Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_09-cv-00863/USCOURTS-almd-3_09-cv-00863-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L.

No. 103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to

Social Security matters were transferred to the Commissioner of Social Security.

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

EASTERN DIVISION

AMY JOHNSON TOLSON, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 3:09-CV-863-CSC

) (WO)

MICHAEL J. ASTRUE, )

COMMISSIONER OF SOCIAL )

SECURITY, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction.

The plaintiff applied for supplemental security income benefits under Title XVI of

the Social Security Act, 42 U.S.C. § 1381 et seq., alleging that she was unable to work

because of a disability. Her application was denied at the initial administrative level. The

plaintiff then requested and received a hearing before an Administrative Law Judge

("ALJ"). Following the hearing, the ALJ also denied the claim. The Appeals Council

rejected a subsequent request for review. The ALJ's decision consequently became the

final decision of the Commissioner of Social Security (Commissioner).1

 See Chester v.

Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The case is now before the court for review

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Pursuant to 28 U.S.C. § 636(c), the parties have consented to entry of final judgment by the

United States Magistrate Judge.

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A "physical or mental impairment" is one resulting from anatomical, physiological, or

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.

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pursuant to 42 U.S.C. §§ 405 (g) and 1383(c)(3).2

 Based on the court's review of the

record in this case and the briefs of the parties, the court concludes that the decision of the

Commissioner should be affirmed.

II. Standard of Review

Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the

person is unable 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...

 To make this determination3

 the Commissioner employs a five step, sequential

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.

(1) Is the person presently unemployed?

(2) Is the person's impairment severe?

(3) Does the person's impairment meet or equal one of the specific

impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?

(4) Is the person unable to perform his or her former occupation?

(5) Is the person unable to perform any other work within the economy?

An affirmative answer to any of the above questions leads either to the next

question, or, on steps three and five, to a finding of disability. A negative

answer to any question, other than step three, leads to a determination of

"not disabled."

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).

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The standard of review of the Commissioner's decision is a limited one. This court

must find the Commissioner's decision conclusive if it is supported by substantial

evidence. 42 U.S.C. § 405(g); Ingram v. Comm. of Soc. Sec. Admin., 496 F.3d 1253, 1260

(11th Cir. 2007). "Substantial evidence is more than a scintilla, but less than a

preponderance. It is such relevant evidence as a reasonable person would accept as

adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). A

reviewing court may not look only to those parts of the record which supports the

decision of the ALJ but instead must view the record in its entirety and take account of

evidence which detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804

F.2d 1179, 1180 (11th Cir. 1986). 

[The court must] . . . scrutinize the record in its entirety to determine the

reasonableness of the [Commissioner's] . . . factual findings . . . No similar

presumption of validity attaches to the [Commissioner's] . . . legal

conclusions, including determination of the proper standards to be applied

in evaluating claims.

Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

III. The Issues

A. Introduction. The plaintiff was 28years old at the time of the hearing before

the ALJ and has an 8th grade education. The plaintiff’s prior work experience includes

work as a baby sitter, assistant manager of a gas station, stock clerk, and line packer. 

Following the administrative hearing, the ALJ concluded that the plaintiff has

impairments of minimal disk bulges at L3-4 and L4-5, mild desiccation with minimal

bulge at L5-S1, lumbar radiculopathy, obesity, irritable bowel syndrome and vascular

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headaches. Nonetheless, the ALJ concluded that the plaintiff was not disabled because

the plaintiff has the residual functional capacity to perform her past relevant work as well

as jobs as a bench assembler, hand packager/inspector and food and beverage checker.

B. The Plaintiff's Claims. As stated by the plaintiff, the issues are as follows:

1. Did the Administrative Law Judge commit an error of law by giving “very little

weight” to the consultative examination report obtained by the Social Security

Administration from Dr. Alphonza Vester, M.D.?

2. Is the Administrative Law Judge’s determination of the plaintiff’s residual

functional capacity supported by substantial medical and vocational evidence?

IV. Discussion

A. Weight Accorded Consultative Examiner Report. Dr. Vester conducted a

consultative examination of the plaintiff. His written report states that she is “moderately

limited based on degenerative disc disease,” mildly limited based on irritable bowel

syndrome and chronic vascular headaches. (R. 236) He further found her limited to a mild

extent by her obesity. Id. 

I consider the claimant mildly limited with sitting. There is a moderate

limitation with standing and walking. There is a moderate limitation with

lifting and carrying objects. She is not limited with handling objects . . .

[or] hearing and speaking. There is a moderate limitation with traveling.

Id.

In addition to his written report, Dr. Vester completed a Medical Source Opinion

(Physical) (MSO) in which he opined that the plaintiff was limited in her ability to stand

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or walk to one-quarter hour at a time and sit for three-quarter hours at a time. (R. 238) 

He also opined that the plaintiff could occasionally lift or carry five pounds but never lift

15 pounds or carry 10 pounds. Id. And he further found she could never push/pull with

her left leg and never climb, balance, stoop, kneel, crouch, crawl or reach overhead. (R.

239) Finally, he concluded the plaintiff could never work in extreme cold, heat or high

places. She could never be exposed to vibration, fumes, noxious odors, dust, mists, or

gases or work in poorly ventilated areas. (R. 240) 

The ALJ rejected the MSO findings of Dr. Vester, and the plaintiff complains this

was error. Certainly, a report from a consultative physician can constitute substantial

evidence. Chaparro v. Bowen, 815 F.2d 1008, 1010 (5th Cir.1987). However, just as

with the opinion of treating physicians, an ALJ may reject a consultant’s report if it is

unsupported by objective medical evidence or is merely conclusory. See e.g., Johns v.

Bowen, 821 F.2d 551 (11th Cir. 1987). This is what the ALJ said about Dr. Vester’s

opinion.

As for the opinion evidence, the undersigned Administrative Law Judge

gives some weight to Dr. Vester's opinion regarding claimant's physical

functional abilities as they appear in his narrative. Dr. Vester is an

examining physician. His opinions-- that the claimant is mildly limited with

sitting; moderately limited with standing and walking; moderately limited

with lifting and carrying objects; and not limited with handling objects-- is

supported by his clinical findings and is generally consistent with the

substantial evidence, including claimant's activities of daily living.

The undersigned gives little weight to Dr. Vester's Medical Source Opinion

(MSO) form, dated May 5,2008. This functional assessment appears to have

been based primarily upon claimant's subjective complaints reported at the

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At the end of the MSO, Dr. Vester checked a box indicating that his conclusions were not based

primarily on the claimant’s subjective complaints. Regardless, the ALJ’s expressed adequate reasons for

rejecting the MSO findings of Dr. Vester. 

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time of his evaluation and not his clinical findings.4

 For example, in his

MSO, he states that the claimant can only stand or walk 1⁄4. of an hour at

one time and sit for 3⁄4 of an hour at one time. The claimant had previously

told the doctor that she could only stand for 15 minutes at a time and sit for

35 minutes without having to stand. Dr. Vester's Medical Source Opinion is

inconsistent with claimant's own testimony. For example, the doctor wrote

that the claimant can only occasionally lift and/or carry 5 pounds during an

8-hour day. At the hearing, however, she testified that she can lift a

maximum of 30 pounds and carry a maximum of 40 pounds. Dr. Vester's

Medical Source Opinion is inconsistent with his own narrative regarding

claimant's functional limitations. For example, he wrote in his narrative that

the claimant was mildly limited in her ability to sit, but, in his MSO, he

indicates that she cannot sit for more than 45 minutes at one time and gives

no opinion how long she can sit during an 8-hour day. He wrote in his

narrative that the claimant is moderately limited in her ability to lift and

carry objects but, in his MSO, he markedly restricts her ability to lift and/or

carry objects to5 pounds on an occasional basis. Further, his MSO is not

substantiated by other evidence in the file. For example, the MRIs reflect

only "mild" bulges with "minimal" or "slight" effect. In addition, her x-rays

have been negative.

(R. 19)

The ALJ’s careful and thorough review and rejection of Dr. Vester’s MSO report

is supported by substantial evidence. Moreover, the ALJ’s conclusion is supported by the

record as a whole. For example, the plaintiff’s testimony about her activities of daily

living are consistent with the ALJ’s residual functional capacity determination. (R. 39-40) 

There is no error in the ALJ’s conclusion about and rejection of Dr. Vester’s MSO report.

B. The Residual Functional Capacity Determination. The ALJ concluded that

the plaintiff could perform light work with some additional functional and non-exertional

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restrictions. (R. 21-22) The plaintiff complains that because Dr. Vester’s assessment is

the only assessment of a physician who actually saw the plaintiff, it must prevail,

resulting in her being unable to work. The difficulty with this argument is that in fact

there are two assessments of the plaintiff, both by Dr. Vester. As noted above, Dr.

Vester’s narrative portrays a very different and much more able person than the person

described in Dr. Vester’s MSO. As already noted, the ALJ’s rejection of the MSO is

supported by substantial evidence. The ALJ’s conclusion that the plaintiff can perform

light work subject to the additional limitations described by him is supported by the

record as a whole.

V. Conclusion

For the foregoing reasons, the decision of the Commissioner will be affirmed. A

separate final judgment will be entered.

Done this 10th day of March, 2011.

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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