Heywood v. Commissioner of Social Security
Filing
25
OPINION AND ORDER affirming the decision of the Commissioner. The Clerk of Court is directed to enter judgment accordingly, terminate any pending motions and deadlines, and close the case. Signed by Magistrate Judge Mac R. McCoy on 9/6/2018. (brh)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
FORT MYERS DIVISION
BRENDA S. HEYWOOD,
Plaintiff,
v.
Case No: 2:17-cv-316-FtM-MRM
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
/
OPINION AND ORDER
This cause is before the Court on Plaintiff Brenda S. Heywood’s Complaint, filed on June
7, 2017. (Doc. 1). Plaintiff seeks judicial review of the final decision of the Commissioner of
the Social Security Administration (“SSA”) denying her claim for supplemental security income.
The Commissioner filed the Transcript of the proceedings (Doc. 16) (hereinafter referred to as
“Tr.” followed by the appropriate page number), and the parties filed a joint memorandum (Doc.
23), setting forth their respective positions. For the reasons set out herein, the decision of the
Commissioner is AFFIRMED.
I.
Social Security Act Eligibility, Procedural History, the ALJ’s Decision, and
Standard of Review
A.
Eligibility
The law defines disability as the inability to do any substantial gainful activity by reason
of any medically determinable physical or mental impairment that can be expected to result in
death or that has lasted or can be expected to last for a continuous period of not less than twelve
months. 42 U.S.C. §§ 416(i), 423(d)(1)(A); 20 C.F.R. § 416.905. 1 The impairment must be
severe, making the claimant unable to do her previous work, or any other substantial gainful
activity that exists in the national economy. 42 U.S.C. §§ 423(d)(2), 1382c(a)(3)(B); 20 C.F.R.
§§ 416.905-416.911. Plaintiff bears the burden of persuasion through step four, while the burden
shifts to the Commissioner at step five. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
B.
Procedural History
On July 24, 2014, Plaintiff filed an application for supplemental security income with an
alleged onset date of December 30, 2004. (Tr. at 88, 98, 166-69). The application was denied
initially on October 14, 2014, and upon reconsideration on December 5, 2014. (Id. at 96, 109).
A hearing was held before Administrative Law Judge (“ALJ”) William G. Reamon on
September 19, 2016. (Tr. at 37-87). The ALJ issued an unfavorable decision on December 9,
2016. (Tr. at 19-32). The ALJ found Plaintiff not to be under a disability since July 24, 2014,
the date Plaintiff’s application was filed. (Tr. at 32).
On April 18, 2017, the Appeals Council denied Plaintiff’s request for review. (Tr. at 14). Plaintiff filed a Complaint in this Court on June 7, 2017. (Doc. 1). The parties consented to
proceed before a United States Magistrate Judge for all proceedings. (See Doc. 17). This case is
ripe for review.
1
After Plaintiff filed her application and the ALJ issued the decision, certain Social Security
rulings and regulations have been amended, such as the regulations concerning the evaluation of
medical opinions and evaluation of mental impairments. See, e.g., 20 C.F.R. §§ 416.920a,
416.920c, and 416.927 (effective Mar. 27, 2017); SSR 16-3p, 2016 WL 1119029 (Mar. 16,
2016). The Court applies the rules and regulations in effect at the time of the ALJ’s decision
because the regulations do not specify otherwise. See Green v. Soc. Sec. Admin., Comm’r, 695
F. App’x 516, 521 (11th Cir. 2017).
2
C.
Summary of the ALJ’s Decision
An ALJ must follow a five-step sequential evaluation process to determine if a claimant
has proven that she is disabled. Packer v. Comm’r of Soc. Sec., 542 F. App’x 890, 891 (11th Cir.
2013) (citing Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999)). 2 An ALJ must determine
whether the claimant: (1) is performing substantial gainful activity; (2) has a severe impairment;
(3) has a severe impairment that meets or equals an impairment specifically listed in 20 C.F.R.
Part 404, Subpart P, Appendix 1; (4) has the residual functional capacity (“RFC”) to perform her
past relevant work; and (5) can perform other work of the sort found in the national economy.
Phillips v. Barnhart, 357 F.3d 1232, 1237-40 (11th Cir. 2004). The claimant has the burden of
proof through step four and then the burden shifts to the Commissioner at step five. Hines-Sharp
v. Comm’r of Soc. Sec., 511 F. App’x 913, 915 n.2 (11th Cir. 2013).
At step one of the sequential evaluation, the ALJ found that Plaintiff had not engaged in
substantial gainful activity since July 24, 2014, the application date. (Tr. at 24). At step two, the
ALJ found that Plaintiff suffered from the following severe impairments: “lumbar spine
degenerative disc disease (DDD) with facet arthropathy and disc protrusions, cervical spine
spondylosis, osteoarthritis (OA) and degenerative joint disease (DJD) at the right hip, medial
compartment joint space loss at the bilateral knees, and obesity.” (Id.). At step three, the ALJ
determined that Plaintiff did not have an impairment or combination of impairments that meets
or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart
2
Unpublished opinions may be cited as persuasive on a particular point. The Court does not
rely on unpublished opinions as precedent. Citation to unpublished opinions on or after January
1, 2007 is expressly permitted under Rule 31.1, Fed. R. App. P. Unpublished opinions may be
cited as persuasive authority pursuant to the Eleventh Circuit Rules. 11th Cir. R. 36-2.
3
P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and
416.926). (Tr. at 26).
After review of the record, the ALJ determined Plaintiff’s RFC. Specifically, the ALJ
determined that Plaintiff had the RFC to perform “sedentary work” except:
[S]he could occasionally lift and carry up to 20 pounds and frequently up to 10
pounds. She is capable of standing and/or walking for 2 hours in an 8[-]hour
workday and sitting for about 6 hours in an 8[-]hour workday. Occasionally, she
is capable of crouching, crawling, and climbing ramps or stairs. She could
frequently kneel, stoop, and balance. However, she should never climb ladders,
ropes, or scaffolds.
(Id. at 27).
At step four, the ALJ determined that Plaintiff is capable of performing her past relevant
work as a secretary as it is generally performed. (Id. at 31). As a result, the ALJ determined
Plaintiff has not been under a disability since July 24, 2014, the date the application was filed.
(Id. at 32).
D.
Standard of Review
The scope of this Court’s review is limited to determining whether the ALJ applied the
correct legal standard, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988), and whether
the findings are supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390
(1971). The Commissioner’s findings of fact are conclusive if supported by substantial
evidence. 42 U.S.C. § 405(g). Substantial evidence is more than a scintilla—i.e., the evidence
must do more than merely create a suspicion of the existence of a fact, and must include such
relevant evidence as a reasonable person would accept as adequate to support the conclusion.
Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672 F.2d 835,
838 (11th Cir. 1982); Richardson, 402 U.S. at 401).
4
Where the Commissioner’s decision is supported by substantial evidence, the district
court will affirm, even if the reviewer would have reached a contrary result as the finder of fact,
and even if the reviewer finds that “the evidence preponderates against” the Commissioner’s
decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); Barnes v. Sullivan, 932
F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking
into account evidence favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560;
accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (stating that the court must
scrutinize the entire record to determine reasonableness of factual findings).
II.
Analysis
Plaintiff raises four issues on appeal:
1. Whether substantial evidence supports the ALJ’s finding that Plaintiff can
perform her past work as a secretary.
2. Whether substantial evidence supports the ALJ’s evaluation of Plaintiff’s
depressive disorder at step [two] of the sequential evaluation and
subsequent RFC finding.
3. Whether the ALJ provided proper notice to Plaintiff of the issues on
appeal.
4. Whether substantial evidence supports the weight the ALJ gave to the
opinion of treating physician J.R. Collins, M.D.
(Doc. 23 at 16, 25, 34, 36). The Court addresses these issues below, beginning with Plaintiff’s
second issue concerning the ALJ’s evaluation of Plaintiff’s depressive disorder.
A.
Step Two Evaluation
Plaintiff argues there was evidence in the record that Plaintiff suffers from an unspecified
depressive disorder that the ALJ should have found to be severe at step two and should have
accounted for in his RFC finding. (Doc. 23 at 25-29). Specifically, Plaintiff argues treatment
records reflect Plaintiff suffered from anxiety, depression, crying, and anhedonia and a
5
consultative examination by Robert J. Kurzhals, Ph.D., revealed Plaintiff had issues with
memory, concentration, and comprehension. (Id. at 26 (citing Tr. at 286, 296)). Plaintiff argues
these issues are severe because limitations in understanding, remembering, and carrying out
instructions affect her ability to perform basic work activities. (Id. at 26-27). Plaintiff contends
that the ALJ erred: (1) in considering her ability to perform activities of daily living as an
indication of her ability to complete tasks in a more demanding and more stressful work
environment; and (2) in rejecting Dr. Kurzhals’ opinion based on a lack of objective evidence.
(Id. at 27-28).
The Commissioner argues in response that substantial evidence supports the ALJ’s
finding at step two that Plaintiff’s medically determinable impairment of depression was not
severe because the ALJ properly found only mild restrictions using the Commissioner’s “special
technique” for evaluating mental impairments. (Id. at 29-34).
At step two of the sequential evaluation, the ALJ analyzes the severity of a claimant’s
impairments. At this step, “[a]n 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, irrespective of age, education or work experience.” McDaniel v. Bowen, 800
F.2d 1026, 1031 (11th Cir. 1986). A severe impairment must bring about at least more than a
minimal reduction in a claimant’s ability to work and must last continuously for at least twelve
months. See 20 C.F.R. § 416.905(a). This inquiry “acts as a filter” so that insubstantial
impairments will not be given much weight. Jamison v. Bowen, 814 F.2d 585, 588 (11th Cir.
1987). While the standard for severity is low, the severity of an impairment “must be measured
in terms of its effect upon ability to work, and not simply in terms of deviation from purely
6
medical standards of bodily perfection or normality.” McCruter v. Bowen, 791 F.2d 1544,
1547 (11th Cir. 1986).
In the Eleventh Circuit, “[n]othing requires that the ALJ must identify, at step two, all
of the impairments that should be considered severe.” Heatly v. Comm’r of Soc. Sec., 382 F.
App’x 823, 825 (11th Cir. 2010). Rather, the ALJ is required to consider a claimant’s
impairments in combination, whether severe or not. Id.
A severe impairment is an impairment or combination thereof that significantly
limits the claimant’s physical or mental ability to do basic work activities. . . . The
determination of whether the claimant suffers from a severe impairment acts as a
filter. Jamison v. Bowen, 814 F.2d 585, 588 (11th Cir. 1987). Thus, while a claim
is denied if the claimant does not suffer from a severe impairment, the finding of
any severe impairment, regardless of whether it qualifies as a disability or results
from a single impairment or combination thereof, is sufficient to satisfy the second
step of the SSA’s sequential analysis. Id. Nonetheless, beyond the second step, the
ALJ must consider the entirety of the claimant’s limitations, regardless of whether
they are individually disabling.
Griffin v. Comm’r of Soc. Sec., 560 F. App’x 837, 841-42 (11th Cir. 2014). If any impairment
or combination of impairments qualifies as “severe,” step two is satisfied and the claim
advances to step three. Gray v. Comm’r of Soc. Sec., 550 F. App’x 850, 852 (11th Cir. 2013)
(citing Jamison, 814 F.2d at 588).
In this case, the ALJ found at step two that Plaintiff had the severe impairments of DDD
with facet arthropathy and disc protrusions, cervical spine spondylosis, OA and DJD at the right
hip, medial compartment joint space loss at the bilateral knees, and obesity. (Tr. at 24). Thus,
even if the ALJ erred in finding that Plaintiff’s mental impairments were not severe, the ALJ
satisfied the step two analysis by finding other impairments severe. See Griffin, 560 F. App’x at
841-42. Therefore, any error is harmless as long as the ALJ considered Plaintiff’s severe
impairments in combination with Plaintiff’s non-severe impairment – including her alleged
mental impairments. See id.
7
Moreover, a review of the record shows that the ALJ specifically considered Plaintiff’s
mental impairments at step two. (Tr. at 24-25). The ALJ conducted a psychiatric review
technique and found Plaintiff had no more than a mild limitation in the first three functional
areas and no episodes of decomposition in the fourth area. (Id. at 25). 3
The ALJ further considered these findings in evaluating Plaintiff’s RFC. “The residual
functional capacity is an assessment, based upon all of the relevant evidence, of a claimant’s
remaining ability to do work despite his impairments.” Lewis v. Callahan, 125 F.3d 1436, 1440
(11th Cir. 1997). An individual’s RFC is her ability to do physical and mental work activities on
a sustained basis despite limitations secondary to her established impairments. Delker v.
Comm’r of Soc. Sec., 658 F. Supp. 2d 1340, 1364 (M.D. Fla. 2009). In determining a claimant’s
RFC, the ALJ must consider all of the relevant evidence of record. Barrio v. Comm’r of Soc.
Sec., 394 F. App’x 635, 637 (11th Cir. 2010). However, the Eleventh Circuit has consistently
held that “the claimant bears the burden of proving that [she] is disabled, and consequently, [she]
is responsible for producing evidence in support of her claim.” Ellison v. Barnhart, 355 F.3d
1272, 1276 (11th Cir. 2003).
When determining Plaintiff’s RFC, the ALJ stated that he considered all of Plaintiff’s
symptoms and the extent to which these symptoms that can reasonably be accepted as consistent
with the objective medical evidence and other evidence. (Tr. at 27); see Griffin, 560 F. App’x at
842 (citing Jones v. Dep’t of Health & Human Servs., 941 F.2d 1529, 1533 (11th Cir. 1991)
3
Under 20 C.F.R. § 416.920a, an ALJ is required to utilize the “special technique” dictated by a
psychiatric review technique form (“PTRF”) when evaluating mental impairments. Moore v.
Barnhart, 405 F.3d 1208, 1213 (11th Cir. 2005). The technique requires evaluation of four
separate function areas on a four-point scale as to how the impairment affects the claimant:
“activities of daily living; social functioning; concentration, persistence or pace; and episodes of
decomposition.” Id. The ALJ then incorporates the results into his findings and conclusions. Id.
at 1213-14.
8
(noting a simple expression of the ALJ’s consideration of the combination of impairments
constitutes a sufficient statement of such findings). In addition, the ALJ also considered the
medical evidence regarding Plaintiff’s mental impairments, explaining he gave the opinions of
William A. Shipley, Ph.D., and Joelle J. Larsen, Ph.D. great weight in determining Plaintiff’s
mental impairment was non-severe. (Tr. at 30, 92-93, 104). The ALJ discounted Dr. Kurzhals’
opinion that Plaintiff had mild concentration problems and mild depression because his
examination findings did not support his opinions, and he only examined Plaintiff one time. (Id.
at 30 (citing Tr. at 295-97)). A one-time examining physician’s opinion is not entitled to great
weight. Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1160 (11th Cir. 2004). Moreover,
internal inconsistency in a physician’s records is also a sufficient basis to discount his opinions.
See id. at 1159. The Court therefore finds no error with regard to the ALJ’s treatment of Dr.
Kurzhals’ opinion.
Plaintiff cites a treatment note to support a finding that she suffered from depression that
she argues the ALJ ignored; however, the ALJ is not required to cite every piece of evidence.
See Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005). The ALJ in this case did consider
Plaintiff’s mental impairment, but ultimately found it non-severe, particularly in light of her
statements to Dr. Kurzhals that she did not describe herself as depressed and indicated that she
was happy most of the time. (Tr. at 30 (citing Tr. at 295)). The additional treatment note does
not establish the severity of Plaintiff’s mental impairment, and it is Plaintiff’s burden to establish
the effect of her impairments on her ability to work. See Robinson v. Astrue, 365 F. App’x 993,
995 (11th Cir. 2010) (“The mere existence of an impairment does not reveal the extent to which
it limits a claimant’s ability to work, nor does it ‘undermine the ALJ’s determination’ regarding
her ability to work.” (quoting Moore, 405 F.3d at 1213 n.6)). Moreover, the question for the
9
Court is whether substantial evidence supports the ALJ’s decision, not whether there is evidence
in the record to support a different conclusion. See Barnes, 932 F.2d at 1358 (“The court need
not determine whether it would have reached a different result based upon the record.”).
The Court finds that even if the ALJ should have found Plaintiff’s mental impairments
severe, the ALJ fulfilled his responsibility to consider Plaintiff’s mental impairments in the
remaining steps of her disability analysis. See Griffin, 560 F. App’x at 842. Here, the ALJ
considered Plaintiff’s severe and non-severe impairments in combination. Therefore, the Court
finds that even if the ALJ erred in his severity finding, the error was harmless because the ALJ
found other severe impairments and considered all of Plaintiff’s impairments in combination.
In sum, the record demonstrates that the ALJ properly considered Plaintiff’s severe and
non-severe impairments at step two. Moreover, even if the ALJ erred in failing to find Plaintiff’s
impairments severe at step two of the sequential evaluation, the error was harmless because the
ALJ considered all of Plaintiff’s impairments, whether severe or non-severe, in determining
Plaintiff’s RFC. The Court, therefore, affirms on this issue.
B.
The Weight Given to Plaintiff’s Treating Sources
Plaintiff argues that the ALJ erred in giving the opinion of Plaintiff’s treating physician
J.R. Collins, M.D., only mild weight because Dr. Collins gave specific diagnoses and his opinion
was supported by other objective medical evidence, including MRIs, X-rays, and CT scans from
the same time, and opinions of Nina Dereska, M.D., and K. Julian, M.D. (Doc. 23 at 37).
Plaintiff therefore argues the ALJ did not have good cause for rejecting Dr. Collins’ opinion.
(Id. at 37).
The Commissioner responds that the ALJ is responsible for assessing Plaintiff’s RFC and
accordingly medical opinions as to this issue are not determinative. (Id. at 38). The
10
Commissioner notes Dr. Collins had only seen Plaintiff once, on the same day he completed a
Determination of Disability for the State of Indiana form rendering the opinion at issue here. (Id.
at 39 (citing Tr. 309-15)). The Commissioner therefore concludes Dr. Collins was not entitled to
deference as Plaintiff’s treating physician. (Id. at 39 n.7). Moreover, the Commissioner argues
the reasons the ALJ identified to afford Dr. Collins’ opinion mild weight constitute good cause
and were supported by substantial evidence. (Id. at 39-40).
1.
Legal Standard for Weight of Physician’s Opinion
At the fourth step in the evaluation process, the ALJ is required to determine a claimant’s
RFC and, based on that determination, decide whether the plaintiff is able to return to his or her
previous work. McCruter v. Bowen, 791 F.2d 1544, 1547 (11th Cir. 1986). The determination
of a claimant’s RFC is within the authority of the ALJ. Lewis v. Callahan, 125 F.3d 1436, 1440
(11th Cir. 1997). Along with the claimant’s age education, and work experience, the RFC is
considered in determining whether the claimant can work. Id. Weighing the opinions and
findings of treating, examining, and non-examining physicians is an integral part of the ALJ’s
RFC determination at step four. See Rosario v. Comm’r of Soc. Sec., 877 F. Supp. 2d 1254, 1265
(M.D. Fla. 2012).
“The Secretary must specify what weight is given to a treating physician’s opinion and
any reason for giving it no weight, and failure to do so is reversible error.” MacGregor v.
Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986) (citations omitted). The Eleventh Circuit has
held that whenever a physician offers a statement reflecting judgments about the nature and
severity of a claimant’s impairments, including symptoms, diagnosis, and prognosis, what the
claimant can still do despite his or her impairments, and the claimant’s physical and mental
restrictions, the statement is an opinion requiring the ALJ to state with particularity the weight
11
given to it and the reasons therefor. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178-79
(11th Cir. 2011). When evaluating a medical opinion, the ALJ considers various factors,
including: (1) whether the doctor has examined the claimant; (2) the length, nature, and extent
of a treating doctor’s relationship with the claimant; (3) the medical evidence and explanation
supporting the doctor’s opinion; (4) how consistent the doctor’s opinion is with the record as a
whole; and (5) the doctor’s specialization. Denomme v. Comm’r, Soc. Sec. Admin., 518 F.
App’x 875, 877 (11th Cir. 2013) (citing 20 C.F.R. §§ 404.1527(c), 416.927(c)). The ALJ need
not explicitly address these factors. Lawton v. Comm’r of Soc. Sec., 431 F. App’x 830, 833
(11th Cir. 2011).
Without a statement specifying the weight given to medical opinions, “it is impossible
for a reviewing court to determine whether the ultimate decision on the merits of the claim is
rational and supported by substantial evidence.” Winschel, 631 F.3d at 1179 (citing Cowart v.
Shweiker, 662 F.2d 731, 735 (11th Cir. 1981)). The opinions of treating physicians are entitled
to substantial or considerable weight unless good cause is shown to the contrary. Phillips, 357
F.3d at 1240. The Eleventh Circuit has concluded that “‘good cause’ exists 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.” Id.
2.
Dr. Collins’ Opinion
Dr. Collins rendered his opinion by completing State Form 1380. (Tr. at 309-15). On
this form, Dr. Collins responded to how long Plaintiff had been treated by him with “today,
4/27/11.” (Id. at 310). For diagnostic tests and evaluations, Dr. Collins listed a thyroid
ultrasound showing multiple benign-appearing thyroid nodules on April 20, 2011. (Id.). He
12
noted Plaintiff had 13 abdominal surgeries relative to her impairments, listed three medications
she was taking (Celexa 20 mg, Tylenol 500, and ibuprofen), and stated she was compliant with
her medications and treatment. (Id.). After noting her height, weight, and vital signs, Dr. Collins
also noted under the box entitled “abnormalities” that he was told an ultrasound found a mitral
valve prolapse in the past that caused fainting but, at the time of the appointment, Plaintiff had
gone over ten (10) years without fainting. (Id. at 311). Dr. Collins checked “yes” for dyspnea
and edema, but either checked “no” or left the remaining boxes blank. (Id.). As to Plaintiff’s
nervous system, Dr. Collins listed carpel tunnel syndrome and dysthymia. (Id. at 312). As to her
musculo-skeletal system, Dr. Collins opined that her bones, joints, and extremities were not
normal due to bilateral carpal tunnel syndrome, bilateral knee pain, bilateral hand pain, right
shoulder pain, and right hip pain. (Id.). Dr. Collins diagnosed Plaintiff with arthritis, indicated
she had mild osteophytes, and observed her abdomen was diffusely tender. (Id. at 312-13).
Asked to list Plaintiff’s diagnosis and his prognosis, Dr. Collins listed abdomen pain/adhesions
and right hip pain as her prime diagnosis and CTS (carpal tunnel syndrome) and back
pain/scoliosis as her secondary diagnosis. (Id. at 313).
When asked if Plaintiff’s impairments together or individually affect her ability to
perform work, Dr. Collins opined that Plaintiff’s impairments did impair work ability and were
likely to continue for over 30 years. (Id. at 314). He listed: (1) no treatment for abdominal
adhesion; (2) surgery for carpal tunnel syndrome; (3) possible surgery for the right hip; and (4)
checked “yes” for whether the limitations are substantial enough to impair Plaintiff’s ability to
perform labor or services or engage in a useful occupation. (Id.). Dr. Collins then filled in a
chart of Plaintiff’s limitations, opining that she: (1) cannot lift, push/pull, squat, or crawl; (2) is
limited in her ability to bend or climb, or perform housework; (3) is weak and drops items when
13
grasping or manipulating; and (4) is limited on her right side for reaching above her shoulders,
repetitive leg movements for her right leg, and left knee. (Id. at 315). Dr. Collins further opined
that Plaintiff could sit, stand, and drive for 10 to 15 minutes and could walk for 10 minutes.
(Id.). Dr. Collins certified that he examined Plaintiff on April 27, 2011, and listed his specialty
as a “G.P.” (Id.).
The ALJ explained that Dr. Collins’ opinions merited only mild weight, explaining:
First, Dr. Collins provides no explanation of what impairments cause the stated
limitations. He noted only vague descriptions, such as “right hip pain” or bilateral
knee pain” rather than medical diagnoses. Second, Dr. Collins is the claimant’s
primary care provider, not an orthopedic specialist. Finally, this opinion was
rendered prior to the period being adjudicated in the present case. Accordingly,
mild weight is appropriate.
(Id. at 30).
The ALJ therefore provided explicit reasons for discounting Dr. Collins opinion, and the
Court determines that these reasons constitute good cause and substantial evidence supports
them. Although Dr. Collins listed carpal tunnel syndrome and osteoarthritis as diagnoses, Dr.
Collins does not explain how these diagnoses relate to the limitations he found. (See id. at 30915). Moreover, there are no treatment notes in which Dr. Collins makes any other diagnoses or
provides any insight into how he reached his opinions based on a single examination of Plaintiff.
Indeed, a one-time examining physician is not considered a treating physician whose opinion is
entitled to deference. See Crawford, 363 F.3d at 1160. Moreover, the imaging reports Plaintiff
cites do not establish the basis for Dr. Collins’ opinions as they were taken after he completed his
form. (See Doc. 23 at 37 (citing Tr. at 268, 271, 387)).
While the ALJ’s remaining reasons, that the opinion was three (3) years before Plaintiff’s
application and that Dr. Collins is not a specialist, might not be sufficient to discount Dr. Collins’
opinion on their own, when combined with the lack of support for the opinion and the extremely
14
short (consisting of one day) treatment history, they do support a finding of good cause. The
Court therefore affirms on this issue.
C.
Past Relevant Work
Plaintiff argues the ALJ erred in finding that she could perform her past work as a
secretary. (Doc. 23 at 17-20). Specifically, Plaintiff argues that she had not performed the job of
secretary long enough to learn how to do it, given that it was a skilled position and a composite
job. (Id.).
The Commissioner argues Plaintiff has not established that she did not learn the secretary
job in eleven months and has not established that her position was a composite one as she
described her position as a secretary and did not testify to additional duties or dispute the VE’s
testimony classifying the position. (Id. at 20-25).
At step four of the sequential evaluation, the burden lies with Plaintiff to show that she
cannot return to her past relevant work as she actually performed it or as it is performed in the
general economy. Levie v. Comm’r of Soc. Sec., 514 F. App’x 829, 830 (11th Cir. 2013); Battle
v. Astrue, 243 F. App’x 514, 522 (11th Cir. 2007); Waldrop v. Comm’r of Soc. Sec., 379 F.
App’x 948, 953 (11th Cir. 2010). Even though the burden lies with Plaintiff, the ALJ must
consider all of the duties of Plaintiff’s past relevant work and evaluate Plaintiff’s ability to
perform that work despite her impairments. Levie, 514 F. App’x at 830. Past relevant work is
defined as “work that [the claimant has] done within the past 15 years, that was substantial
gainful activity, and that lasted long enough for [the claimant] to learn to do it.” 20 C.F.R. §
404.1560(b)(1). Before determining whether a claimant can perform her past relevant work, the
ALJ first determines the claimant’s RFC. See 20 C.F.R. § 404.1520(a)(4)(iv). Based on the
15
individual RFC, if the claimant is capable of doing the past relevant work, then the ALJ will find
the claimant is not disabled. 20 C.F.R. § 404.1560(b)(2)-(3).
The Court finds no error in the ALJ’s determination that Plaintiff’s work as a secretary
was past relevant work and that she was capable of performing it. The Court rejects Plaintiff’s
argument that the secretary position was not past relevant work because she spent less than a full
year on the job and, therefore, did not work long enough to learn the job. (See Doc. 23 at 17-20).
Although Plaintiff argues the SVP level of 6 for secretary indicates it could take up to two years
to learn, the Specific Vocational Preparation for a job is meant to be “a guideline to help
determine how long it would generally take to learn a particular job.” POMS DI 25005.015(D),
https://secure.ssa.gov/apps10/poms.nsf/lnx/0425005015; see also Bond v. Comm’r of Soc. Sec.,
No. 6:15-cv-333-ORL-GJK, 2016 WL 3906929, at *3 (M.D. Fla. July 19, 2016) (internal
citations omitted) (finding that “each SVP level is the amount of time a ‘typical worker’ needs to
learn the job,” but “does not mandate that every worker needs to perform a particular job for the
period of time associated with that job’s SVP”). Here, Plaintiff offers no argument that she
actually failed to learn how to do the job of secretary. Indeed, other than a technicality based on
her own calculations, Plaintiff provided no proof showing that she did not adequately learn the
job. (See Doc. 23 at 17-20).
Furthermore, this Court has previously rejected arguments that a plaintiff did not learn
how to do the job when the plaintiff failed to raise objections to the VE’s testimony at the
hearing. See Turner v. Comm’r of Soc. Sec., No. 2:13-cv-485-FTM-DNF, 2014 WL 4542975, at
*4 (M.D. Fla. Sept. 12, 2014) (finding that the plaintiff did not meet her burden of proving that
she did not learn how to do the job while performing it, in part, because she did not raise
objections during the VE’s testimony). Here, when the VE testified at the hearing that Plaintiff
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could perform her past relevant work as a secretary, Plaintiff did not raise any argument or
objection that she did not adequately learn the job. (Tr. at 81). As a result, the Court finds that
Plaintiff failed to meet her burden of showing that she did not learn how to do the job of
secretary. See Turner, 2014 WL 4542975, at *4.
In reaching this conclusion, the Court finds Plaintiff’s composite job argument
unpersuasive. As noted above, Plaintiff argues that she cannot do the job of secretary as it is
generally performed because her past relevant work is a composite job. (Doc. 23 at 17-20).
Plaintiff contends that her job required additional duties. (Id. at 20). In essence, what Plaintiff
actually argues is that the job of secretary does not count as past relevant work at all because the
job, as she performed it, required duties of other jobs. (See id.). Based on these other duties,
Plaintiff argues that there is no basis for the ALJ to evaluate the job of secretary as past relevant
work. (See id.).
A composite job is “one that has significant elements of two or more occupations and, as
such, has no counterpart in the DOT.” Paxton v. Colvin, No. 8:12-CV-583-T-TGW, 2013 WL
1909609, at *4 (M.D. Fla. May 8, 2013) (citing SSR 82-61, 1982 WL 31387, at *2 (1982)).
Nevertheless, Plaintiff “bears the burden of proving that [she] cannot return to [her] past relevant
work.” Levie, 514 F. App’x at 831 (citation omitted). Moreover, Plaintiff “must demonstrate an
inability to perform [her] ‘past kind of work, not that [she] merely be unable to perform a
specific job [she] held in the past.’” Id. (emphasis in original; citing Jackson v. Bowen, 801 F.2d
1291, 1293 (11th Cir. 1986)). Additionally, Social Security Ruling 82-61 addresses the agency’s
process in situations where there is a composite job. Specifically, when there is a composite job,
the situation “will be evaluated according to the particular facts of each individual case. For
those instances where available documentation and vocational resource material are not
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sufficient to determine how a particular job is usually performed, it may be necessary to utilize
the services of a vocational specialist or vocational expert.” SSR 82-61, 1982 WL 31387, at *2.
In this case, the ALJ asked a VE to testify as to Plaintiff’s past relevant work. (Tr. at 81).
After having heard Plaintiff’s testimony and reviewing the record, the VE testified that Plaintiff’s
past relevant work included the position of secretary. (Id.). Plaintiff made no objection as to the
VE’s testimony that her past relevant work included the job of secretary. In fact, Plaintiff makes
no argument now that the ALJ erred in relying on the VE’s testimony. Accordingly, based on
the unobjected-to testimony of the VE, the Court finds that the ALJ was not wrong to conclude
that Plaintiff’s past relevant work included the position of secretary.
Furthermore, Plaintiff made no specific argument that she could not perform the job
requirements of a secretary as generally performed. At most, Plaintiff only demonstrated that
she merely cannot perform a specific job she held in the past. See Levie, 514 F. App’x at 831.
Plaintiff has not demonstrated “an inability to perform [her] “past kind of work.” See id.
(emphasis in original; citations omitted). Moreover, the ALJ – relying on the VE’s testimony –
found that Plaintiff could perform the job of secretary as it is generally performed. (Tr. at 31).
Accordingly, although Plaintiff may not have been able to perform her past relevant work as a
secretary as she actually performed it, Plaintiff has not established that she could not perform the
job of a secretary as it is generally performed. Thus, the Court finds that the ALJ did not err in
finding that Plaintiff could perform her past relevant work as a secretary as it is generally
performed. The Court affirms on this issue.
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D.
Notice
Plaintiff argues the ALJ failed to provide her with required notice that he was
reconsidering the previously favorable decision that all of her past work was unskilled. (Doc. 23
at 34 (citing 20 C.F.R §§ 416.968(a), 416.1446)). The Commissioner responds that the state
agency had not determined her past relevant work was unskilled but rather determined that she
was not disabled without addressing her capacity to perform past relevant work. (Id. at 35 (citing
Tr. at 95)).
Under 20 C.F.R. § 416.1446:
The issues before the administrative law judge include all the issues brought out in
the initial, reconsidered or revised determination that were not decided entirely in
[the claimant’s] favor. However, if evidence presented before or during the hearing
causes the administrative law judge to question a fully favorable determination, he
or she will notify [the claimant] and will consider it an issue at the hearing.
20 C.F.R. § 416.1446(a).
The Court agrees with the Commissioner that the issue of Plaintiff’s past relevant work had
not been decided at the agency level and, therefore, was not a decision in Plaintiff’s favor that
the ALJ questioned. The state agency decisions, both initially and on reconsideration, explicitly
stated, “A finding about the capacity for PRW has not been made. However, this information is
not material because all potentially applicable Medical-Vocational Guidelines would direct a
finding of ‘not disabled’ given the individual’s age, education, and RFC. Therefore, the
individual can adjust to other work.” (Tr. at 95, 107). Contrary to Plaintiff’s assertion, this was
not a finding in her favor. (Doc. 23 at 34). Moreover, in the Notice of Hearing, the ALJ
informed Plaintiff that he would follow a step-by-step process to determine whether she was
disabled and listed the steps as including whether Plaintiff could do the kind of work she did in
the past. (Tr. at 147). The Notice also directed Plaintiff to notify the ALJ if she disagreed with
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any of the issues, which the record does not reflect Plaintiff did. (Id. at 148). The Court
therefore affirms on this issue.
III.
Conclusion
Upon consideration of the submissions of the parties and the administrative record, the
Court finds that the decision of the ALJ is supported by substantial evidence and decided upon
proper legal standards. See McRoberts, 841 F.2d at 1080.
Accordingly, the Court hereby ORDERS that:
The decision of the Commissioner is hereby AFFIRMED pursuant to sentence four of
42 U.S.C. §405(g). The Clerk is directed to enter judgment accordingly, terminate any pending
motions and deadlines, and close the case.
DONE AND ORDERED in Fort Myers, Florida on September 6, 2018.
Copies furnished to:
Counsel of Record
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