   instructions   is   moderately   limited;;   however,   her   ability   to   carry   out  
very  short  and  simple  instructions  is  not  significantly  limited,  nor  is  her  ability  to  sustain  
an   ordinary   routine   without   special   supervision   or   to   make   simple   work-­related  
decisions,  etc.)).    Interestingly,  the  ALJ  accorded  “some”  weight  to  Dr.  Hinton’s  opinion  
(Tr.  31)  but  then  curiously  states  that  “the  functional  limitations  given  by  Dr.  Hinton  differ  
6

In   addition,   the   medical   records   indicate   that   a   licensed   professional   mental  
health  counselor  indicated  on  June  12,  2015,  that  Plaintiff’s  ability  to  understand,  remember  and  
carry  out  instructions  was  affected  by  her  depression  and  anxiety  (Tr.  337-­38).  
7

Plaintiff’s  hearing  testimony  is  clear  that  when  she  worked  for  her  aunt,  her  aunt  
accommodated   her   “health   problems.”   (Tr.   45   (“I   worked   for   my   aunt,   wh[o]   had   a   catering  
business.   She   understood   my   situation.   She   worked   with   me   as   far   as   my   situation   and   she  
closed   her   business   in   2010.   And   I   knew   that   nobody   else   would   be   as   reasonable   and   work  
with  me  as  she  did  as  far  as  my  health  problems.”)).    

18

slightly  from  those  in  the  residual  functional  capacity  assessment”  (id.),  even  though  the  
ALJ’s   RFC   assessment   contains   no   mental   functional   limitations   (Tr.   30),   much   less  
mental  functional  limitations  that  differ  only  slightly  from  those  noted  by  Dr.  Hinton  in  his  
mental   RFC   assessment   (compare   id.   with   Tr.   69-­70).8   And,   of   course,   it   bears  
repeating  that  Dr.  Hinton  set  forth  mental  functional  limitations  as  part  of  a  mental  RFC  
assessment  only  after  concluding  that  Carney  had  a  severe  impairment  (see  id.  at  66  &  
68-­70).  
In  light  of  the  foregoing,  it  is  clear  that  substantial  evidence  does  not  support  the  
ALJ’s  step  two  finding  that  Carney’s  mental  impairments  were  not  severe,  inasmuch  as  
the  medical  evidence  demonstrated  that  her  mental  impairments  caused  her  difficulties  
in   maintaining   concentration,   persistence   and   pace.   See   Delia   v.   Commissioner   of  
Social  Security,  433  Fed.Appx.  885,  887  (11th  Cir.  Jul.  14,  2011)  (“Substantial  evidence  
does   not   support   the   ALJ’s   finding,   at   step   two,   that   Delia’s   mental   impairments   were  
not   severe   because   the   medical   evidence   showed   that   these   impairments   did   cause  
restrictions  in  daily  living,  social  functioning,  and  maintaining  concentration,  persistence,  
or   pace.”).   However,   provided   the   ALJ   finds   at   least   one   severe   impairment,   see  
Tuggerson-­Brown   v.   Commissioner   of   Social   Security,   572   Fed.Appx.   949,   951   (11th  
Cir.   Jul.   24,   2014)   (“[W]e   have   recognized   that   step   two   requires   only   a   finding   of   ‘at  

8

As  set  forth  infra,  the  ALJ  clearly  intended  to  include  mental  functional  limitations  
in   his   RFC   assessment   similar   to   Dr.   Hinton’s   limitations,   which   he   at   no   time   rejects   (see   Tr.  
31),   and,   instead,   prominently   cites   (Tr.   28   (“Dr.   Hinton   also   completed   a   Mental   Residual  
Functional   Capacity   Assessment   indicating   no   more   than   moderate   limitations   in   any   area.  
Specifically,  Dr.  Hinton  opined  the  claimant  has  the  ability  to  understand,  remember,  and  carry  
out  many  short  and  simple  instructions.  He  opined  the  claimant  can  attend  and  concentrate  for  
two-­hour   periods.   He   lastly   opined   work   setting   changes   should   be   minimal,   gradual,   and   fully  
explained  and  she  may  require  assistance  with  goal  setting.”)).  

19

least   one’   severe   impairment   to   continue   to   the   later   steps.”),9   and   gives   “full  
consideration   to   the   consequences   of   [the   claimant’s]   mental   impairments   on   [her]  
ability  to  work  at  later  stages  of  the  analysis,10  [any]  error  at  step  two  [i]s  harmless  and  
is  not  cause  for  reversal.”  Delia,  supra,  433  Fed.Appx.  at  887  (citation  omitted;;  footnote  
added).  Here,  of  course,  is  where  the  ALJ  committed  reversible  error  inasmuch  as  the  
ALJ  did  not  give  full  consideration  to  the  consequences  of  Carney’s  mental  impairments  
on  her  ability  to  work  at  later  stages  of  the  analysis.    
In   reaching   his   RFC   determination,   at   step   four,   it   is   clear   that   the   ALJ   in   this  
case   gave   no   consideration   to   the   consequences   of   Carney’s   mental   impairments   on  
her   ability   to   work   inasmuch   as   neither   that   assessment   (see   Tr.   30),   nor   the  
hypothetical   posed   to   the   vocational   expert   (see   Tr.   56)   upon   which   the   ALJ   relied   to  
find   Carney   not   disabled   (compare   id.   with   Tr.   30   &   32),   contain   mental   functional  
9

The  ALJ  did  that  in  this  case.  (See  Tr.  23.)  

10

“At   steps   three,   four,   and   five,   the   ALJ   considers   the   claimant’s   entire   medical  
condition,  including  impairments  that  are  not  severe  at  step  two.”  Delia,  433  Fed.Appx.  at  887,  
citing  Jamison  v.  Bowen,  814  F.2d  585,  588  (11th  Cir.  1987);;  see  also  Tuggerson-­Brown,  supra,  
572   Fed.Appx.   at   951   (“While   the   ALJ   did   not   need   to   determine   whether   every   alleged  
impairment  was  ‘severe,’  he  was  required  to  consider  all  impairments,  regardless  of  severity,  in  
conjunction   with   one   another   in   performing   the   latter   steps   of   the   sequential   evaluation  
[process].”);;   Sanchez   v.   Commissioner   of   Social   Security,   507   Fed.Appx.   855,   858   (11th   Cir.  
Feb.   8,   2013)   (“Before   reaching   step   four,   the   ALJ   must   assess   the   claimant’s   RFC—which   is  
the  most  work  the  claimant  can  do  despite  her  physical  and  mental  limitations—by  considering  
all   of   the   relevant   medical   and   medically   determinable   impairments,   including   any   such  
impairments  that  are  not  ‘severe.’  In  assessing  the  RFC,  the  ALJ  must  consider  the  claimant’s  
ability   to   meet   the   physical,   mental,   sensory,   and   other   requirements   of   work.”   (citations  
omitted;;  emphasis  supplied)).    
Although   this   Court’s   focus   is   on   step   4,   it   bears   noting   that   the   ALJ   failed   to   consider  
Carney’s   mental   impairments   at   step   3   (see   Tr.   29-­30   (no   mention   of   Carney’s   mental  
impairments   or   any   mental   listings,   such   as   12.04)),   though   this   is   required,   Delia,   supra,   433  
Fed.Appx.  at  887  (“At  steps  three,  four,  and  five,  the  ALJ  considers  the  claimant’s  entire  medical  
condition,   including   impairments   that   are   not   severe.   .   .   .   The   ALJ   considered   Delia’s   mental  
impairments  at  steps  three,  four  and  five.”).  This  error  simply  constitutes  an  additional  basis  why  
this  action  need  be  remanded  for  further  consideration.  

20

limitations  found  in  the  record  (compare  Tr.  30  with,  e.g.,  Tr.  69-­70  (indicating  Carney’s  
ability  to  understand  and  remember  detailed  instructions  is  moderately  limited,  as  is  her  
ability  to  carry  out  detailed  instructions  and  to  maintain  attention  for  extended  periods—
although  she  can  attend  and  concentrate  for  two-­hour  periods—11  and  that  her  ability  to  
respond   appropriately   to   changes   in   the   work   setting   is   moderately   limited,   as   is   her  
ability   to   set   realistic   goals   or   make   plans   independently   of   others,   such   that   work  
setting   changes   should   be   minimal   and   gradual   and   she   may   require   assistance   with  
goal   setting;;   however,   Dr.   Hinton   did   indicate   that   Carney’s   ability   to   understand,  
remember,   and   carry   out   very   short   and   simple   instructions   is   not   significantly   limited,  
nor   is   her   ability   to   make   simple   work-­related   decisions)   &   Tr.   239   (“She   has   .   .   .  
isolation[]  and  anhedonia.  She  has  the  ability  to  learn,  perform,  and  complete  job  tasks  
but   her   concentration,   pace,   and   persiste[nce]   could   be   distracted   and   result   in  
imprecise   product   secondary   to   pain.”)),   though   the   ALJ   specifically   insisted   he   did  
include   such   mental   functional   limitations   in   his   RFC   assessment   (see   Tr.   31  
(“Although[]  the  functional  limitations  given  by  Dr.  Hinton  differ  slightly  from  those  
in   the   residual   functional   capacity   assessment   .   .   .   .”   (emphasis   supplied)).   Given  
that  the  ALJ  obviously  intended  to  include  mental  functional  limitations  (similar  to  those  

11

As   previously   indicated,   the   Commissioner’s   regulations   make   clear   that   basic  
work  activities  include  the  ability  to  understand,  carry  out,  and  remember  simple  instructions;;  the  
ability  to  use  judgment;;  the  ability  to  respond  appropriately  to  supervision,  coworkers,  and  usual  
work   situations;;   and   the   ability   to   deal   with   changes   in   a   routine   work   setting,   20   C.F.R.   §  
404.1522(a),  all  of  which  are  addressed  in  some  manner  by  Dr.  Hinton  (see  Tr.  69-­70)  but  not  in    
the  ALJ’s  RFC  assessment  (see  Doc.  30)  or  his  primary  hypothetical  posed  to  the  VE  (see  Tr.  
56).  

21

noted  by  Dr.  Hinton)  in  his  RFC  assessment  (id.),12  this  cause  is  due  to  be  remanded  to  
the   Commissioner   for   further   consideration,   particularly   since   “the   Commissioner’s  
policy   requires   ALJs   to   be   more   detailed   in   evaluating   a   claimant’s   RFC   at   step   four  
than   in   assessing   the   severity   of   mental   impairments   at   steps   two   and   three.”   Hines-­
Sharp   v.   Commissioner   of   Social   Security,   511   Fed.Appx.   913,   916   (11th   Cir.   Mar.   6,  
2013),  citing  Winschel  v.  Commissioner  of  Social  Security,  631  F.3d  1176,  1180  (11th  
Cir.   2011);;   cf.   Sanchez,   supra,   507   Fed.Appx.   at   859   (affirming   fifth-­step   denial   of  
benefits   where   the   ALJ’s   RFC   assessment   and   hypothetical   questions   to   the   VE  
accounted   for   all   of   the   claimant’s   mental   limitations,   including   any   limitations  
attributable   to   BPD,   which   the   ALJ   failed   to   identify   as   a   severe   impairment).   Had   the  
ALJ   included   the   mental   functional   limitations   he   obviously   intended   to   include   in   his  
RFC   assessment,   and   his   hypothetical   to   the   VE,   this   Court   would   have   no   cause   to  
remand   this   step   4   case,   see   Hines-­Sharp,   supra,   511   Fed.Appx.   at   916   &   917  
(affirming  step  4  denial  of  benefits  where  the  ALJ  “did  not  simply  restrict  the  hypothetical  
to   unskilled   work,”   but   also   included   in   the   hypothetical   the   findings   that   the   claimant  
had   “’marked   limitations   in   understanding   and   remembering   complex   instructions,’  
carrying   out   those   instructions,   and   ‘making   judgments   on   complex   work-­related  
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Certainly,  that  this  is  what  the  ALJ  should  have  done  here  is  clear  given  that  the  
ALJ   found   Carney’s   “physical”   impairments   (that   is,   obesity,   diabetes   mellitus,   history   of  
fibromyalgia,   history   of   restless   leg   syndrome,   hypertension,   history   of   diabetic   ketoacidosis,  
and   history   of   acute   sinusitis   and   bronchitis)   to   be   non-­severe   individually   but   nonetheless  
“considered  the  impairments  collectively  in  assessing  the  residual  functional  capacity[]”  (Tr.  23),  
and   elsewhere   signaled   that   he   was   doing   this   with   respect   to   Plaintiff’s   mental   impairments  
(see  Tr.  27  (“The  mental  residual  functional  capacity  assessment  used  at  steps  4  and  5  of  the  
sequential   evaluation   process   requires   a   more   detailed   assessment   by   itemizing   various  
functions   contained   in   broad   categories   found   in   paragraph   B   of   the   adult   mental   disorders  
listings   in   12.00   of   the   Listing   of   Impairments.   Therefore,   the   following   residual   functional  
capacity   assessment   reflects   the   degree   of   limitation   the   undersigned   has   found   in   the  
“paragraph  B”  mental  function  analysis.”  (emphasis  supplied)).  

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decisions,’   along   with   ‘moderate   limitations   in   responding   appropriately   to   usual   work  
situations  and  to  changes  in  a  routine  work  setting  .  .  .  .’”);;  however,  his  failure  to  do  so  
requires   a   remand   as   it   constitutes   reversible   error,   see   id.;;   compare   id.   with   Dial   v.  
Commissioner  of  Social  Security,  403  Fed.Appx.  420,  421  (11th  Cir.  Nov.  18,  2010)  (in  
a   case   where   the   ALJ   denied   the   claimant’s   application   on   the   basis   that   he   could  
perform   his   past   relevant   work   and   other   work   in   the   national   economy,   remand   was  
required  where  hypothetical  to  the  VE  did  not  include  all  of  the  claimant’s  employment  
limitations);;   and   Hennes   v.   Commissioner   of   Social   Security   Admin.,   130   Fed.Appx.  
343,   346   (11th   Cir.   May   3,   2005)   (affirming   ALJ’s   fourth-­step   denial   of   benefits   where  
the   hypotheticals   to   the   VE   comprised   all   of   the   claimant’s   impairments),   particularly  
since  the  limitations  noted  by    Dr.  Hinton  (see  Tr.  69-­70)  appear  to  be  inconsistent  with  
Carney’s  past  relevant  semiskilled  work  as  a  caterer  helper  (see  Tr.  59  (VE’s  testimony  
that  claimant  could  not  perform  her  work  as  a  caterer  helper  if  she  was  limited  to  simple,  
routine,   and   repetitive   work   activity)),   see   Pinion   v.   Commissioner   of   Social   Security,  
522   Fed.Appx.   580,   582   (11th   Cir.   Jun.   19,   2013)   (“Where   an   ALJ   determines   at   step  
two  of  the  sequential  evaluation  process  that  the  claimant’s  mental  impairments  caused  
limitations  in  concentration,  persistence,  or  pace,  the  ALJ  must  include  those  limitations  
in  the  hypothetical  questions  posed  to  the  VE.  However,  the  ALJ  may  instead  include  in  
the  hypothetical  questions  the  limitation  that  the  claimant  is  restricted  to  unskilled  
work  if  the  medical  evidence  shows  that  the  claimant  can  perform  simple,  routine  
tasks   or   unskilled   work   despite   her   limitations   in   concentration,   persistence,   or  
pace.”  (citations  omitted;;  emphasis  supplied)).    

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In  light  of  the  foregoing,  and,  in  short,  because  the  ALJ  in  this  case  did  not  give  
full   consideration   to   the   consequences   of   Carney’s   mental   impairments   at   steps   three  
and   four   of   the   sequential   evaluation   process,   his   error   at   step   two   was   harmful   (not  
harmless)   and   is   cause   for   reversal   and   remand   for   further   consideration   not  
inconsistent  with  this  decision.  
CONCLUSION  
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  this  matter.  
DONE  and  ORDERED  this  the  7th  day  of  March,  2018.  

s/P.  BRADLEY  MURRAY    

UNITED  STATES  MAGISTRATE  JUDGE  

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