Steakin v. Commissioner of Social Security

Filing 22

OPINION AND ORDER reversing and remanding the Commissioner's final decision; Clerk to enter judgment accordingly and close the file. Signed by Magistrate Judge James R. Klindt on 3/7/2025. (KAW)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
ORLANDO DIVISION
DANIEL SCOTT STEAKIN,
Plaintiff,
v.

Case No. 6:24-cv-325-JRK

LELAND C. DUDEK,
Acting Commissioner of Social
Security, 1
Defendant.
OPINION AND ORDER 2
I.

Status

Daniel Scott Steakin (“Plaintiff”) is appealing the Commissioner of the
Social Security Administration’s (“SSA(’s)”) final decision denying his claim for
disability insurance benefits (“DIB”). Plaintiff’s alleged inability to work is the
result of “PTSD, Depression, ADHD, Dizziness, Genetic brain injury,
febriculosity [sic], knee pain, [GERD], sleep apnea, fatty liver, pulmonary

1

Leland C. Dudek became the Acting Commissioner of Social Security in
February 2025. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Mr. Dudek is
substituted as Defendant in this suit. No further action need be taken to continue this suit by
reason of the last sentence of section 205(g) of the Social Security Act, 42 U.S.C. § 405(g).
2
The parties consented to the exercise of jurisdiction by a United States
Magistrate Judge. See Order Regarding Consent to Magistrate Judge Jurisdiction in Social
Security Appeals (Doc. No. 117), Case No. 3:21-mc-1-TJC (outlining procedures for consent
and Defendant’s generalized consent to Magistrate Judge jurisdiction in social security
appeals cases); consent by Plaintiff indicated in docket language for Complaint (Doc. No. 1).

nauseas, hypothyroidism, cholesterol, nauseas, allergies, HBP, migraines,
shortness of breath, asthma, h[eart] palpitations, obesity, multiple disc[s] on
back that flipped, pancreatitis, [and] pin in multiple bones.” Transcript of
Administrative Proceedings (Doc. No. 10; “Tr.” or “administrative transcript”),
filed April 12, 2024, at 111; see Tr. at 123, 319. Plaintiff protectively filed an
application for DIB on August 1, 2022, alleging a disability onset date of
February 12, 2019. 3 Tr. at 281-87. Later, the alleged onset disability date was
amended to December 24, 2021. Tr. at 78; see Tr. at 423. The application was
denied initially, Tr. at 123-34, 135, 166-69, and upon reconsideration, Tr. at
110, 111-22, 176-78.
On November 2, 2023, an Administrative Law Judge (“ALJ”) held a
hearing,

4

during which she heard testimony from Plaintiff, who was

represented by counsel, and a vocational expert (“VE”). See Tr. at 73-109. On
December 12, 2023, the ALJ issued a Decision finding Plaintiff not disabled
through the date of the Decision. See Tr. at 25-47. 5

3

Although actually completed on August 16, 2022, see Tr. at 281, the protective
filing date for the DIB application is listed elsewhere in the administrative transcript as
August 1, 2022, see, e.g., Tr. at 111, 123.
4

234-35.

The hearing was held via videoconference with Plaintiff’s consent. See Tr. at 75,

5

The administrative transcript also includes an ALJ decision and Appeals
Council denial adjudicating an earlier-filed claim for DIB. Tr. at 136-39, 146-57. Those
adjudications are not at issue here.
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Thereafter, Plaintiff sought review of the Decision by the Appeals Council
and submitted additional medical evidence and a brief authored by his counsel.
See Tr. at 2, 5-6 (Appeals Council exhibit list and orders), 16-17 (medical
evidence), 278-80 (request for review), 423-25 (brief). On January 8, 2024, the
Appeals Council denied Plaintiff’s request for review, Tr. at 1-4, thereby making
the ALJ’s Decision the final decision of the Commissioner. On February 14,
2024, Plaintiff commenced this action under 42 U.S.C. § 405(g) by timely filing
a Complaint (Doc. No. 1), seeking judicial review of the Commissioner’s final
decision.
On appeal, Plaintiff challenges “[w]hether the ALJ provided adequate
analysis of the medical source opinions and specifically, did the ALJ adequately
consider the explanations offered by the medical sources.” Memorandum in
Support of Plaintiff (Doc. No. 15; “Pl.’s Mem.”), filed May 28, 2024, at 17. On
June 12, 2024, Defendant filed a Memorandum in Support of the
Commissioner’s Decision (Amended) (Doc. No. 19; “Def.’s Mem.”) addressing the
issue. Then, on July 9, 2024, Plaintiff’s Memorandum in Reply (Doc. No. 20;
“Reply”) was filed.
After a thorough review of the entire record and consideration of the
parties’ respective arguments, the undersigned finds that the Commissioner’s
final decision is due to be reversed and remanded for the reasons explained
below.
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II.

The ALJ’s Decision

When determining whether an individual is disabled, 6 an ALJ must
follow the five-step sequential inquiry set forth in the Code of Federal
Regulations (“Regulations”), determining as appropriate whether the claimant
(1) is currently employed or engaging in substantial gainful activity; (2) has a
severe impairment; (3) has an impairment or combination of impairments that
meets or medically equals one listed in the Regulations; (4) can perform past
relevant work; and (5) retains the ability to perform any work in the national
economy. 20 C.F.R. § 404.1520; see also Simon v. Comm’r, Soc. Sec. Admin., 7
F.4th 1094, 1101-02 (11th Cir. 2021) (citations omitted); Phillips v. Barnhart,
357 F.3d 1232, 1237 (11th Cir. 2004). The claimant bears the burden of
persuasion through step four, and at step five, the burden shifts to the
Commissioner. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
Here, the ALJ followed the five-step inquiry. See Tr. at 27-47. At step one,
the ALJ determined that Plaintiff “has not engaged in substantial gainful
activity since December 24, 2019, the amended onset date.”

7

Tr. at 27

6

“Disability” is defined in the Social Security Act 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. §§ 423(d)(1)(A),
1382c(a)(3)(A).
7

The ALJ erroneously stated that Plaintiff’s attorney had amended the alleged
onset date to December 24, 2019, instead of 2021. Tr. at 25, 27; see Tr. at 423.
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(emphasis and citation omitted). At step two, the ALJ found that Plaintiff “has
the following severe impairments: post-traumatic stress disorder (PTSD),
anxiety, mild cognitive impairment with memory loss, right shoulder
interstitial tear and joint arthrosis, history of lumbar spine disorder, obesity,
history of traumatic brain injury, headaches, and tachycardia.” Tr. at 27
(emphasis and citation omitted). At step three, the ALJ found that Plaintiff
“does 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 P, Appendix 1.” Tr. at 31 (emphasis and citation omitted).
The ALJ determined that Plaintiff has the following residual functional
capacity (“RFC”):
[Plaintiff can] perform light work as defined in 20 CFR [§]
404.1567(b) except occasional push/pull of hand controls with the
right upper extremities; occasional overhead reaching with the
right upper extremity and frequent reach other directions with the
right upper extremity; occasional climbing ramps/stairs, balancing,
stooping, kneeling, crouching and crawling; and no climbing ropes,
ladders, or scaffolds; no work around hazards including unprotected
heights, moving mechanical parts, and operating motorized
vehicles; [Plaintiff] is limited to unskilled work only with simple
tasks and simple decision making with an average production
paced quota with goal oriented work but no fast paced assemblyline work; no limitation on amount of contact with others but all
interactions in a static non-confrontational environment with n[o]
conflict resolution, arbitration, or negotiating and with infrequent
changes in work tasks for low stress.
Tr. at 33-34 (emphasis omitted).

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At step four, the ALJ found that Plaintiff “is unable to perform any past
relevant work” as a “Police Officer,” a “Security Guard,” and a “Traffic Control
Signaler.” Tr. at 45-46 (some emphasis and citation omitted). The ALJ then
proceeded to step five. After considering Plaintiff’s age (“a younger individual
age 18-49”), education (“at least a high school education”), work experience, and
RFC, the ALJ relied on the VE’s testimony and found that “there are jobs that
exist in significant numbers in the national economy that [Plaintiff can]
perform,” such as “Garment Sorter,” “Fruit Cutter,” and “Housekeeping
Cleaner.” Tr. at 46-47 (some emphasis and citation omitted). The ALJ concluded
Plaintiff “has not been under a disability . . . from February 12, 2019, through
the date of th[e D]ecision.” 8 Tr. at 47 (emphasis and citation omitted).
III.

Standard of Review

This Court reviews the Commissioner’s final decision as to disability
pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Although no deference is given
to the ALJ’s conclusions of law, findings of fact “are conclusive if . . . supported
by ‘substantial evidence.’” Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir.
2001) (citing Falge v. Apfel, 150 F.3d 1320, 1322 (11th Cir. 1998)). “Substantial
evidence is something ‘more than a mere scintilla, but less than a
preponderance.’” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)

8

This ultimate finding relied upon the original alleged onset date, rather than
the amended one.
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(quoting Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987)). The substantial
evidence standard is met when there is “such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.” Falge, 150 F.3d at 1322
(quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)); see also Biestek v.
Berryhill, 587 U.S. 97, 103 (2019); Samuels v. Acting Comm’r of Soc. Sec., 959
F.3d 1042, 1045 (11th Cir. 2020) (citation omitted). It is not for this Court to
reweigh the evidence; rather, the entire record is reviewed to determine
whether “the decision reached is reasonable and supported by substantial
evidence.” Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991) (citation
omitted). The decision reached by the Commissioner must be affirmed if it is
supported by substantial evidence—even if the evidence preponderates against
the Commissioner’s findings. Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155,
1158-59 (11th Cir. 2004) (per curiam).
IV.

Discussion

Plaintiff argues the ALJ erred in assessing the medical opinion evidence,
focusing on opinions from treating psychologists Lisa Webb, Ph.D. and Kenith
Robins, Ph.D.; treating nurse practitioner Michael Lomonaco, DNP, APRN,
FNP-C; and Department of Veteran’s Affairs (“VA”) evaluating psychologist
Christina Jones, Psy.D. See Pl.’s Mem. at 17-25; Reply at 1-7. According to
Plaintiff, the ALJ did not fully address the required factors in evaluating the
first three opinions and the ALJ’s findings are undermined by the evidence,
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particularly the fluctuation of symptoms. See Pl.’s Mem. at 17-24. As to the
fourth opinion, that of Dr. Jones, Plaintiff contends the ALJ failed to address it
altogether. See id. at 24-25. Responding, Defendant argues the ALJ properly
analyzed the first three opinions and complied with applicable regulations.
Def.’s Mem. at 5-14. As to Dr. Jones, Defendant contends her evaluation
findings do not constitute an “opinion” as defined in the Regulations. Id. at 1416.
As explained below, the undersigned finds the ALJ erred in failing to
evaluate the findings of Dr. Jones that indeed constitute an “opinion” as defined
by the Regulations. The matter must be reversed and remanded for
consideration of this opinion in the first instance. Because Dr. Jones’s opinion
is largely consistent with the other medical opinions at issue here, the
Administration’s analysis of those opinions could be affected on remand. Thus,
if appropriate, the remaining opinions at issue should also be reconsidered on
remand.
The SSA revised the rules regarding the evaluation of medical evidence
for claims filed on or after March 27, 2017. See Revisions to Rules Regarding
the Evaluation of Medical Evidence, 82 Fed. Reg. 5844, 5844 (January 18,
2017); see also 82 Fed. Reg. 15,132 (March 27, 2017) (amending and correcting
the final Rules published at 82 Fed. Reg. 5,844). Under the new rules and
Regulations, “A medical opinion is a statement from a medical source about
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what [the claimant] can still do despite [his or her] impairment(s) and whether
[the claimant] ha[s] one or more impairment-related limitations or restrictions
in the following abilities:” 1) the “ability to perform physical demands of work
activities”; 2) the “ability to perform mental demands of work activities”; 3) the
“ability to perform other demands of work, such as seeing, hearing, or using
other senses”; and 4) the “ability to adapt to environmental conditions.” 20
C.F.R. §§ 404.1513(a)(2), 416.913(a)(2); see also 20 C.F.R. § 404.1502 (defining
“[a]cceptable medical sources”). Particularly regarding the mental demands of
work activities, “medical opinions are about” matters “such as understanding;
remembering; maintaining concentration, persistence, or pace; carrying out
instructions; or responding appropriately to supervision, co-workers, or work
pressures in a work setting.” 20 C.F.R. §§ 404.1513(a)(2), 416.913(a)(2).
An ALJ need not “defer or give any specific evidentiary weight, including
controlling weight, to any medical opinion(s) or prior administrative medical
finding(s), including those from [the claimant’s] medical sources.” 20 C.F.R.
§§ 404.1520c(a), 416.920c(a). 9 “Because section 404.1520c falls within the scope
of the Commissioner’s authority and was not arbitrary and capricious, it
abrogates [the United States Court of Appeals for the Eleventh Circuit’s] prior

9

Plaintiff filed his application after the effective date of sections 404.1520c and
416.920c, so the undersigned applies the revised rules and Regulations.
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precedents applying the treating-physician rule.” Harner v. Soc. Sec. Admin.,
Comm’r, 38 F.4th 892, 896 (11th Cir. 2022).
The following factors are relevant in an ALJ’s consideration of a medical
opinion or a prior administrative medical finding: (1) “[s]upportability”; (2)
“[c]onsistency”; (3) “[r]elationship with the claimant”; (4) “[s]pecialization”; and
(5) other factors, such as “evidence showing a medical source has familiarity
with the other evidence in the claim or an understanding of [the SSA’s]
disability program’s policies and evidentiary requirements.” 20 C.F.R.
§§ 404.1520c(c), 416.920c(c). Supportability and consistency are the most
important factors, and the ALJ must explain how these factors were considered.
20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). Generally, the ALJ is not required
to explain how he or she evaluated the remaining factors. 20 C.F.R.
§§ 404.1520c(b)(2), 416.920c(b)(2). However, if the ALJ “find[s] that two or more
medical

opinions . . . about

the

same

issue

are

both

equally

well-

supported . . . and consistent with the record . . . but are not exactly the same,
[the ALJ must] articulate how [he or she] considered the other most persuasive
factors . . . .” 20 C.F.R. §§ 404.1520c(b)(3), 416.920c(b)(3). 10

10

When a medical source provides multiple opinions, the ALJ is also not required
to articulate how he or she evaluated each medical opinion individually. 20 C.F.R.
§§ 404.1520c(b)(1), 416.920c(b)(1). Instead, the ALJ must “articulate how [he or she]
considered the medical opinions . . . from that medical source together in a single analysis
using the factors listed [above], as appropriate.” 20 C.F.R. §§ 404.1520c(b)(1), 416.920c(b)(1).
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Here, Dr. Jones examined Plaintiff on May 6, 2021 via “video telehealth”
at the request of the VA in connection with Plaintiff’s request for VA benefits.
Tr. at 982-86. Plaintiff argues—and Defendant does not dispute—that the ALJ
failed altogether to address the examination findings of Dr. Jones. Defendant
argues, however, that the ALJ did not err because Dr. Jones’s findings do not
qualify as a “medial opinion” as defined by the SSA. Def.’s Mem. at 14-15.
According to Defendant, Dr. Jones did not “assess[] Plaintiff’s ability to perform
the physical or mental demands of work activity,” but instead relied on
“subjective allegations and even clinical observations.” Id.
The undersigned finds that Dr. Jones’s findings qualify as a medical
opinion, and the ALJ erred by failing to address the opinion. First, Dr. Jones
did not merely rely on subjective allegations or clinical observations. Dr. Jones’s
report indicates she reviewed the “VA e-folder,” and the “VA electronic health
record,” as well as “conduct[ing] a thorough psychosocial evaluation.” Tr. at 983.
In the report, Dr. Jones provided details on matters “such as understanding;
remembering; maintaining concentration, persistence, or pace; carrying out
instructions; or responding appropriately to supervision, co-workers, or work
pressures in a work setting.” 20 C.F.R. §§ 404.1513(a)(2), 416.913(a)(2); see Tr.
at 982-86. According to Dr. Jones, as a result of the PTSD, Plaintiff suffers the
following symptoms, among others: “[m]ild memory loss, such as forgetting
names, directions or recent events”; “[i]mpaired judgment”; “[d]isturbances in
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motivation and mood”; “[d]ifficulty in establishing and maintaining effective
work and social relationships”; “[d]ifficulty adapting to stressful circumstances,
including work or a work like setting”; “[o]bsessional rituals which interfere
with routine activities”; “[i]mpaired impulse control”; and “[i]ntermittent
inability to perform activities of daily living.” Tr. at 985. These findings qualify
the report as a medical opinion under the Regulations. Thus, the ALJ was
required to at least explain how the consistency and supportability factors were
considered. See 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). But, the ALJ did
not provide any such analysis, frustrating judicial review.
In sum, the matter must be remanded for consideration of Dr. Jones’s
opinion.
V.

Conclusion

In light of the foregoing, it is
ORDERED:
1.

The Clerk of Court is directed to enter judgment pursuant to

sentence four of 42 U.S.C. § 405(g), REVERSING the Commissioner’s final
decision and REMANDING this matter with the following instructions:
(A)

Consider Dr. Jones’s opinion in accordance with applicable

regulations;
(B)

If necessary, reconsider the opinions of Dr. Webb, Dr. Robins, and

Mr. Lomonaco; and
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(C)

Take such other action as may be necessary to resolve this claim

properly.
2.

The Clerk is further directed to close the file.

DONE AND ORDERED in Jacksonville, Florida on March 7, 2025.

kaw
Copies:
Counsel of Record

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