Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_05-cv-00528/USCOURTS-alsd-1_05-cv-00528-0/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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IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

VONCILLE HOLDEN, :

Plaintiff, :

vs. CA 05-0528-C

:

JO ANNE B. BARNHART,

Commissioner of Social Security, :

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action pursuant to 42 U.S.C. §§ 405(g) and

1383(c)(3), seeking judicial review of a final decision of the Commissioner of

Social Security denying her claims for disability insurance benefits, widow’s

insurance benefits, and supplemental security income. The parties have

consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to

28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 21 (“In accordance

with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this

case consent to have a United States Magistrate Judge conduct any and all

proceedings in this case . . . and order the entry of a final judgment, and

conduct all post-judgment proceedings.”); see also Doc. 22 (order of

reference)) Upon consideration of the administrative record, plaintiff's

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 1 of 12
1 Any appeal taken from this memorandum opinion and order and judgment shall

be made to the Eleventh Circuit Court of Appeals. (See Doc. 21 (“An appeal from a judgment

entered by a Magistrate Judge shall be taken directly to the United States Court of Appeals for

this judicial circuit in the same manner as an appeal from any other judgment of this district

court.”))

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proposed report and recommendation, the Commissioner's proposed report and

recommendation, and the parties' arguments at the April 25, 2006 hearing

before the Court, it is determined that the Commissioner's decision denying

benefits should be reversed and remanded for further proceedings not

inconsistent with this decision.1

Plaintiff alleges disability due to arthritis and degenerative changes,

obesity, and skin rashes. The Administrative Law Judge (ALJ) made the

following relevant findings:

1. The claimant was born on July 13, 1946 and she was 52

years of age at the time of her alleged disability onset date.

2. The claimant is the surviving spouse of the deceased

wage earner Willie Holden, who died fully insured for Title II

purposes on March 15, 1994. The claimant remarried after [] the

wage earner’s death but she meets the requirements set forth in

20 CFR Section 404.335(e)(3)(i) and (ii). 

3. The prescribed period during which the claimant must

establish that she is under a disability began in March, 1994, and

it extended through March, 2001, i.e., a period of 84 months or

7 years.

4. The claimant met the insured status requirements under

Title II of the Act (for purposes of drawing benefits against her

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 2 of 12
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own earnings) on January 1, 1999, the date she stated that she

became unable to work, and she continued to meet those

requirements through September 30, 2001.

5. The claimant has not engaged in substantial gainful

activity at any time since January 1, 1999.

6. The claimant alleged back pain, leg pain, and skin rash as

possible “severe” impairments, but the same have not been

established as entailing significant work-related limitations of

record for a continuous period of twelve months during the

times at issue. The medical evidence of record does not establish

that the claimant has any medically determinable impairment or

combination of impairments which is considered “severe”

within the meaning of the Social Security Act.

7. The claimant’s testimony regarding pain and functional

limitations is not fully credible and consistent with respect to

severity, given that there is no objective medical evidence to

establish a severe, functionally limiting impairment or

combination of impairments over a continuous period of twelve

months and the lack of persistent and regular medical treatment

for the alleged impairments.

8. The claimant does not have any impairment or

impairments which significantly limit her ability to perform

basic work-related activities; therefore, the claimant does not

have a severe impairment. (20 CFR Sections 404.1521 and

416.921).

9. For purposes of her claim for widow’s insurance benefits

and disability insurance benefits, the claimant has not been

under a disability as defined by the Social Security Act and

Regulations at any time through the date of this decision; for

purposes of her claim for Supplemental Security Income

benefits, the claimant has not been under a disability as defined

in the Social Security Act, as amended, at any time through the

date of this decision.

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 3 of 12
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(Tr. 22-23) The Appeals Council affirmed the ALJ's decision (Tr. 6-8) and

thus, the hearing decision became the final decision of the Commissioner of

Social Security.

DISCUSSION

This Court must determine whether the Commissioner’s decision to

deny claimant benefits on the basis that she does not have a severe physical

impairment is supported by substantial evidence. Substantial evidence is

defined as more than a scintilla and means such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.

Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971).

"In determining whether substantial evidence exists, we 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).

The Commissioner's severity regulation requires the claimant to make

a threshold showing that she has an impairment which significantly limits her

physical or mental ability to perform basic work activities. 20 C.F.R. §§

416.920(c), 416.921(a) (1998); Bowen v. Yuckert, 482 U.S. 137, 147 n.5, 107

S.Ct. 2287, 2294 n.5, 96 L.Ed.2d 119 (1987). Basic work activities include

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2 It is clear that in Yuckert, the Supreme Court did not impose a standard higher

than the de minimis standard set out in Brady. See Stratton v. Bowen, 827 F.2d 1447, 1451 n.7,

1452 n.9, 1452-1453 (11th Cir. 1987).

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functions such as walking, standing, sitting, lifting, pushing, pulling, reaching,

carrying, or handling; understanding, carrying out and remembering simple

instructions; use of judgment, responding appropriately to supervision, coworkers, and usual work situations; and dealing with changes in a routine work

setting. 20 C.F.R. § 416.921(b). An impairment can be considered not severe

"only if it is a slight abnormality which has such a minimal effect on the

individual that it would not be expected to interfere with the individual's ability

to work, irrespective of age, education, or work experience." Brady v.

Heckler, 724 F.2d 914, 920 (11th Cir. 1984); see Yuckert, supra, 482 U.S. at

153, 107 S.Ct. at 2297 ("The severity regulation increases the efficiency and

reliability of the evaluation process by identifying at an early stage those

claimants whose medical impairments are so slight that it is unlikely they

would be found to be disabled even if their age, education and experience were

taken into account").2

 

Inherent in a finding of a medically not severe impairment or

combination of impairments is the conclusion that the

individual’s ability to engage in SGA [substantial gainful

activity] is not seriously affected. Before this conclusion can be

reached, however, an evaluation of the effects of the

impairment(s) on the person’s ability to do basic work activities

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 5 of 12
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must be made. A determination that an impairment(s) is not

severe requires a careful evaluation of the medical findings

which describe the impairment(s) and the informed judgment

about its (their) limiting effects on the individual’s physical and

mental ability(ies) to perform basic work activities; thus, an

assessment of the function is inherent in the medical process

itself.

SSR 85-28. The claimant's burden at step two of the sequential evaluation

process is mild. McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986)

(“Step two is a threshold inquiry. It allows only claims based on the most

trivial impairments to be rejected."). 

In analyzing the severity issue at step two of the sequential evaluation

process, the ALJ wholly failed to mention or assign weight to the physical

residual functional capacity assessment of a non-examining, reviewing

physician wherein the physician listed the evidence he reviewed in concluding

that plaintiff has a severe musculoskeletal impairment thereby warranting the

assessment. (Compare Tr. 14-24 with Tr. 233-241) While it is true in this

circuit that “‘[t]he opinions of nonexamining, reviewing physicians, when

contrary to those of examining physicians are entitled to little weight in a

disability case, and standing alone do not constitute substantial evidence[,]’”

Lamb v. Bowen, 847 F.2d 698, 703 (11th Cir. 1988), it is also clear that the

opinions of non-examining, reviewing physicians are entitled to be accorded

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weight when they are consistent with the medical evidence of record, cf.

Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir. 1981) (“In the case before

us [], Dr. Gordon’s opinion that claimant was not disabled on or before

December 31, 1975, is supported by the medical records of physicians who

had examined claimant, including the records of Dr. Harris. Consequently, it

is Dr. Harris’ opinion that is contrary to the evidence. The Secretary was

justified in accepting the opinion of Dr. Gordon, a qualified reviewing

physician, that was supported by the evidence, and in rejecting the conclusory

statement of Dr. Harris, a treating physician, that was contrary to the evidence.

The law is clear that, although the opinion of an examining physician is

generally entitled to more weight than the opinion of a non-examining

physician, the ALJ is free to reject the opinion of any physician when the

evidence supports a contrary conclusion.”). Because this Court perceives

nothing inconsistent in the medical records listed by the non-examining,

reviewing physician in this case and his conclusion that plaintiff suffers from

a severe musculoskeletal impairment, his opinion was entitled to be accorded

weight by the ALJ. The ALJ’s failure to state the weight he was according the

non-examiner’s opinion, or his reasons for according it no weight, arguably

requires that same be accepted as true. Cf. MacGregor v. Bowen, 786 F.2d

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1050, 1053 (11th Cir. 1986) (“Where the [Commissioner] has ignored or failed

properly to refute a treating physician’s testimony, we hold as a matter of law

that he has accepted it as true.”). If nothing else, it was error for the ALJ to

determine that the claimant does not have a severe physical impairment given

the non-examiner’s report and in absence of evidence from an examining

physician supporting such a determination. 

This is not the only problem with the ALJ’s determination that plaintiff

suffers from no severe physical impairment. Specifically, although the ALJ

twice in his decision makes passing reference to Jackson’s obesity in the

course of summarizing the medical evidence (see Tr. 18 & 19 (“Dr. Middleton

noted that the claimant was obese, that she walked with an antalgic gait, and

that she had tenderness to percussion in her low back. . . . He recommended

that the claimant take muscle relaxers and anti-inflammatory medications and

that she lose weight.”); Tr. 20 (“[I]t appears as though the claimant underwent

neurological evaluation at the Stanton Road Clinic in March, 2002 and April,

2002. . . . It was also recommended that she lose weight and perform back

strengthening exercises.”)), he wholly failed to consider whether plaintiff’s

obesity was a severe impairment, either alone or in combination with

plaintiff’s musculoskeletal impairments. Boston v. Barnhart, 332 F.Supp.2d

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 8 of 12
3 The Commissioner cannot be heard to argue that the plaintiff never listed obesity

as an impairment in her application for benefits because plaintiff, as well, did not list her skin

rashes as an impairment, yet the ALJ considered this impairment apparently based upon

plaintiff’s testimony at the hearing and the composition of the medical records. The

Commissioner must necessarily acknowledge that plaintiff gave testimony establishing her

obesity at the hearing (see Tr. 361 (plaintiff’s testimony that she was 5'3" tall and weighed 204

pounds)) and that the medical evidence of record contains two separate diagnoses of obesity (see

Tr. 334 (Dr. Middleton’s letter to Dr. Hassell describing plaintiff as an obese female); Tr. 199

(“Abd: morbid obesity[.]”)). Masch v. Barnhart, 406 F.Supp.2d 1038, 1049 (E.D. Wis. 2005)

(“At step two, the ALJ must first decide whether the claimant’s obesity constitutes a medically

determinable impairment. Ordinarily, this is accomplished based on a diagnosis of obesity by a

treating source or consultative examiner. SSR 02-1p at 3.”); Boston, supra, 332 F.Supp.2d at

886-887 (“Social Security Ruling 02-1p does not provide precise height and weight requirements

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879, 886 (D. Md. 2004) (“In this case the ALJ failed to consider the plaintiff’s

obesity when finding the plaintiff’s impairments and identifying impairments,

or combinations of impairments, which were severe. [] Thus, the ALJ failed

to make a determination as to whether the plaintiff’s obesity alone was a

severe impairment, and the effects the plaintiff’s obesity had on his other

impairments.”); cf. Allison v. Commissioner of Social Security, 347 F.Supp.2d

439, 446 (E.D. Mich. 2004) (“This Court recognizes that obesity can cause a

person to be disabled, especially when in concert with other factors.”); Shoate

v. Barnhart, 2003 WL 21556939, *3 (N.D. Cal. 2003) (“Even if Shoate’s

obesity did not constitute a ‘severe impairment’ by itself, the objective medical

evidence of obesity in combination with the evidence or arthritis in her weightbearing joints could ‘reasonably be expected to . . . produce some degree of

symptom.’”). In completely failing to analyze plaintiff’s obesity at step 2,3

 the

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 9 of 12
for obesity. Instead it states that the existence of obesity is established by: ‘generally rely[ing] on

the judgment of a physician who has examined the claimant and reported his or her appearance

and build, as well as weight and height. Thus in the absence of evidence to the contrary in that

case record, we will accept a diagnosis of obesity given by a treating source or consultative

examiner.”).

4 The evidence in this case is not like that in other cases where courts have found

that the record did not establish that a claimant’s weight contributed to her other conditions or

impairments. See, e.g., Prochaska v. Barnhart, 2005 WL 901202, *9 (W.D. Wis. 2005) (“Dr.

Lochmann, the doctor who evaluated plaintiff’s knee pain, did not suggest that plaintiff’s knee

pain was exacerbated by her obesity and he did not advise plaintiff to lose weight. In contrast to

other cases in which courts have chastised ALJs for ignoring the effects of obesity, . . . the record

in this case does not suggest that plaintiff’s excessive weight contributes to her back or knee

conditions.”). In contrast to Prochaska, as the ALJ’s very decision establishes, Jackson’s obesity

contributes to her musculoskeletal conditions, particularly her back impairment. (Compare Tr.

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ALJ did not abide by the Commissioner’s very regulations which require the

adjudicator to determine whether a claimant suffers from a severe impairment

or combinations of impairments, 20 C.F.R. § 404.1520(c) (2005), and where

multiple impairments exist, to “consider the combined effect of all of [the]

impairments without regard to whether any such impairment, if considered

separately, would be of sufficient severity. If . . . a medically severe

combination of impairments [is found], the combined impact of the

impairments will be considered throughout the disability determination

process.” 20 C.F.R. § 404.1523. Therefore, this Court can reach no other

conclusion but that the ALJ committed reversible error by failing to explain

why he “did not consider obesity an impairment, severe or not severe, at step

two[.]” Boston, supra, 332 F.Supp.2d at 885.4

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 10 of 12
18 & 19 (“Dr. Middleton noted that the claimant was obese, that she walked with an antalgic

gait, and that she had tenderness to percussion in her low back. . . . He recommended that the

claimant take muscle relaxers and anti-inflammatory medications and that she lose weight.”) &

Tr. 20 (“[I]t appears as though the claimant underwent neurological evaluation at the Stanton

Road Clinic in March, 2002 and April, 2002. . . . It was also recommended that she lose weight

and perform back strengthening exercises.”) with, e.g., Tr. 333 (“[Dr. Middleton] suggest[s] I

call in an Rx for muscle relaxers and anti-inflammatories, also he feels you need to lose wt. in

order to have a healthy back.”)) 

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In light of the foregoing, this cause is REMANDED to the

Commissioner of Social Security for consideration of plaintiff’s severe

physical impairments, the precise functional limitations attendant to that

combination of severe impairments, and a determination of whether plaintiff

is capable of performing her past relevant work or any other job existing in

significant numbers in the national economy in light of her functional

limitations.

CONCLUSION

The Court ORDERS that the decision of the Commissioner of Social

Security denying plaintiff benefits be reversed and remanded pursuant to

sentence four of § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct.

2157, 115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this

decision. The remand pursuant to sentence four of § 405(g) makes the plaintiff

a prevailing party for purposes of the Equal Access to Justice Act, 28 U.S.C.

§ 2412, Shalala v. Schaefer, 509 U.S. 292, 113 S.Ct. 2625, 125 L.Ed.2d 239

Case 1:05-cv-00528-C Document 23 Filed 05/12/06 Page 11 of 12
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(1993), and terminates this Court’s jurisdiction over this matter.

DONE and ORDERED this the 11th day of May, 2006.

s/WILLIAM E. CASSADY 

UNITED STATES MAGISTRATE JUDGE

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