Foland v. Commissioner of Social Security

Filing 26

MEMORANDUM AND OPINION. The final decision of the Commissioner is REVERSED and REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g). The Clerk is directed to enter judgment for Claimant and against the Commissioner, and close the case. Signed by Magistrate Judge Daniel C. Irick on 11/13/2023. (TNP)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
ORLANDO DIVISION
MELISSA SUE FOLAND
Plaintiff,
v.

Case No: 6:22-cv-2363-DCI

KILOLO KIJAKAZI, ACTING
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

MEMORANDUM AND OPINION
THIS CAUSE is before the Court on Claimant’s appeal of an administrative decision
denying applications for a period of disability, Disability Insurance Benefits (DIB) and
Supplemental Security Income (SSI). In a decision dated May 12, 2022, the Administrative Law
Judge (ALJ) found that Claimant had not been under a disability, as defined in the Social Security
Act, since November 30, 2015, through the date of the decision. R. 12.
Having considered the parties’ memorandums and being otherwise fully advised, the Court
concludes, for the reasons set forth herein, that the Commissioner’s decision is due to be
REVERSED and REMANDED.
I.

Issues on Appeal
Claimant raises one issue on appeal: Whether the mental limitations set forth in the residual

functional capacity are based on an adequate analysis of all medical opinions in the record. Doc.
23 at 19.

II.

Standard of Review

As the Eleventh Circuit has stated:
In Social Security appeals, we must determine whether the Commissioner’s
decision is supported by substantial evidence and based on proper legal standards.
Substantial evidence is more than a scintilla and is such relevant evidence as a
reasonable person would accept as adequate to support a conclusion. We may not
decide the facts anew, reweigh the evidence, or substitute our judgment for that of
the [Commissioner].
Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011) (citations and quotations
omitted). “With respect to the Commissioner’s legal conclusions, however, our review is de
novo.” Lewis v. Barnhart, 285 F.3d 1329, 1330 (11th Cir. 2002).
III.

Discussion
Claimant asserts that the RFC conflicts with the opinions of Dr. Coffman, Dr. MacKay,

and Dr. Gates and that the ALJ did not properly assess those medical opinions. The Court finds
that Claimant’s argument relating to the ALJ’s treatment of Dr. Coffman’s opinion is dispositive
of this case. Thus, there is no need here to address Claimant’s arguments relating to Dr. MacKay
and Dr. Gates. See McClurkin v. Soc. Sec. Admin., 625 F. App’x 960, 963 n.3 (11th Cir. 2015)
(per curiam) (finding no need to analyze other issues when case must be reversed due to other
dispositive errors).
At step four of the sequential evaluation process, the ALJ assesses the claimant’s residual
functional capacity (RFC) and ability to perform past relevant work. Phillips v. Barnhart, 357
F.3d 1232, 1238 (11th Cir. 2004). “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). The ALJ is responsible for determining
the claimant’s RFC. 20 C.F.R. §§ 404.1546(c); 416.946(c). In doing so, the ALJ must consider
all relevant evidence, including, but not limited to, the medical opinions of the treating, examining,

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and non-examining medical sources. 20 C.F.R. §§ 404.1545(a)(1), (3); 416.945(a)(1), (3); see
also Rosario v. Comm’r of Soc. Sec., 877 F. Supp. 2d 1254, 1265 (M.D. Fla. 2012).1 The
consideration of medical source opinions is an integral part of steps four and five of the sequential
evaluation process.
The Social Security Administration revised its regulations regarding the consideration of
medical evidence—with those revisions applicable to all claims filed after March 27, 2017. See
82 FR 5844-01, 2017 WL 168819 (Jan. 18, 2017). Because Claimant filed the claim after March
27, 2017,2 20 C.F.R. § 404.150c and 20 C.F.R. § 416.920c are applicable in this case. Under these
provisions, the ALJ must apply the same factors in the consideration of the opinions from all
medical sources, rather than afford specific evidentiary weight to certain sources’ opinions. 20
C.F.R. §§ 404.1520c(a); 416.920c(a). The ALJ will assess the persuasiveness of a medical
source’s opinion in light of five factors: 1) supportability; 2) consistency; 3) relationship with the

1

Here, in assessing the Claimant’s RFC, the ALJ stated:
The claimant has the residual functional capacity to perform light work as defined
in 20 CFR 1567(b) and 416.967(b) with these specific restrictions: in an eight-hour
workday, she can stand/walk for four hours and sit for six hours; she an never climb
ladders, ropes, or scaffolds; she can occasionally climb ramps and stairs; she can
occasionally stoop and balance (on uneven terrain); she can occasionally kneel,
crouch, and crawl; she can tolerate occasional exposure to temperatures over ninety
degrees Fahrenheit; she can tolerate no concentrated exposure to wetness, humidity,
or vibration; she can have no exposure to unprotected heights or dangerous moving
machinery; she can occasionally reach overhead; she can frequently reach in all
other directions bilaterally; she is limited to simple, one to four step work tasks; she
can have occasional interaction with the public, coworkers, and supervisors; she
can a [sic] work environment in which changes in the work setting are introduced
gradually.

R. 20.
2

Claimant filed her claims on September 13, 2020. R. 15.

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claimant;3 4) specialization and 5) “other factors that tend to support or contradict a medical
opinion or prior administrative medical finding.” 20 C.F.R. §§ 404.1520c(c); 416.920c(c).
Supportability and consistency constitute the most important factors in any evaluation, and
the ALJ must explain the consideration of those two factors. 20 C.F.R. §§ 404.1520c(b)(2);
416.920c(b)(2). Supportability relates to the extent to which a medical source has articulated
support for the medical source’s own opinion, while consistency relates to the relationship between
a medical source’s opinion and other evidence within the record.4 In other words, the ALJ’s
analysis is directed to whether the medical source’s opinion is supported by the source’s own
records and consistent with the other evidence of record—familiar concepts within the framework
of social security litigation.
The ALJ may, but is not required to, explain how the ALJ considered the remaining three
factors (relationship with claimant, specialization, and “other factors”).

20 C.F.R. §§

404.1520c(b)(2); 416.920c(b)(2); see also Freyhagen v. Comm’r of Soc. Sec. Admin., No. 3:18CV-1108-J-MCR, 2019 WL 4686800, at *2 (M.D. Fla. Sept. 26, 2019) (“The new regulations are
not inconsistent with Eleventh Circuit precedent holding that ‘the ALJ may reject any medical
opinion if the evidence supports a contrary finding.”) (quoting Wainwright v. Comm’r of Soc. Sec.

3

This factor combines consideration of the following issues: length of the treatment relationship,
frequency of examinations, purpose of the treatment relationship, extent of the treatment
relationship, and examining relationship. 20 C.F.R. §§ 404.1520c(c)(3)(i)–(v); 416.920c(c)(3)(i)–
(v).

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The regulations provide, in relevant part, that “[t]he more relevant the objective medical evidence
and supporting explanations presented by a medical source are to support his or her medical
opinion(s) or prior administrative medical finding(s),” and “[t]he more consistent a medical
opinion(s) or prior administrative medical finding(s) is with the evidence from other medical
sources and nonmedical sources the more persuasive the medical opinions or prior administrative
medical finding(s) will be.” 20 C.F.R. §§ 404.1520c(c)(1)–(2); 416.920c(c)(1)–(2).

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Admin., 2007 WL 708971, *2 (11th Cir. Mar. 9, 2017) (per curiam) and citing Sryock v. Heckler,
764 F.2d 834, 835 (11th Cir. 1985) (per curiam) (same)).
On November 23, 2020, Dr. Coffman performed a consultative examination of Claimant
for purposes of developing a vocational rehabilitation plan. R. 631-46. Dr. Coffman administered
a battery of psychological and psychoeducational tests. R. 632, 635-42. Dr. Coffman opined that
Claimant met the criteria for PTSD with panic attacks, major depressive disorder, and borderline
personality disorder. R. 644. She found Claimant had the following mental health limitations: (1)
difficulty regulating emotions and/or tolerating stress; (2) difficulty with motivation; (3) avoidance
of situations that cause stress/anxiety; (4) experiences significant distress (e.g., panic attacks,
frequent crying); (5) at increased risk of hurting self/and or others; and (6) at increased risk for
problematic substance use. R. 643. Dr. Coffman opined that Claimant required individual
accommodation to perform work. T. 644. She further opined that Claimant “is likely to be able
to obtain employment, but her interpersonal skills and symptoms related to her Borderline
Personality Disorder are likely to create a significant barrier to maintaining competitive
employment.” R. 645.
In addressing Dr. Coffman’s opinion, the ALJ stated the following:
Theodora Coffman, Ph.D., examined the claimant in November 2020. (Exhibit10F; B-11F) She noted that the claimant has difficulty regulating emotions, is at
increased risk for hurting herself or others, is at risk for problematic substance
abuse, and requires individualized accommodation to perform work. (Exhibit
B10F, pages 14 and 15) While the statements regarding “increased risk” are not
opinions regarding functional limitation, the undersigned as limited the claimant’s
interaction with others.
However, the opinion that claimant requires
accommodation to work is not supported by Dr. Coffman’s examination. Nor is
the degree of mental limitation consistent with other evidence; the record indicates
that the claimant’s treatment for mental impairments has been relatively
conservative in nature. No other source has identified the extreme degree of
limitation indicated by Dr. Coffman. In addition, the claimant’s ability to perform
volunteer work once a week suggests a higher level of functioning than Dr.

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Coffman describes. The undersigned has found Dr. Coffman’s report to be not
persuasive.
R. 22-23.
Claimant contends that the ALJ’s “minimal analysis” finding that Dr. Coffman’s opinion
that Plaintiff requires individualized accommodation to perform work was not supported by her
examination does not satisfy the ALJ’s duty to consider the supportability of the opinion. Doc. 23
at 23. She further argues that the ALJ’s finding with regard to consistency is not supported by
substantial evidence. Id. at 25-27. The Commissioner responds that it was reasonable for the ALJ
to find that Dr. Coffman did not support her opinions with sufficient findings. Doc. 24 at 12.
The Court agrees with Claimant that the ALJ’s analysis of the supportability of Dr.
Coffman’s opinion is insufficient. The ALJ’s analysis of the supportability factor in its entirety
is: “the opinion that claimant requires accommodation to work is not supported by Dr. Coffman’s
examination.” R. 23. The ALJ did not link any evidence, such as specific test results or other
findings in Dr. MacKay’s evaluation, that contradict her opinion. McDaniel v. Comm’r of Soc.
Sec., 2022 WL 11348279, at *5 (M.D. Fla. July 5, 2022) (remanding for failure to articulate
consideration of the supportability factor because “the exhibits the ALJ references are from other
medical sources—the ALJ nowhere explains how [the examiner’s] own treatment and examination
notes fail to support his opinions”); Mayfield v. Comm’r of Soc. Sec. Admin, 2021 WL 5300925,
*5 (N.D. Alabama November 15, 2021) (remanding where even if ALJ sufficiently addressed
consistency of opinions, she failed to explain how she considered the supportability of the
opinions). The Court, therefore, is unable to conduct a meaningful review. See Hanna v. Astrue,
395 F. App’x 634, 636 (11th Cir. 2010) (per curiam) (“The ALJ must state the grounds for his
decision with clarity to enable [the court] to conduct meaningful review.”); Brown v. Comm’r of
Soc. Sec., 2021 WL 2917562, at *4 (M.D. Fla. July 12, 2021) (noting that when evaluating medical

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opinions under the new Regulations, the ALJ must “explain his decision, particularly with respect
to supportability and consistency”) (citation omitted). “Conclusory statements about consistency
and supportability are insufficient to show that substantial evidence supports the ALJ’s decision.”
Battie v. Kijakazi, 2022 WL 4000728, at *6 (S.D. Fla. Aug. 9, 2022) (citing Pierson v. Comm’r of
Soc Sec., 2020 WL 1957597, at *4 (M.D. Fla. Apr. 8, 2020), report and recommendation adopted
by 2020 WL 1955341)); 2020 C.F.R. 404.1520c(b)(2) and 416.920c(b)(2) (“[W]e will explain how
we considered the supportability and consistency factors for a medical source’s medical opinions
...”).
Accordingly, the Court finds that this matter is to be remanded for further proceedings.
Since this issue is dispositive, the Court finds that there is no need to address Claimant’s remaining
arguments relating to Dr. MacKay and Dr. Gates. See Diorio v. Heckler, 721 F.2d 726, 729 (11th
Cir. 1983) (finding that on remand the ALJ must reassess the entire record); McClurkin v. Soc.
Sec. Admin., 625 F. App’x 960, 963 n.3 (11th Cir. 2015) (per curiam) (finding no need to analyze
other issues when case must be reversed due to other dispositive errors).
IV.

Conclusion
For the stated reasons, it is ORDERED that:
1. The final decision of the Commissioner is REVERSED and Remanded for further
proceedings pursuant to sentence four of 42 U.S.C. § 405(g); and
2. The Clerk is directed to enter judgment for Claimant and against the Commissioner,
and close the case.
ORDERED in Orlando, Florida on November 13, 2023.

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