Anderson v. Berryhill

Filing 17

MEMORANDUM OPINION AND ORDER entered that the decision of the Commissioner of Social Security denying Plaintiff benefits be affirmed. Signed by Magistrate Judge P. Bradley Murray on 5/15/2018. (eec)

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

JENNIFER  ANDERSON,  

:  

Plaintiff,  

:  

vs.    

:  
CA  17-­0380-­MU  

NANCY  A.  BERRYHILL,    

:  
Deputy  Commissioner  for  Operations,    
performing  the  duties  and  functions  not   :  
reserved  to  the  Commissioner  of  
Social  Security,1    

:  

Defendant.  

 MEMORANDUM  OPINION  AND  ORDER  

Plaintiff   Jennifer   Anderson   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   her   claims   for   a   period   of   disability,   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.   (Doc.   14   (“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.”);;   see   also   Doc.   16   (order   of  
reference)).   Upon   consideration   of   the   administrative   record,   Plaintiff’s   brief,   the  
Commissioner’s  brief,  and  the  parties’  arguments  at  the  May  9,  2018  hearing  before  the  
1

8:53  a.m.)  

See   https://www.ssa.gov/agency/commissioner.html   (last   visited,   April   17,   2018,  

undersigned,   the   Court   concludes   that   the   Commissioner’s   decision   denying   benefits  
should  be  affirmed.2      
I.  Procedural  Background  
Plaintiff   filed   applications   for   a   period   of   disability,   disability   insurance   benefits,  
and   supplemental   security   income   on   April   24,   2014,   alleging   disability   beginning   on  
April   6,   2014.   (See   Tr.   148-­55.)   Anderson’s   claims   were   initially   denied   on   June   24,  
2014  (Tr.  92-­101)  and,  following  Plaintiff’s  August  12,  2014  written  request  for  a  hearing  
before  an  Administrative  Law  Judge  (“ALJ”)  (see  Tr.  104-­05),  a  hearing  was  conducted  
before  an  ALJ  on  November  16,  2015  (Tr.  44-­63).  On  August  29,  2016,  the  ALJ  issued  
a   decision   finding   that   the   claimant   was   not   disabled   and,   therefore,   not   entitled   to   a  
period   of   disability,   disability   insurance   benefits,   or   supplemental   security   income.   (Tr.  
22-­38.)  More  specifically,  the  ALJ  proceeded  to  the  fifth  step  of  the  five-­step  sequential  
evaluation   process   and   determined   that   Anderson   retains   the   residual   functional  
capacity  to  perform  those  light  jobs  identified  by  the  vocational  expert  (“VE”)  during  the  
administrative   hearing   (compare   id.   at   37   with   Tr.   60-­61).   On   October   11,   2016,   the  
Plaintiff  appealed  the  ALJ’s  unfavorable  decision  to  the  Appeals  Council  (Tr.  145);;  the  
Appeals  Council  denied  Anderson’s  request  for  review  on  July  26,  2017  (Tr.  1-­3).  Thus,  
the  hearing  decision  became  the  final  decision  of  the  Commissioner  of  Social  Security.  

2

Any  appeal  taken  from  this  memorandum  opinion  and  order  and  judgment  shall  
be   made   to   the   Eleventh   Circuit   Court   of   Appeals.   (See   Doc.   14   (“An   appeal   from   a   judgment  
entered  by  a  Magistrate  Judge  shall  be  taken  directly  to  the  United  States  Court  of  Appeals  for  
this   judicial   circuit   in   the   same   manner   as   an   appeal   from   any   other   judgment   of   this   district  
court.”)).  

2

Plaintiff   alleges   disability   due   to   affective   disorder,   personality   disorder,   obesity,  
diabetes  mellitus,  back  and  hip  pain,  and  right-­sided  weakness.  The  Administrative  Law  
Judge  (ALJ)  made  the  following  relevant  findings:  
3.  
The   claimant   has   the   following   severe   impairments:   affective  
disorder,   personality   disorder,   obesity,   and   diabetes   mellitus   (20  
CFR  404.1520(c)  and  416.920(c)).  

.  
.  
.  

4.  
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,   404.1526,   416.920(d),   416.925   and  
416.926).  

.  
.  
.  

5.  
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)  and  
416.967(b),  except  that  she  cannot  climb  ladders,  ropes,  or  scaffolds;;  
can   occasionally   climb   ramps   and   stairs;;   can   occasionally   stoop,  
kneel,   crouch,   and   crawl;;   can   have   no   exposure   to   unprotected  
heights/hazardous   machinery;;   can   perform   no   commercial   driving;;  
can   have   occasional   exposure   to   chemicals,   fumes,   odors,   and  
gases;;   is   limited   to   simple   routine   tasks;;   and   can   have   occasional  
interaction  with  the  public.    

.  
.  
.  

6.  
The   claimant   is   unable   to   perform   any   past   relevant   work   (20  
CFR  404.1565  and  416.965).  

.  
.  
.  

7.  
The  claimant  was  born  on  June  8,  1970,  and  was  43  years  old,  
which   is   defined   as   a   younger   individual   age   18-­49,   on   the   alleged  
disability  onset  date  (20  CFR  404.1563  and  416.963).  

8.  
The  claimant  has  at  least  a  high  school  education  and  is  able  
to  communicate  in  English  (20  CFR  404.1564  and  416.964).  
3

9.  
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  CFR  404,  Subpart  P,  Appendix  2).  

10.   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  CFR  404.1569,  404.1569(a),  416.969,  and  416.969(a)).    

.  
.  
.  

11.   The  claimant  has  not  been  under  a  disability,  as  defined  in  the  
Social   Security   Act,   from   April   6,   2014,   through   the   date   of   this  
decision  (20  CFR  404.1520(g)  and  416.920(g)).    

(Tr.  24,  28,  29,  36  &  37  (emphasis  in  original)).      
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  

3

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

4

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,   as  
here,  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   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   those   light   jobs  
identified   by   the   VE   during   the   administrative   hearing,   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  

5

[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,   Anderson   asserts   two   reasons   the   Commissioner’s  
decision  to  deny  her  benefits  is  in  error  (i.e.,  not  supported  by  substantial  evidence):  (1)  
the  ALJ  committed  reversible  error  in  failing  to  find  her  back  and  hip  pain  and  right-­sided  
weakness   to   be   severe   impairments;;   and   (2)   the   ALJ   committed   reversible   error   in  
failing  to  assign  controlling  weight  to  the  opinions  of  her  treating  physician,  Dr.  Juanita  
Lopez.  
A.  

Whether   the   ALJ   Committed   Reversible   Error   in   Failing   to   Find  

Plaintiff’s   Back   and   Hip   Pain   and   Right-­Sided   Weakness   to   be   Severe  
Impairments.     In   her   brief,   Plaintiff   points   to   evidence   in   the   administrative   record  
regarding   her   back   and   hip   pain   and   right-­sided   weakness   (see   Doc.   9,   at   3-­5)   and  
contends   that   the   ALJ   erred   to   reversal   in   failing   to   find   that   these   impairments   were  
severe  impairments  (see  id.  at  2-­3  &  6).  And,  looking  at  the  ALJ’s  decision,  there  can  be  
little  question  but  that  the  ALJ  specifically  determined  that  Plaintiff’s  back  and  hip  pain  

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).  

6

and  her  right-­sided  weakness  were  non-­severe  impairments.  (See  Tr.  24-­28  (specifically  
finding  “no  medically  determinable  impairment  related  to  any  musculoskeletal  condition,  
including   the   back   or   hip[]”   and   also   noting   that   while   Anderson   may   have   had   some  
mild  right-­sided  weakness  in  June  of  2014,  which  even  her  treating  doctor  identified  as  
“subjective,”   the   “objective   treatment   record   failed   to   document   the   claimant’s   ongoing  
difficulty   with   weakness   and   reduced   strength.”)).   Thus,   the   question   for   this   Court  
becomes  whether  the  ALJ  reversibly  erred  in  failing  to  find  these  identified  impairments  
to  be  severe  impairments.  
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.  

7

In   this   case,   the   ALJ   concluded   that   Anderson’s   back   and   hip   pain   and   right-­
sided  weakness  were  non-­severe  (Tr.  24-­28).  Plaintiff  argues  that  substantial  evidence  
does  not  support  the  ALJ’s  step  two  finding  in  this  regard  (see  Doc.  9,  at  3-­5).  However,  
even  if  the  Court  agreed  with  Plaintiff  on  this  point,  the  law  in  this  Circuit  dictates  that  
she   would   not   be   entitled   to   a   remand   of   this   action.   When   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   least   one’   severe   impairment   to   continue   to   the   later  
steps.”),5  and  then  gives  full  consideration  to  the  consequences  of  all  of  the  claimant’s  
impairments,  in  combination,  on  her  ability  to  work  at  later  stages  of  the  analysis,6  see,  
e.g.,  Tuggerson-­Brown,  572  Fed.Appx.  at  951  (recognizing  that  the  ALJ  is  “required  to  
consider   all   impairments,   regardless   of   severity,   in   conjunction   with   one   another   in  
performing   the   latter   steps   of   the   sequential   evaluation   [process].”),   any   error   at   step  

5

The   ALJ   did   that   in   this   case.   (See   Tr.   24   (“The   claimant   has   the   following  
severe   impairments:   affective   disorder,   personality   disorder,   obesity,   and   diabetes  
mellitus[.]”)).  
6

“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   v.   Commissioner   of  
Social  Security,  433  Fed.Appx.  885,  887  (11th  Cir.  Jul.  14,  2011),  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  
[and  step  five],  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)).    

8

two  is  harmless  and  is  not  cause  for  reversal,  see,  e.g.,  Hearn  v.  Commissioner,  Social  
Security  Admin.,  619  Fed.Appx.  892,  895  (11th  Cir.  Jul.  31,  2015)  (finding  any  step  two  
error   harmless   where   the   ALJ   “properly   noted   that   he   considered   [the   claimant’s]  
impairments   in   the   later   steps   [of   the   sequential   evaluation   process].”);;   Gray   v.  
Commissioner  of  Social  Security,  550  Fed.Appx.  850,  853-­54  (11th  Cir.  Dec.  30,  2013)  
(“Here,   we   need   not   consider   whether   substantial   evidence   supports   the   ALJ’s  
conclusion   at   step   two—that   Gray’s   cervical   spine   impairment   was   not   a   severe  
impairment—because  even  if  there  was  error,  it  would  be  harmless.  In  assessing  Gray’s  
RFC,  the  ALJ  found  that  Gray  had  severe  impairments  and  that  the  step  two  test  was  
satisfied,   and   then   specifically   considered   and   discussed   the   symptoms   that   Gray  
alleged  stemmed  from  a  cervical  spine  impairment  elsewhere  in  the  five-­step  sequential  
process.  .  .  .  The  ALJ  thus  performed  the  analysis  that  would  have  been  required  had  
he  determined  a  cervical  spine  impairment  was  severe  at  step  two.”).    
Stated   somewhat   differently,   this   Court   need   not   consider   whether   substantial  
evidence  supports  the  ALJ’s  step  two  decision—that  Anderson’s  back  and  hip  pain  and  
right-­sided  weakness  are  not  severe  impairments—because  any  error  in  this  regard  is  
harmless  given  the  ALJ  identified  severe  impairments  and  proceeded  to  the  remaining  
steps   in   the   sequential   evaluation   process,   giving   full   consideration   to   the  
consequences   of   all   of   Plaintiff’s   impairments   (both   severe   and   non-­severe)   on   her  
ability  to  work  at  later  stages  of  the  analysis.7  Although  by  no  means  the  entirety  of  the  
7

The   ALJ   also   specifically   evaluated   whether   Anderson   had   an   impairment   or  
combination   of   impairments   that   met   a   listed   impairment   (see   Tr.   28),   which   is   a   sufficient  
enough  statement  “to  demonstrate  that  the  ALJ  considered  all  necessary  evidence.”  Tuggerson-­
Brown,   supra,   572   Fed.Appx.   at   952,   citing   Wilson   v.   Barnhart,   284   F.3d   1219,   1224-­25   (11th  
Cir.  2002).  

9

ALJ’s  later-­stage  analysis,  the  following  language  demonstrates  that  the  ALJ  considered  
all   of   Anderson’s   impairments—even   those   not   specifically   found   to   be   severe—in  
reaching  both  the  remaining  steps  of  the  sequential  evaluation  process  (that  is,  steps  3-­
5)  and  the  ultimate  conclusion  that  Plaintiff  is  not  disabled:    
Medical   expert   Ari   B.   Magill,   M.D.,   a   neurologist,   completed   a  
medical  interrogatory  in  which  he  cited  the  claimant’s  lower  back  pain  with  
decreased  range  of  motion  in  the  lumbosacral  spine  according  to  physical  
therapy   notations   and   right   hip   pain   with   painful   range   of   motion   of   the  
extremities.   Dr.   Magill   opined   that   no   impairment   established   by   the  
medical   evidence,   either   combined   or   separately,   met   or   equaled   any  
impairment  described  in  the  Listing  of  Impairments.  

.  
.  
.  

Dr.   Magill   completed   a   medical   source   statement   of   ability   to   do   work-­
related  activities  (physical),  in  which  he  concluded  that  the  claimant  could  
continuously  lift  and/or  carry  up  to  twenty  pounds  .  .  .  .  In  comments,  Dr.  
Magill   cited   the   claimant’s   back   and   hip   pain,   with   physical   therapy  
assessment   showing   reduced   range   of   motion   of   the   lumbosacral   spine.  
Dr.   Magill   further   opined   that   the   claimant   could   sit,   stand,   and   walk   for  
eight   hours   at   one   time   and   over   the   course   of   an   eight-­hour   workday.  
According   to   Dr.   Magill,   the   claimant   could   continuously   reach,   handle,  
finger,  feel,  and  push/pull  with  both  hands  and  could  continuously  operate  
foot   controls   bilaterally.   Dr.   Magill   also   indicated   that   the   claimant   could  
frequently   climb,   stoop,   kneel,   crouch,   and   crawl   and   could   continuously  
balance.    

(Tr.  32;;  see  also  Tr.  31  (ALJ’s  discussion  of  Anderson’s  right-­sided  weakness  within  the  
context   of   her   RFC   assessment);;   Tr.   35-­36   (ALJ’s   consideration   of   Anderson’s  
symptoms   in   determining   her   RFC)).   In   short,   therefore,   this   Court   finds   no   reversible  
error   with   respect   to   Anderson’s   first   assignment   of   error   because   the   record  
demonstrates  that  the  ALJ  properly  considered  all  of  Anderson’s  impairments,  including  
those   she   found   to   be   non-­severe   (that   is,   her   hip   and   back   pain   and   her   right-­sided  
weakness),   in   reaching   the   conclusion   that   Plaintiff   was   not   disabled.   See,   e.g.,  
Tuggerson-­Brown,  supra,  572  Fed.Appx.  at  952.  
10

B.  

Whether  the  ALJ  Erred  in  Failing  to  Assign  Controlling  Weight  to  the  

Medical  Opinions/Statements  of  Plaintiff’s  Treating  Physician,  Dr.  Juanita  Lopez.  
Plaintiff’s  only  other  assignment  of  error  is  that  the  ALJ  failed  to  give  controlling  weight  
to  the  opinions/statements  of  her  treating  physician,  Dr.  Juanita  Lopez.  (Doc.  9,  at  6-­7.)  
Anderson   describes   Dr.   Lopez’   November   20,   2015   letter   opinions/statements   in   the  
following  manner:  “Dr.  Lopez  stated  that  Plaintiff’s  clinical  course  is  labile  and  guarded  
at   best,   due   to   her   multi-­system   organ   affliction.   []   Dr.   Lopez   then   concluded   that   the  
Plaintiff  has  poor  ability  for  functional  productivity.”  (Doc.  9,  at  5,  citing  Tr.  4268.)    
“Weighing   the   opinions   and   findings   of   treating,   examining,   and   non-­examining  
physicians   is   an   integral   part   of   the   process   for   determining   disability.”   Kahle   v.  
Commissioner   of   Social   Security,   845   F.Supp.2d   1262,   1271   (M.D.   Fla.   2012).   In  
particular,   “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,  supra,  357  F.3d  at  1240  
(other  citation  omitted);;  see  Nyberg  v.  Commissioner  of  Social  Security,  179  Fed.Appx.  
589,   591   (11th   Cir.   May   2,   2006)   (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  
8

Dr.  Lopez’  November  20,  2015  letter  opinion  precisely  reads,  as  follows:  “Due  to  
the   multi-­system   organ   affliction,   her   clinical   course   is   labile   &   guarded   at   best.   All   things  
considered,   Ms.   Anderson   is   deemed   disabled   &   incapacitated,   w/poor   ability   for   functional  
productivity.”  (Tr.  426.)  

11

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   Social   Sec.,   396   Fed.Appx.   652,   655   (11th   Cir.   Sept.   21,  
2010)  (per  curiam).      

The   ALJ   discussed   Dr.   Lopez’   letter   opinion(s)   at   significant   length   in   the  

administrative  decision.  (Tr.  30-­32.)  
On  November  20,  2015,  treating  source  Juanita  Lopez,  M.D.,  completed  a  
narrative  in  which  she  cited  seizure  disorder;;  vascular  headaches;;  history  
of   transient   cerebrovascular   ischemic   episodes   with   residual   left  
hemiparesis;;   thyroid   disorder;;   diabetes   mellitus;;   and   lumbar   disc   disease  
with   radiculopathy.   Dr.   Lopez   noted   that   the   claimant   had   been   through  
various   modalities   of   treatment   and   care   as   she   continued   to   take  
numerous   medications   and   undergo   physical   therapy.   Dr.   Lopez   opined  
that,  due  to  the  claimant’s  multi-­system  organ  affliction,  her  clinical  course  
was   labile   and   guarded   at   best.   Dr.   Lopez   further   concluded   that   the  
claimant   was   disabled   and   incapacitated   with   a   poor   ability   for   functional  
productivity.    

The   undersigned   emphasizes   that   notations   with   Dr.   Lopez   referenced  
treatment  or  laboratory  workup  from  April  2014  through  September  2015,  
with   decreasing   frequency   of   treatment   noted   over   time.   Regarding   the  
claimant’s   migraine   headache[s],   notations   revealed   that   she   was  
prescribed  Esgic-­Plus,  Fioricet,  and  Lorazepam  and,  while  notations  from  
early   June   2014   referenced   daily   right-­sided   headaches,   subsequent  
notations   failed   to   reference   ongoing   issues   with   migraine   headaches.  
According   to   Dr.   Lopez’s   notations,   the   claimant’s   diabetes   mellitus   was  
treated   with   Glucophage,   Glipizide,   and   Invokana   (briefly)   and   was  
considered   to   be   uncontrolled   on   only   two   occasions.   The   claimant   was  
given  an  appointment  for  a  diabetes  education  class,  and  the  undersigned  
notes   that   no   end-­organ   damage   as   a   result   of   diabetes   mellitus   was  
referenced  in  Dr.  Lopez’s  notations.  According  to  notations  with  Dr.  Lopez,  
the   claimant’s   seizure   disorder   was   documented   to   be   controlled   on  
medications.  Further,  Dr.  Lopez’s  notations  referenced  her  assessment  of  
cerebrovascular   accident   vs.   conversion   reaction,   with   examination  
disclosing   mild   weakness   of   the   right   arm   and   leg   in   April   2014   and   mild  
right  hemiparesis  noted  in  April  and  June  2014.  At  a  visit  in  May  2014,  the  
claimant   was   found   to   have   right   upper   extremity   motor   strength   of   1/5  
proximal  and  distal  strength.  The  claimant’s  right  lower  extremity  proximal  
and  distal  strength  was  1/5;;  however,  Dr.  Lopez  also  noted  that  she  was  
able   to   lift   her   right   leg   without   difficulty   during   other   parts   of   testing.  
Although  the  claimant  was  noted  to  ambulate  with  a  walker  at  a  particular  
12

visit,   Dr.   Lopez   described   the   claimant’s   mild   right-­sided   weakness   as  
“subjective”.  

Notations   from   June   4,   2014,   disclosed   that   the   claimant’s   right-­sided  
weakness   was   getting   better.   The   undersigned   finds   that   subsequent  
treatment  notes  from  Dr.  Lopez  failed  to  document  ongoing  complaints  or  
objective  findings  of  weakness  and  that  there  was  no  evidence  of  residual  
left  hemiparesis  documented.  In  other  words,  notations  referenced  various  
inconsistencies   in   strength   testing.   As   previously   set   forth,   notations   of  
record   failed   to   document   the   existence   of   a   medically   determinable  
musculoskeletal   impairment   for   the   claimant.   Physical   examination   was  
primarily  normal,  with  negative  imaging,  and  the  claimant  was  prescribed  
anti-­inflammatory   medications   and   muscle   relaxers   for   symptoms.   While  
Dr.  Lopez  referenced  the  claimant’s  thyroid  condition  in  her  narrative,  her  
treatment  notations  made  a  singular  reference  to  thyroid  symptomatology,  
with  swelling  noted  around  the  thyroid  area.  As  set  forth,  the  undersigned  
finds  that  treatment  notations  of  Dr.  Lopez  have  failed  to  entirely  support  
the  assertions  stated  in  her  narrative.  There  is  little  evidence  to  support  
Dr.   Lopez’   reports   of   multi-­system   organ   affliction,   and   the  
undersigned   specifically   finds   no   indication   from   her   treatment  
notations  that  her  clinical  course  was  labile  and  guarded  at  best.  The  
undersigned   additionally   cannot   ignore   that   subsequent   notations  
regarding   the   claimant’s   extremity   strength   with   USA   Department   of  
Neurology   indicated   that   her   arm   and   leg   were   stable   since   her   original  
episode.  The  claimant’s  gait  was  found  to  be  normal  and  her  strength  was  
observed   to   be   4+/5   in   the   right   upper   and   right   lower   extremities.  
Treatment   notations   of   record   from   August   2015   disclosed   that   the  
claimant   moved   all   extremities   well   and   ambulated   without   difficulty.   The  
undersigned   emphasizes   that   the   objective   treatment   record   failed   to  
document   ongoing   difficulty   with   weakness   and   reduced   strength.   Dr.  
Lopez’s   treatment   notes,   as   well   as   the   remainder   of   the   objective  
record,   failed   to   support   a   conclusion   that   the   claimant   was  
incapacitated  with  a  poor  ability  for  functional  productivity.    

Further,   the   undersigned   emphasizes   that   Social   Security   Rulings   96-­2p  
and   96-­5p   indicate   that   a   physician’s   opinion   on   issues   reserved   to   the  
Commissioner   of   Social   Security   is   never   entitled   to   controlling   weight   or  
special   significance.   Examples   of   opinions   that   may   not   be   given  
controlling   weight   are   opinions   about   what   an   individual’s   residual  
functional   capacity   is   and   whether   an   individual   is   disabled.   Since   Dr.  
Lopez’s   opinion   that   the   claimant   was   disabled   concerns   an   issue  
reserved  to  the  Commissioner,  it  cannot  be  given  controlling  weight.  
Based  on  the  foregoing,  the  undersigned  grants  only  partial  weight  to  Dr.  
Lopez,   accepting   conclusions   to   the   extent   that   such   conclusions   were  
consistent  with  the  residual  functional  capacity  statement  herein.  Although  
her   treatment   notations   arguably   documented   some   degree   of   limitation,  
13

Dr.   Lopez’s   notations   failed   to   support   a   finding   that   the   claimant  
experienced  totally  debilitating  functional  limitations.  

(Id.  (emphasis  supplied)).    
Initially,  the  undersigned  notes  that  the  determination  of  disability  is  reserved  for  
the   Commissioner   and   because   Dr.   Lopez’s   statement   that   Plaintiff   is   “deemed  
disabled”  is  not  a  medical  opinion,  the  ALJ  is  absolutely  correct  that  this  statement  is  not  
entitled   to   be   given   any   weight,   much   less   controlling   weight.   Compare   Kelly   v.  
Commissioner   of   Social   Sec.,   401   Fed.Appx.   403,   407   (11th   Cir.   Oct.   21,   2010)   (“A  
doctor’s  opinion  on  a  dispositive  issue  reserved  for  the  Commissioner,  such  as  whether  
the  claimant  is  ‘disabled’  or  ‘unable  to  work,’  is  not  considered  a  medical  opinion  and  is  
not  given  any  special  significance,  even  if  offered  by  a  treating  source[.]”)  with  Symonds  
v.   Astrue,   448   Fed.Appx.   10,   13   (11th   Cir.   Oct.   31,   2011)   (“[T]he   ultimate   issue   of  
disability  is  left  to  the  determination  of  the  Commissioner;;  and  a  statement  by  a  medical  
source  that  a  claimant  is  ‘disabled’  or  ‘unable  to  work’  is  not  binding  on  the  ALJ.”).9    
In   addition   to   rejecting   Dr.   Lopez’s   opinion   that   Plaintiff   was   “disabled,”   the   ALJ  
also  refused  to  accord  controlling  weight  to  Dr.  Lopez’s  statement  that  Plaintiff’s  “clinical  
course   is   labile   &   guarded   at   best”   (see   Tr.   426)   and   her   conclusion   that   Anderson   is  
“incapacitated,   w/poor   ability   for   functional   productivity[]”   (id.),   finding   the   statement  
inconsistent   with   the   treating   physician’s   own   clinical   records   (Tr.   31)   and   her  
conclusion   inconsistent   with   both   her   own   clinical   records   and   the   remaining   objective  

9

Plaintiff   makes   no   argument   to   the   contrary   in   her   brief   (see   Doc.   9,   at   5   (only  
making  mention  of  Dr.  Lopez’s  statement  that  Plaintiff’s  clinical  course  is  labile  and  guarded  at  
best,   due   to   her   multi-­system   organ   affliction   and   to   the   treating   physician’s   conclusion   that  
Plaintiff  has  poor  ability  for  functional  productivity)),  nor  did  Plaintiff’s  counsel  make  a  contrary  
argument  during  the  hearing  on  May  9,  2018.  

14

treatment  evidence  of  record  (see  id.).  The  Court  concludes  that  the  foregoing  reasons  
articulated   by   the   ALJ   are   valid   reasons   for   failing   to   give   Dr.   Lopez’s   opinions  
controlling   weight,   compare   Gilabert,   supra,   396   Fed.Appx.   at   655   (recognizing   that  
good   cause   for   rejecting   a   treating   physician’s   opinion   include   that   the   opinion   is  
inconsistent  with  the  doctor’s  own  medical  records  and  that  the  opinion  is  not  bolstered  
by   the   evidence)   with   Jones   v.   Colvin,   2013   WL   1909485,   *3   (N.D.   Ala.   May   6,   2013)  
(recognizing  as  a  valid  reason  for  failing  to  give  a  treating  physician’s  opinion  controlling  
weight   the   fact   that   the   opinion   is   inconsistent   with   the   treating   physician’s   own  
treatment   records),   and   are   reasons   that   are   supported   by   the   record.   Indeed,   as  
articulated   by   the   ALJ   (see   Tr.   31),   Dr.   Lopez’s   own   treatment   records   reflect   that  
though,   at   times,   Anderson’s   diabetes   mellitus   was   uncontrolled   it   was   otherwise  
without   complication   (compare   Tr.   373   with   Tr.   380);;   any   thyroid   concerns   were  
exhibited  only  once  and  presented  no  long-­term  issues  (see  Tr.  392;;  compare  id.  with  
Tr.   373-­90   (no   additional   mention   of   thyroid   problems));;   her   vascular/migraine  
headaches   were   present   but   there   is   no   indication   that   they   were   either   constant   or  
debilitating   (see,   e.g.,   Tr.   238-­39,   317-­24,   &   373-­403);;   her   history   of   transient  
cerebrovascular   episodes   with   residual   left   hemiparesis   was   just   that,   a   past   history,  
with   evidence   of   only   mild   right-­sided   weakness   (see   Tr.   238,   317,   320-­23,   380,   384,  
386,  389  &  396);;  her  seizure  disorder  was  under  control  before  Dr.  Lopez  penned  her  
November  20,  2015  letter  (see,  e.g.,  Tr.  380;;  compare  id.  with  Tr.  426);;  and  though  Dr.  
Lopez   referenced   lumbar   disc   disease   with   radiculopathy   in   her   November   20,   2015  
letter,   and   her   office   notes   do   reference   back   and   hip   pain   (Tr.   373,   384,   386,   396   &  
401),  those  same  office  notes  also  consistently  reference  that  Anderson  was  in  no  acute  

15

distress   on   examination   and/or   that   her   x-­rays   were   negative   (see   Tr.   373   (noting  
negative  x-­rays);;  Tr.  380,  384,  386,  389  &  396  (noting  no  acute  distress)).  Based  on  the  
foregoing  evidence,  therefore,  the  Court  finds  that  the  ALJ  did  not  reversibly  err  in  failing  
to   accord   controlling   weight   to   Dr.   Lopez’s   statement   that   Plaintiff’s   “clinical   course   is  
labile  &  guarded  at  best.”10    
Additionally,  the  evidence  just  set  forth  from  the  records  of  Dr.  Lopez,  along  with  
evidence  from  June  of  2014  indicating  a  normal  gait  and  station  and  4+/5  strength  in  the  
right   upper   and   lower   extremity   (Tr.   327),   normal   testing   of   the   brain/head   and  
extremities  from  April  of  2014  through  August  of  2015  (see,  e.g.,  Tr.  273  (normal  EEG  
awake   and   asleep   on   April   7,   2014);;   Tr.   274   (normal   nerve   conduction   study   of   both  
lower  extremities  on  April  7,  2014);;  Tr.  298  (normal  MRI  of  the  brain);;  Tr.  350  (normal  
unenhanced  MR  of  the  brain  on  July  24,  2015);;  Tr.  371  (normal  unenhanced  CT  of  the  
head   on   August   28,   2015)),   and   evidence   from   August   of   2015   indicating   that   Plaintiff  
had   no   peripheral   edema,   moved   all   extremities   well   and   ambulated   without   difficulty,  
though  complaining  of  right  big  toe  pain  (Tr.  363-­366),  certainly  constitutes  substantial  
evidence  supporting  the  ALJ’s  decision  to  not  accord  controlling  weight  to  Dr.  Lopez’s  
“conclusion”  that  Anderson,  as  of  November  of  2015,  was  “incapacitated[]  w/poor  ability  
for  functional  productivity.”    
The   Court   therefore   finds   that   good   cause   existed   for   the   ALJ   to   not   accord  
controlling   weight   to   the   various   statements/opinions/conclusions   of   Dr.   Lopez.   See  
10

Interestingly,   no   examination   accompanied   Dr.   Lopez’s   November   20,   2015  
opinion   letter   (see   Tr.   426)   and,   indeed,   the   closest   examination   to   that   letter   occurred   on  
September   22,   2015,   almost   two   months   earlier,   an   examination   that   reflects   uncontrolled  
diabetes   mellitus   but   otherwise   does   not   contain   clinical   findings   suggestive   of   an   individual  
encumbered  by  disabling  limitations  (see  Tr.  373-­74).  

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Hunter  v.  Social  Sec.  Admin.,  Commissioner,  808  F.3d  818,  823  (11th  Cir.  2015)  (“We  
will   not   second   guess   the   ALJ   about   the   weight   the   treating   physician’s   opinion  
deserves  so  long  as  he  articulates  a  specific  justification  for  it.”),  cert.  denied,    136  S.Ct.  
2487,  195  L.Ed.2d  823  (2016).    
Given  that  Anderson’s  assignments  of  error  are  properly  overruled  and  Plaintiff  
does  not  otherwise  directly  challenge  the  ALJ’s  residual  functional  capacity  assessment  
or  the  VE’s  identification  of  light  jobs  an  individual  with  such  residual  functional  capacity  
can  perform  (compare  Doc.  9  with  Tr.  29,  37  &  60-­61),  the  Commissioner’s  fifth-­step  
determination  is  due  to  be  affirmed.  See,  e.g.,  Owens  v.  Commissioner  of  Social  
Security,  508  Fed.Appx.  881,  883  (11th  Cir.  Jan.  28,  2013)  (“The  final  step  asks  
whether  there  are  significant  numbers  of  jobs  in  the  national  economy  that  the  claimant  
can  perform,  given  h[er]  RFC,  age,  education,  and  work  experience.  The  Commissioner  
bears  the  burden  at  step  five  to  show  the  existence  of  such  jobs  .  .  .  [and  one]  avenue[]  
by  which  the  ALJ  may  determine  [that]  a  claimant  has  the  ability  to  adjust  to  other  work  
in  the  national  economy  .  .  .  [is]  by  the  use  of  a  VE[.]”(internal  citations  omitted));;  Land  
v.  Commissioner  of  Social  Security,  494  Fed.Appx.  47,  50  (11th  Cir.  Oct.  26,  2012)  (“At  
step  five  .  .  .  ‘the  burden  shifts  to  the  Commissioner  to  show  the  existence  of  other  jobs  
in  the  national  economy  which,  given  the  claimant’s  impairments,  the  claimant  can  
perform.’  The  ALJ  may  rely  solely  on  the  testimony  of  a  VE  to  meet  this  burden.”  
(internal  citations  omitted)).  In  short,  substantial  evidence  supports  the  ALJ’s  
determination  that  Anderson  was  not  disabled.    
CONCLUSION  
It  is  ORDERED  that  the  decision  of  the  Commissioner  of  Social  Security  denying    

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Plaintiff  benefits  be  affirmed.  
DONE  and  ORDERED  this  the  15th  day  of  May,  2018.  

s/P.  BRADLEY  MURRAY    

UNITED  STATES  MAGISTRATE  JUDGE  

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