Williams v. Colvin

Filing 24

Order re: 1 Complaint filed by Tamika Williams stating that the decision of the Commissioner of Social Security denying Plaintiffs claim for supplemental security income be AFFIRMED. Signed by Magistrate Judge Sonja F. Bivins on 9/23/2016. Copies to parties. (mpp)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
TAMIKA WILLIAMS,

*
*
*
*
*
*
*
*
*
*
*

Plaintiff,
vs.
CAROLYN W. COLVIN,
Commissioner of Social
Security,
Defendant.

CIVIL ACTION NO. 15-00130-B

ORDER
Plaintiff Tamika Williams (hereinafter “Plaintiff”) seeks
judicial
Social

review

of

Security

a

final

denying

her

decision
claim

of

for

the

Commissioner

supplemental

of

security

income under Title XVI of the Social Security Act, 42 U.S.C. §§
1381, et seq.

On June 8, 2016, the parties consented to have

the undersigned conduct any and all proceedings in this case.
(Doc. 21).
conduct

Thus, the action was referred to the undersigned to

all

proceedings

and

order

the

entry

of

judgment

in

accordance with 28 U.S.C. § 636(c) and Federal Rule of Civil
Procedure 73.

Upon careful consideration of the administrative

record and the memoranda of the parties, it is hereby ORDERED
that the decision of the Commissioner be AFFIRMED.
I.

Procedural History
Plaintiff filed her application for benefits on March 1,

2012.

(Tr. 154).

Plaintiff alleged that she has been disabled

since February 2012,1 due to diabetes, chronic back pain, bulging
disc, pinched nerve, panic attacks, and depression.

(Id. at 43,

176).
Plaintiff’s application was denied and upon timely request,
she was granted an administrative hearing before Administrative
Law Judge Bruce MacKenzie (hereinafter “ALJ”) on August 5, 2013.
(Id. at 40).

Plaintiff attended the hearing with her counsel

and provided testimony related to her claims.
vocational

expert

(“VE”)

provided testimony.

also

appeared

(Id. at 66).

at

(Id. at 45).
the

hearing

A
and

On September 26, 2013, the

ALJ issued an unfavorable decision finding that Plaintiff is not
disabled.
request

(Id. at 18).
for

review

The Appeals Council denied Plaintiff’s

on

January

16,

2015.

(Id.

at

1-2).

Therefore, the ALJ’s decision dated September 26, 2013, became
the final decision of the Commissioner.
Having

exhausted

her

administrative

timely filed the present civil action.

remedies,

(Doc. 1).

Plaintiff

The parties

waived oral argument on June 8, 2016 (Doc. 20), and agree that
this case is now ripe for judicial review and is properly before
this Court pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
II.

Issues on Appeal
1. Whether the ALJ erred in rejecting the

1

Plaintiff amended her onset
February 20, 2012. (Tr. 43).

date

2

from

January

1,

2009,

to

opinions
of
Plaintiff’s
treating
physician, Dr. Judy C. Travis, M.D.?
2.

Whether the ALJ erred in evaluating
Plaintiff’s complaints of pain?

III. Factual Background
Plaintiff was born on January 2, 1979, and was thirty-four
years of age at the time of her administrative hearing on August
5, 2013.

(Tr. 40, 173).

exam

lacked

but

diploma.

one

Plaintiff passed her high school exit

class

credit

(Id. at 47, 177).

and

did

not

receive

her

Plaintiff’s past work includes

working as a babysitter in 2009, working as a packer at a fish
plant from 2005 to 2008, and working as a packer in a poultry
processing

plan

from

1998

to

2001.

(Id.

at

48-49,

177).

Plaintiff stopped working in 2008 (except for babysitting) to
take care of her children.

(Id. at 177, 240, 251).

At her hearing on August 5, 2013, Plaintiff testified that
she can no longer work because of depression and diabetes.
at 49).
other

(Id.

She testified that she takes insulin shots, as well as

medication

depression.

for

(Id.

her
at

diabetes,

50).

high

According

medication helps, but it makes her dizzy.

blood
to

pressure,

and

Plaintiff,

the

(Id.).

She also has

back pain but has not had any physical therapy or surgery to
treat her condition.

(Id. at 51).

3

She has received steroid

shots for her back, but they did not help. 2

(Id. at 51).

She

sometimes wears a back brace that she bought over the counter,
and it helps.
relief.

(Id. at 51).

Pain medications provide temporary

(Id. at 54).

With respect to her depression, Plaintiff takes medication
and goes to therapy every other month.

(Id. at 52).

Plaintiff

testified that she has crying spells every other day and panic
attacks every day, as well as insomnia and occasional thoughts
of

harming

herself.

(Id.

at

64).

She

has

had

no

hospitalizations related to depression or any medical condition.
(Id.

at

51-52).

Plaintiff

testified

problems that prevent her from working.

to

no

other

medical

(Id.).

Plaintiff testified that she lives alone in an apartment
with her two children, ages ten and eleven.

(Id. at 46).

Her

sister does all of her cooking, laundry, and grocery shopping,
and her sister and children do all of the housework.
59).

(Id. at

She does not get out of the house, does not go anywhere,

and does not visit with anyone except her sister.

(Id.).

She

can drive, but her license is suspended because of a ticket.
(Id. at 47).

2

Plaintiff rated her back pain as a seven or eight on a ten-point
pain scale with medication and a ten without medication.
(Tr.
61-62).
She declined epidural injections for her back pain
because she was afraid of the procedure. (Id. at 61).

4

IV.

Analysis
A.

Standard of Review

In reviewing claims brought under the Act, this Court’s
role

is

a

limited

determining

1)

one.

whether

The
the

Court’s
decision

review
of

the

is

limited

to

Secretary

is

supported by substantial evidence and 2) whether the correct
legal standards were applied.
1520, 1529 (11th Cir. 1990).

3

Martin v. Sullivan, 894 F.2d

A court may not decide the facts

anew, reweigh the evidence, or substitute its judgment for that
of the Commissioner.
Cir.

1986).

The

Sewell v. Bowen, 792 F.2d 1065, 1067 (11th
Commissioner’s

findings

of

fact

affirmed if they are based upon substantial evidence.

must

be

Brown v.

Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v.
Heckler,

703

F.2d

1233,

1239

(11th

Cir.

1983)

(holding

substantial evidence is defined as “more than a scintilla, but
less

than

a

preponderance”

and

consists

of

“such

relevant

evidence as a reasonable person would accept as adequate to
support

a

conclusion.”).

In

determining

whether

substantial

evidence exists, a court 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); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4
3

This Court’s review of the Commissioner’s application of legal
principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th
Cir. 1987).
5

(S.D. Ala. June 14, 1999).
B.

Discussion

An individual who applies for Social Security disability
benefits

must

prove

404.1512, 416.912.

his

or

her

disability.

20

C.F.R.

§§

Disability is defined as the “inability to

engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months.”

42

U.S.C.

§§

404.1505(a),

416.905(a).

provide

five-step

a

423(d)(1)(A);
The

see

Social

sequential

also

20

Security

evaluation

§§

regulations
process

determining if a claimant has proven his disability. 4

4

C.F.R.

for

20 C.F.R.

The claimant must first prove that he or she has not engaged in
substantial gainful activity.
The second step requires the
claimant to prove that he or she has a severe impairment or
combination of impairments. If, at the third step, the claimant
proves that the impairment or combination of impairments meets
or
equals
a
listed
impairment,
then
the
claimant
is
automatically found disabled regardless of age, education, or
work experience.
If the claimant cannot prevail at the third
step, he or she must proceed to the fourth step where the
claimant must prove an inability to perform their past relevant
work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In
evaluating whether the claimant has met this burden, the
examiner must consider the following four factors: (1) objective
medical facts and clinical findings; (2) diagnoses of examining
physicians; (3) evidence of pain; and (4) the claimant’s age,
education and work history.
Id.
Once a claimant meets this
burden, it becomes the Commissioner’s burden to prove at the
fifth step that the claimant is capable of engaging in another
kind
of
substantial
gainful
employment
which
exists
in
significant
numbers
in
the
national
economy,
given
the
6

§§ 404.1520, 416.920.
In the case sub judice, the ALJ determined that Plaintiff
has not engaged in substantial gainful activity since February
20, 2012, her application date, and that she has the severe
impairments of obesity, diabetes mellitus Type II, degenerative
disc disease of the lumbar spine, asymmetric right sided disc
bulge at L4-L5 without canal stenosis, adjustment disorder with
disturbance of mood, panic disorder with agoraphobia, depressive
disorder
features. 5

not

otherwise

(Tr. 20).

specified,

and

Cluster

B

personality

The ALJ further found that Plaintiff does

not have an impairment or combination of impairments that meets
or medically equals any of the listed impairments contained in
20 C.F.R. Part 404, Subpart P, Appendix 1.6
The

ALJ

concluded

that

Plaintiff

(Id. at 21).
retains

the

residual

functional capacity (hereinafter “RFC”) to perform a range of
claimant’s residual functional capacity, age, education, and
work history.
Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir.
1985). If the Commissioner can demonstrate that there are such
jobs the claimant can perform, the claimant must prove inability
to perform those jobs in order to be found disabled. Jones v.
Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v.
Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.
Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).
5

The ALJ found Plaintiff’s hypertension to be non-severe.
21).

6

(Tr.

The ALJ concluded that Plaintiff has only mild restrictions in
activities of daily living, moderate difficulties in social
functioning and concentration, persistence or pace, and no
episodes of decompensation. (Tr. 22).

7

light work, except that “she would require a sit/stand option to
relieve pain and discomfort and she can ambulate short distances
of up to 75 yards.

She could frequently use foot controls and

frequently reach overhead.
ladders or scaffolds.

She could never climb ramps, stairs,

She can frequently balance and crouch but

only occasionally stoop and kneel but never crawl.
never

be

exposed

to

dangerous

machinery,

dangerous

hazardous processes or unprotected heights.
operate

a

exposed

commercial

to

extreme

motor
cold,

vehicle.
extreme

She
heat,

atmospheric conditions and weather.
exposed

to

vibration.

She

should

She could
tools,

She could never
can

be

frequently

wetness,

humidity,

She can be occasionally
never

be

exposed

to

concentrated dust, fumes, gases or other pulmonary irritants.
She can be exposed to moderate noise levels.

She could only

remember short, simple instructions and would be unable to deal
with detailed instructions.

She is able to do simple routine,

repetitive tasks but would be unable to do detailed or complex
tasks.
She

She would be limited to simple work-related decisions.

would

be

able

to

accept

constructive

non-confrontational

criticism, work in small group settings and be able to accept
changes in the workplace setting if introduced gradually and
infrequently.

She would be unable to work at a production rate

pace but could perform goal-oriented work.

Any time off task by

the claimant could be accommodated by normal breaks.”

8

(Id. at

23).
The ALJ also determined that while Plaintiff’s medically
determinable impairments could reasonably be expected to produce
the alleged symptoms, her statements concerning the intensity,
persistence and limiting effects of the alleged symptoms were
only

partially

decision.

credible

(Id. at 26).

for

the

reasons

explained

in

the

The ALJ found that Plaintiff is unable

to perform any of her past relevant work as a packer (unskilled,
medium), hand fish filleter (unskilled, medium), and baby sitter
(semi-skilled, medium).
testimony

of

a

VE,

(Id. at 35).
the

ALJ

However, utilizing the

concluded

that

considering

Plaintiff’s residual functional capacity for a range of light
work, as well as her age, education and work experience, there
are jobs existing in the national economy that Plaintiff is able
to perform, such as a “garment folder,” “office helper,” and
“mail clerk/sorter,” all of which are classified as unskilled
and light.

(Id. at 36).

is not disabled.
The

Court

Thus, the ALJ concluded that Plaintiff

(Id.).
now

considers

the

foregoing

in

light

record in this case and the issues on appeal.
1.

Issue

A. Whether the ALJ erred in rejecting the
opinions
of
Plaintiff’s
treating
physician, Dr. Judy C. Travis, M.D.?

9

of

the

In

this

case,

Plaintiff

argues

that

the

ALJ

erred

in

rejecting the opinions of her treating physician, Dr. Judy C.
Travis, M.D., set forth in a Medical Source Statement Physical
(MSS)

form

and

a

Clinical

completed on July 17, 2013.

Assessment

of

Pain

(Doc. 13 at 4-5).

(CAP)

form

In the forms,

Dr. Travis opined that, because of Plaintiff’s diabetes, lumbar
disk disease, and anxiety, she has the following limitations:
she can sit for only four hours in an eight-hour work day; she
can stand/walk for less than one hour in an eight-hour work day;
she can lift only five pounds frequently; she would miss work
more than three times in a month; her pain is present to such an
extent as to be distracting to the adequate performance of daily
activities; physical activity would greatly increase her pain to
such

a

degree

as

abandonment

of

significant

side

to

cause

task;

distraction

prescribed

effects

that

may

from

task

medications
limit

her

or

could

total
cause

performance

of

everyday tasks; and her pain is so severe as to prevent her from
maintaining concentration, persistence, or pace for periods of
at least two hours.

(Id. at 5; Tr. 330-31).

The Commissioner counters that the medical evidence does
not support Dr. Travis’ opinions set forth in the MSS and CAP
forms.
are

The Commissioner also contends that Dr. Travis’ opinions

inconsistent

thus, they

with

the

substantial

evidence

were properly discredited by the ALJ.

10

in

the

case;

(Doc. 18 at

3-6).

The

Commissioner

further

argues

that

the

ALJ’s

RFC

assessment is supported by the substantial evidence in the case.
(Id. at 3).

Having carefully reviewed the record in this case,

the Court finds that Plaintiff’s claim is without merit.
As part of the disability determination process, the ALJ is
tasked

with

examining,

weighing
and

the

opinions

non-examining

and

findings

physicians.

of

In

treating,

reaching

a

decision, the ALJ must specify the weight given to different
medical opinions and the reasons for doing so.

See Winschel v.

Commissioner of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011).
The failure to do so is reversible error.

See Williams v.

Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1
(M.D. Fla. 2009).
When
ALJ

weighing

the

opinion

of

a

treating

physician,

the

must give the opinions “substantial weight,” unless good

cause exists for not doing so.

Costigan v. Commissioner, Soc.

Sec. Admin., 2015 U.S. App. LEXIS 2827, *10, 2015 WL 795089, *4
(11th Cir. Feb. 26, 2015) (citing Crawford v. Commissioner of
Soc. Sec., 363 F.3d 1155, 1160 (11th Cir. 2004) and Broughton v.
Heckler, 776 F.2d 960, 962 (11th Cir. 1985)).

The opinion of “a

one-time examining physician — or psychologist,” on the other
hand,

is

physician.

not

entitled

to

the

same

deference

as

a

treating

Petty v. Astrue, 2010 U.S. Dist. LEXIS 24516, *50,

2010 WL 989605, *14 (N.D. Fla. Feb. 18, 2010) (citing Crawford,

11

363 F.3d at 1160).

An ALJ is also “required to consider the

opinions of non-examining state agency medical and psychological
consultants because they ‘are highly qualified physicians and
psychologists who are also experts in Social Security disability
evaluation.’”
(11th

Milner v. Barnhart,

Cir.

2008)

404.1527(f)(2)(i)).
examining

(unpublished)
“The

sources

when

examining sources.”

275 Fed. Appx. 947, 948

ALJ

they

may
do

(citing
rely

not

on

20

C.F.R.

opinions

conflict

with

of

§
non-

those

of

Id. (citing Edwards v. Sullivan, 937 F.2d

580, 584-85 (11th Cir. 1991)).
Whether considering the opinions of treating, examining, or
non-examining

physicians,

testimony

any

of

good

medical

cause

source

exists

when

it

to

is

discredit

contrary

to

the
or

unsupported by the evidence of record.

Phillips v. Barnhart,

357 F.3d 1232, 1240 (11th Cir. 2004).

“Good cause may also

exist

where

a

doctor’s

opinions

are

merely

conclusory,

inconsistent with the doctor’s medical records, or unsupported
by objective medical evidence.”

Hogan v. Astrue, 2012 U.S.

Dist. LEXIS 108512, *8, 2012 WL 3155570, *3 (M.D. Ala. 2012).
The ALJ is “free to reject the opinion of any physician when the
evidence supports a contrary conclusion.”
764

F.2d

834,

835

(11th

Cir.

1985)

(per

Sryock v. Heckler,
curiam)

(citation

omitted); Adamo v. Commissioner of Soc. Sec., 365 Fed. Appx.
209,

212

(11th

Cir.

2010)

(The

12

ALJ

may

reject

any

medical

opinion if the evidence supports a contrary finding.).
In

support

of

her

argument

that

the

ALJ

erred

in

discrediting 7 Dr. Travis’ opinions that her limitations from her
diabetes, lumbar disk disease, and anxiety preclude her from
working, Plaintiff points to the following evidence which she
alleges establishes her disability:
(1) From 2000 to 2013, Plaintiff was treated by Dr. Edgar
Brown, M.D., for back and neck pain and diabetes, for which Dr.
Brown prescribed medications and administered injections.

Dr.

Brown also ordered an MRI in 2011 that showed a right-sided disk
bulge at L4-5.
Dr.

Wesley

Dr. Brown referred Plaintiff to a specialist,

Spruill,

M.D.,

at

Plaintiff saw on March 15, 2012.

the

Spine

Care

Center,

who

(Doc. 13 at 1-2, Tr. 220-37,

234-35, 247-49, 256, 272-312, 345-57);
(2) In 2010, Plaintiff was treated on one occasion by Dr.
Bruce Taylor, M.D., for pain, paresthesia, and radiculopathy in
her back, neck, and shoulder.

Dr. Taylor gave Plaintiff a Depo-

Medrol injection and prescribed Flexeril and Ultram.
did not return for further treatment.

Plaintiff

(Doc. 13 at 2; Tr. 214-

18);
(3) On February 2, 2012, Plaintiff was

7

examined at the

The record shows that the ALJ assigned “some weight” to portions
of Dr. Travis’ opinions contained in her treatment records but
not to those expressed in the MSS and CAP forms. (Tr. 34).

13

request of the Agency by consultative physician, Dr. Stephen J.
Robidoux, M.D., who diagnosed “diabetes type two NOT on insulin”
and opined that Plaintiff had a
age.”

“normal examination for her

(Doc. 13 at 2; Tr. 239-242).

Dr. Robidoux’s physical

examination findings showed normal unaided gait, normal heel and
toe walking, able to squat and raise, and normal neuromuscular
findings.

(Tr.

241-42).

hospitalizations,

no

Dr.

surgery,

no

Robidoux

also

physical

noted

therapy,

no
no

chiropractic care, and no epidural blocks for her alleged of
back pain.

(Id. at 242).

radiculopathy

or

any

other

He noted an abnormal MRI “without
positive

physical

normal physical examination for her age.”

findings

(Id.).

and

a

He further

noted that Plaintiff was taking only a low dose of NSAIDs for
pain.

(Id.).

Dr. Robidoux assessed no functional limitations

whatsoever, concluding that Plaintiff had “NO limitations for
her

age

to

any

walking,

lifting,

kneeling,

crawling,

activities

including,

carrying,

climbing,

using

hand

and

foot

sitting,
squatting,
controls,

standing,
bending,
handling

objects, speaking, listening or travel” (id.);
(4) On March 15, 2012, Plaintiff saw Dr. Wesley L. Spruill,
M.D., at the Spine Care Center.
Dr.

Spruill’s

physical

(Doc. 13 at 2; Tr. 256-61).

examination

findings

showed

increased

pain with flexion at 60 degrees and tenderness to palpation in
the mid lumbosacral region. Dr. Spruill found no numbness or

14

weakness in Plaintiff’s legs, but tingling in both legs, which
Plaintiff
257).

reported

was

alleviated

with

medication.

(Id.

at

Plaintiff’s lumber exam was largely “normal,” with the

exception of “tenderness” in the mid lumbosacral region, with no
pain in the cervical or thoracic regions, the sacroiliac joint,
or bilateral facets.

(Id. at 260).

She had no swelling or

atrophy in the upper or lower extremities.

(Id.).

She had

normal range of motion, strength, and sensation in the upper
extremities bilaterally.

(Id.).

She had 4/5 grasp strength in

both hands and 4/5 muscle strength in both legs.
had normal patellar reflex in both knees.
pain in her hips during range of motion.

(Id.).

(Id.).

She

She had no

(Id. at 261).

She had

a positive straight leg raise in the right leg at sixty degrees.
(Id.).

She described her sleep as “fair,” reporting that she

averages seven hours of sleep each night.
was

alert

and

nervousness,
diagnosed

or

oriented
mood

Plaintiff

and

denied

swings.
with

(Id. at 257).
anxiety,

(Id.
back

low

at

259).

pain,

depression,
Dr.

L4-5

Spruill

herniation,

persistent pain, and failure of conservative treatment.
261).

She

(Id. at

He recommended an epidural steroid injection and physical

therapy, both of which Plaintiff declined.

(Id.).

Plaintiff

never returned for further treatment;
(5)

On

April

25,

2012,

Plaintiff

was

examined

at

the

request of the Agency by consultative psychologist, Dr. Nina E.

15

Tocci,

Ph.D.,

findings

whose

revealed

comprehensive

“appropriate,

mental

normal,

status

and

examination

stable”

mood

and

affect and thought content; oriented to time, place, person, and
situation;

“fair”

judgment;

some

attention

insight;

and

and

concentration;

ability

to

fair

abstract

social
intact.

However, Plaintiff was not able to calculate change or perform
multiplication

problems

and

could

not

perform

serial

threes

backward or serial fours forward; she could not name five famous
people; and she could not spell “world” or “earth” backward.
She

was

able

president.

to

identify

the

current

and

immediate

past

She demonstrated a “good” fund of information and

comprehension.

Dr. Tocci opined that Plaintiff was functioning

in the low average range of intellectual ability and diagnosed
her with Adjustment Disorder with Disturbance of Mood, finding
that her prognosis was guarded.
was

in

no

distress

and

opined

Dr. Tocci found that Plaintiff
that

obtaining her GED and job training.8

she

would

benefit

from

(Doc. 13 at 3; Tr. 251-53);

(6) From August 1, 2012, to October 22, 2013, Plaintiff saw
a psychiatrist, Dr. Timothy Baltz, M.D., at Cahaba Mental Health
Center, who diagnosed her with Panic Disorder with Agoraphobia,
Depressive Disorder, and Cluster B Personality features.
at

327).

Plaintiff

reported

8

multiple

daily

panic

(Id.

attacks

Plaintiff reported to Dr. Tocci that the reason that she stopped
working was because of child care issues. (Tr. 251).

16

lasting about three minutes, suicidal thoughts with no attempts,
and a reluctance to be around people.

(Id. at 264-65, 327).

Dr. Baltz prescribed medication and counseling.

(Id.).

At no

time did Dr. Baltz assign any functional limitations as a result
of Plaintiff’s mental condition.

(Doc. 13 at 3; Tr. 264-68,

326-28, 360-61); and
(7) On three occasions from May 13, 2012, to July 17, 2013,
Plaintiff saw physician, Dr. Judy C. Travis, M.D., who diagnosed
her with diabetes, anxiety, hypertension, displaced lumbar disk,
and joint pain and treated her with medications.
Tr. 330-43).
Travis

(Doc. 13 at 4;

On Plaintiff’s first visit on May 13, 2013, Dr.

completed

a

physical

examination

and

found

a

“symmetrical” musculoskeletal system with “no deformities,” “no
swelling,” “good muscle mass bilaterally,” “full range of motion
of

all

joints,”

atrophy.”
262.

“all

muscles

(Id. at 341).

(Id.).

well,”

and

“no

Plaintiff’s blood glucose level was

Plaintiff

medication follow up.

functioning

returned

(Id. at 338).

on

May

28,

2013,

for

a

On her third visit on July

17, 2013, Dr. Travis completed MSS and CAP forms, opining that
Plaintiff’s

uncontrolled

diabetes,

lumbar

disk

anxiety prevent her from working.

(Id. at 330-31).

physical

that

disease,

examination

findings

on

date

were

and

Dr. Travis’
unremarkable

except for notations that Plaintiff had “pain in arms and legs,”
“decreased

movement

of

upper

body

17

due

to

muscle

pain”

and

“tender[ness]” in her neck. (Id. at 334-35).
Contrary

to

Plaintiff’s

argument,

the

evidence

detailed

above does not support Dr. Travis’ opinions set forth in the MSS
and

CAP

forms

disabling

that

Plaintiff

diabetes,

Plaintiff’s

evidence

lumbar
shows

is

unable

disk
nothing

to

work

disease,
more

than

because

and

of

anxiety.

conservative

treatment of her conditions with medication, with no physical
therapy, no epidural injections, no chiropractic care, and no
surgeries for her back, as well as no hospitalizations 9 related
to any of her medical conditions.
With respect to Plaintiff’s back,
right-sided
treatment

disk

with

bulge

epidural

at

L4-5;

steroid

her 2011 MRI

yet,

injections

Plaintiff
or

even

shows a
declined
physical

therapy, choosing only conservative treatment with medication.
(Id. at 261).

Curiously, Dr. Travis’ own examination findings

on the date that she completed the MSS and CAP forms reflect
nothing more than “pain in arms and legs,” “decreased movement
of upper body due to muscle pain” and “tender[ness]” in her
neck.

(Id. at 334-35).

Even more curious, on May 13, 2013, Dr.

9

The record reveals one emergency room visit on March 2, 2013, in
which Plaintiff complained of back pain, which she rated as a
nine on a ten-point pain scale.
(Tr. 314).
Upon examination,
the emergency room physician noted that she was in “no acute
distress,” and his findings related to her neck, back, and
extremities were completely normal.
(Tr. 316, 318).
She was
prescribed
Lortab
and
Bactrim
and
discharged
in
“good”
condition. (Id. at 320).

18

Travis

noted

a

deformities,”

“symmetrical”

“no

swelling,”

musculoskeletal
“good

muscle

system

mass

with

“no

bilaterally,”

“full range of motion of all joints,” “all muscles functioning
well,” and “no atrophy.”

(Id. at 341).

All of these findings

are inconsistent with the severity of the opinions set forth in
the MSS and CAP forms.
In addition to being inconsistent with her own treatment
records, Dr. Travis’ opinions are inconsistent with the opinions
of

one-time

examining

physician,

Dr.

Spruill,

whose

physical

examination findings were largely normal, with the exception of
“tenderness” in the lumbosacral region.
Spruill

further

noted

that

Plaintiff

mood

swings,

or

(Id. at 260).

depression.

anxiety,

denied

any

(Id.

Dr.

nervousness,

at

259).

He

recommended epidural steroid injections and physical therapy,
both of which Plaintiff declined, and he assigned no functional
limitations whatsoever.
Dr.
opinions

Travis’
of

(Id. at 261).

opinions

consultative

are

also

inconsistent

physician,

Dr.

with

Robidoux,

the
whose

examination findings were largely “normal” and who opined that
Plaintiff

had

a

“normal

limitations whatsoever.

examination

for

her

age,”

with

no

(Id. at 239-242).

Dr. Travis’ opinions are inconsistent with the opinions of
consultative psychologist, Dr. Tocci, who diagnosed Plaintiff
with Adjustment Disorder with Disturbance of Mood but opined

19

that she would benefit from obtaining her GED and job training.
(Id. at 251-53).
Dr. Travis’ opinions are inconsistent with the treatment
records

of

Plaintiff

treating
with

psychiatrist,

Panic

Disorder

Dr.

with

Baltz,

who

Agoraphobia,

diagnosed
Depressive

Disorder, and Cluster B Personality features, but treated her
conservatively

with

prescribed

functional limitations.

medications

and

assigned

no

(Id. at 327).

Because Dr. Travis’ opinions in the MSS and CAP forms are
inconsistent with her own

treatment records, as well as

the

remaining substantial evidence in this case detailed above, the
ALJ had good cause to discredit those opinions.

In addition,

the Court finds, based upon the evidence detailed above, that
substantial evidence supports the ALJ’s RFC assessment for a
range of light work, with the stated restrictions.

(Id. at 23).

Accordingly, Plaintiff’s claim must fail.10

10

The Court notes that Plaintiff also submitted additional
records from Dr. Baltz, Dr. Travis, Vaughn Regional Medical
Center, and Bryan Whitfield Memorial Hospital to the Appeals
Council after the date of the ALJ’s decision on September 26,
2013, which the Appeals Council reviewed and found did not
warrant remand.
(Id. at 4-5).
Of particular note in the new
evidence is a lumbar spine bone scan dated January 10, 2014,
which was “normal,” and a lumbar spine MRI dated December 2,
2013, which showed a “dehydrated” disc at L4-5 with a “small”
posterior annular tear associated with a “very small” posterior
protrusion at L5-S1, without spinal stenosis.
(Id. at 394-95,
400).
Although Plaintiff has not alleged any error related to
the Appeals Council’s review of the records, the Court has
nonetheless reviewed the records and finds nothing in the
20

B.

Whether the ALJ erred in evaluating
Plaintiff’s complaints of pain?

Next, Plaintiff argues that the ALJ erred in failing to
properly evaluate her complaints of pain pursuant to SSR 96-7p. 11
records to suggest that Plaintiff’s back pain, diabetes,
anxiety, or any other impairment is disabling. To the contrary,
the Court finds that the additional medical records are
cumulative of the treatment records considered by the ALJ and
reflect nothing more than ongoing treatment of the same medical
conditions considered by the ALJ.
For this reason, they would
not have changed the administrative outcome and, thus, do not
warrant a remand for further consideration of the evidence. See
Ingram v. Commissioner of Soc. Sec. Admin., 496 F.3d 1253, 126162 (11th Cir. 2007) (“[W]hen a claimant properly presents new
evidence to the Appeals Council, a reviewing court must consider
whether that new evidence renders the denial of benefits
erroneous.”); Caulder v. Bowen, 791 F. 2d 872, 877 (llth Cir.
1986) (new evidence is material if it is “relevant and probative
so that there is a reasonable possibility that it would change
the administrative outcome.”).
11

Plaintiff refers to the following language in SSR 96-7p:
Assessment of the credibility of an individual’s
statements about pain or other symptoms and about
the effect the symptoms have on his or her
ability
to
function
must
be
based
on
a
consideration of all of the evidence in the case
record. This includes, but is not limited to:
The medical signs and laboratory findings;
Diagnosis, prognosis, and other medical
opinions provided by treating or examining
physicians
or
psychologists
and
other
medical sources; and
Statements and reports from the individual
and from treating or examining physicians or
psychologists and other persons about the
individual’s medical history, treatment and
response, prior work record and efforts to
work,
daily
activities,
and
other
information
concerning
the
individual’s
21

(Doc.

13

at

Spruill’s

11).

medical

Specifically,
records,

Plaintiff

which

show

argues

“pain

that

with

Dr.

flexion,

tenderness to palpation and reduced strength on examination,”
and

Dr.

Travis’

medical

records,

which

“repeatedly”

show

“decreased movement of the upper body due to muscle spasms,”
constitute “medical signs” which satisfy the pain standard and
establish her disability.

(Id.).

The Commissioner counters that the ALJ reasonably evaluated
all of the evidence of record, including Plaintiff’s subjective
complaints of pain, that the ALJ identified valid reasons for
discounting
ALJ’s

Plaintiff’s

credibility

evidence.

subjective

evaluation

(Doc. 18 at 6).

statements,

is

supported

and
by

that

the

substantial

Having carefully reviewed the record

in this case, the Court finds that Plaintiff’s claim is without
merit.
When
symptoms,

evaluating
the

statements,
persons,

and

ALJ

a

claim

considers

statements
evidence

by
of

based
medical

the
how

on

findings,

treating
the

disabling

pain

subjective

a

physician
(or

other

claimant’s
or

other

subjective

symptoms) affects the claimant’s daily activities and ability to
work.

20 C.F.R. § 416.929(a).

In a case where a claimant

symptoms and how the symptoms
individual’s ability to work.

affect

SSR 96-7p, 1996 SSR LEXIS 4, 1996 WL 374186, *5.

22

the

attempts

to

establish

disability

through

his

or

her

own

testimony concerning pain or other subjective symptoms, a threepart standard applies.

That standard requires: “(1) evidence of

an underlying medical condition and either (2) objective medical
evidence that confirms the severity of the alleged pain [or
other subjective symptoms] arising from that condition or (3)
that the objectively determined medical condition is of such a
severity that it can be reasonably expected to give rise to the
alleged

pain

[or

other

subjective

symptoms].”

Hubbard

v.

Commissioner of Soc. Sec., 348 Fed. Appx. 551, 554 (11th Cir.
2009) (unpublished) (quoting Holt v. Sullivan, 921 F.2d 1221,
1223 (11th Cir. 1991)).

The Social Security regulations further

provide:
[S]tatements
about
your
pain
or
other
symptoms will not alone establish that you
are disabled; there must be medical signs
and laboratory findings which show that you
have a medical impairment(s) which could
reasonably be expected to produce the pain
or other symptoms alleged and which, when
considered with all of the other evidence
(including statements about the intensity
and persistence of your pain or other
symptoms which may reasonably be accepted as
consistent
with
the
medical
signs
and
laboratory
findings),
would
lead
to
a
conclusion that you are disabled.
20 C.F.R. 404.1529(a) (2013).
“A

claimant’s

subjective

testimony

supported

by

medical

evidence that satisfies the pain standard is itself sufficient

23

to support a finding of disability.”
1553, 1561 (11th Cir. 1995).

Foote v. Chater, 67 F.3d

Stated differently, “if a claimant

testifies to disabling pain [or other subjective symptoms] and
satisfies

the

disabled

three

unless

part

that

pain

standard,

testimony

is

he

must

properly

be

found

discredited.”

Reliford v. Barnhart, 444 F. Supp. 2d 1182, 1186 (N.D. Ala.
2006).

Therefore, once the determination has been made that a

claimant has satisfied the three-part standard, the ALJ must
then turn to the question of the credibility of the claimant’s
subjective complaints.
(the

three-part

determination

standard

made

credibility.”).

See id., 444 F. Supp. 2d at 1189 n.1
“is

prior

designed

to

considering

be

a

the

threshold
plaintiff’s

If a claimant does not meet the standard, no

credibility determination is required.
In

to

assessing

a

claimant’s

Id.

credibility,

the

ALJ

must

consider all of the claimant’s statements about his symptoms and
determine the extent to which the symptoms can reasonably be
accepted as consistent with the objective medical evidence.

See

20

are

C.F.R.

§

404.1528.

Such

credibility

within the province of the ALJ.
1208, 1212 (11th Cir. 2005).
credit

a

claimant’s

determinations

Moore v. Barnhart, 405 F.3d

However, if an ALJ decides not to

testimony

about

his

or

her

subjective

symptoms, “the ALJ must articulate explicit and adequate reasons
for doing so or the record must be obvious as to the credibility

24

finding.”

Strickland v. Commissioner of Soc. Sec., 516 Fed.

Appx. 829, 832 (11th Cir. 2013) (unpublished) (citing Foote, 67
F.3d at 1562); see also Tieniber v. Heckler, 720 F.2d 1251, 1255
(11th Cir. 1983) (although no explicit finding as to credibility
is required, the implication must be obvious to the reviewing
court).

Failure

to

articulate

the

reasons

for

discrediting

testimony related to pain or other subjective symptoms requires,
as a matter of law, that the testimony be accepted as true.
Holt, 921 F.2d at 1223.
The Eleventh Circuit has held that the determination of
whether

objective

medical

impairments

could

reasonably

be

expected to produce the pain or other subjective symptoms is a
factual question to be made by the Secretary and, therefore,
“subject only to limited review in the courts to ensure that the
finding is supported by substantial evidence.”

Hand v. Heckler,

761 F.2d 1545, 1549 (11th Cir. 1985), vacated on other grounds
and reinstated sub nom., Hand v. Bowen, 793 F.2d 275 (11th Cir.
1986).

A reviewing court will not disturb a clearly articulated

credibility finding with substantial supporting evidence in the
record.

See Nye v. Commissioner of Social Sec., 524 Fed. Appx.

538, 543 (11th Cir. 2013) (unpublished).
In

this

case,

assuming

arguendo,

that

Plaintiff

has

satisfied the threshold three-part pain standard, the ALJ found
that Plaintiff’s testimony regarding the intensity, persistence,

25

and limiting effects of her symptoms was “not entirely credible”
based on the inconsistency between her testimony and the other
record evidence.
above,

confirms

symptoms

(Id. at 26).
the

(including

ALJ’s
pain)

The record evidence, detailed

findings
have

been

that

all

treated

of

Plaintiff’s

with

medication

only; that while an MRI has shown that she has a bulging disk at
L4-5, she has declined epidural injections and physical therapy;
that

she

has

never

sought

alternative

treatment,

such

as

chiropractic care, for her back pain; that no medical source has
ever recommended surgery for any of her medical conditions; that
she

has

never

been

hospitalized

as

a

result

of

any

of

her

medical conditions; that, other than Dr. Travis (whose opinion
has been discredited), no treating or examining physician has
ever opined that she is unable to work due to a physical or
mental condition or imposed any functional limitations; and that
Plaintiff herself stated that she stopped working because of
child care issues.
In

addition,

(Id. at 26-35).
the

ALJ

observed

that,

during

Plaintiff’s

administrative hearing, Plaintiff showed “no evidence of pain or
discomfort while testifying at the hearing,” that she “walked in
and out with no apparent gait disturbance,” that she “sat down
and arose without issue,” that she “sat for 45 minutes or more
without any distress evident,” and that she “bent over twice

26

during the hearing to her right to pick papers off the floor and
she did so easily.”

(Id. at 32).

After a careful review of the record, the Court finds that
the

ALJ’s

evidence

credibility

and

that

finding

his

reasons

is

supported

for

by

substantial

discrediting

Plaintiff’s

testimony were sufficiently articulated in the decision.
C.F.R. § 404.1529(c)(2)-(4); (Tr. 26-35).

See 20

As previously noted,

this Court may not decide the facts anew, reweigh the evidence,
or substitute its judgment but must accept the factual findings
of

the

Commissioner

where

they

are

supported

by

evidence and based upon the proper legal standards.

substantial
See Bridges

v. Bowen, 815 F.2d 622, 624 (11th Cir. 1987) (“the findings and
decision

of

substantial

the

Secretary

evidence.”);

are

accord

conclusive
Hand,

if

761

supported

F.2d

at

by

1549.

Accordingly, Plaintiff’s claim must fail.
V.

Conclusion
For

the

reasons

set

forth

herein,

and

upon

careful

consideration of the administrative record and memoranda of the
parties,

it

is

hereby

ORDERED

that

the

decision

of

the

Commissioner of Social Security denying Plaintiff’s claim for
supplemental security income be AFFIRMED.
DONE this 23rd day of September, 2016.
/s/ SONJA F. BIVINS
UNITED STATES MAGISTRATE JUDGE

27