Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_14-cv-02338/USCOURTS-alnd-2_14-cv-02338-0/pdf.json

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

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1

UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

JEFFERY LAVON DUNCAN,

Plaintiff,

v.

CAROLYN COLVIN, 

Commissioner, Social Security 

Administration,

Defendant.

}

}

}

}

}

}

}

}

}

}

}

Case No.: 2:14-cv-02338-JEO

MEMORANDUM OPINION

Plaintiff Jeffery Lavon Duncan (hereinafter “Plaintiff” or “Duncan”) brings 

this action pursuant to 42 U.S.C. § 405(g), seeking review of the final decision of 

the Acting Commissioner of Social Security (“Commissioner”) denying his

application for disability insurance benefits. (Doc. 1).

1

 This case has been 

assigned to the undersigned United States Magistrate Judge pursuant to this court’s 

general order of reference. The parties have consented to the jurisdiction of this 

court for the disposition of the matter. (Doc. 16). See 28 U.S.C. § 636(c), Fed. R. 

Civ. P. 73(a). Upon review of the record and the relevant law, the undersigned 

finds that the Commissioner’s decision is due to be remanded. 

 1

References herein to “Doc. ___” are to the electronic numbers at the top of each pleading that 

are assigned by the Clerk of the Court

FILED

 2016 Aug-31 AM 08:56

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 1 of 26
2

I. PROCEDURAL HISTORY

Plaintiff filed his application for disability insurance benefits under Title II 

of the Social Security Act on October 1, 2013, alleging that he became disabled 

beginning September 1, 2008. (R. 218).

2

 His application was initially denied on 

January 21, 2014. (R. 156). On August 19, 2014, following a hearing, an 

Administrative Law Judge (“ALJ”) denied Plaintiff’s application for disability 

benefits, concluding that he is not disabled under the Social Security Act. (R. 81). 

The Appeals Council declined to grant review of the ALJ’s decision. (R. 1). 

Plaintiff then filed this action for judicial review pursuant to § 205(g) of the Social 

Security Act, 42 U.S.C. § 405(g). (Doc. 1, p. 1). 

II. STANDARD OF REVIEW

In reviewing claims brought under the Social Security Act, this court’s role 

is a narrow one. “Our review of the Commissioner’s decision is limited to an 

inquiry into whether there is substantial evidence to support the findings of the 

Commissioner, and whether the correct legal standards were applied.” Wilson v. 

Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002); see also Lamb v. Bowen, 847 F.2d 

698, 701 (11th Cir. 1988). Plaintiff must demonstrate that the decision of the 

Commissioner is not supported by substantial evidence. See, e.g., Allen v. 

 2

References herein to “R. ___” are to the administrative record located at Document 8 (Answer 

of the Commissioner).

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 2 of 26
3

Schweiker, 642 F.2d 799 (5th Cir. (Unit B) 1981).3 “Substantial evidence is more 

than a scintilla and is such relevant evidence as a reasonable person would accept 

as adequate to support a conclusion.” Winschel v. Comm’r. of Soc. Sec., 631 F.3d 

1176, 1178 (11th Cir. 2011) (internal quotations and citations omitted). The court 

gives deference to factual findings and reviews questions of law de novo. 

Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991). The court “may not 

decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of 

the [Commissioner], rather [it] must scrutinize the record as a whole to determine 

if the decision reached is reasonable and supported by substantial evidence.” 

Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990) (quoting Bloodsworth v. 

Heckler, 703 F.2d 1233, 1239 (11th Cir. 1982)) (internal quotations and other 

citations omitted); see also Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 

2005). However, because questions of law are reviewed de novo, “[n]o ... 

presumption of validity attaches to the [Commissioner’s] conclusions of law.” 

Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982).

III. STATUTORY FRAMEWORK

To qualify for disability benefits, a claimant must show “the inability to 

engage in any substantial gainful activity by reason of any medically determinable 

 3 Decisions by a Unit B panel of the former Fifth Circuit are binding precedent in the Eleventh 

Circuit. Stein v. Reynolds Sec., Inc., 667 F.2d 33, 34 (11th Cir. 1982).

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 3 of 26
4

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); 42 U.S.C. § 416(i). A physical or mental 

impairment is “an impairment that results from anatomical, physiological, or 

psychological abnormalities which are demonstrable by medically acceptable 

clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3).

Determination of disability under the Social Security Act requires a five step 

analysis. 20 C.F.R. § 404.1520(a). Specifically, the Commissioner must 

determine in sequence:

whether the claimant: (1) is unable to engage in substantial gainful 

activity; (2) has a severe medically determinable physical or mental 

impairment; (3) has such an impairment that meets or equals a Listing 

and meets the duration requirements; (4) can perform his past relevant 

work, in light of his residual functional capacity; and (5) can make an 

adjustment to other work, in light of his residual functional capacity, 

age, education, and work experience.

Evans v. Comm’r of Soc. Sec., 551 F. App’x 521, 524 (11th Cir. 2014)4 (citing 20 

C.F.R. § 404.1520(a)(4)). “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 

 4 Unpublished opinions of the Eleventh Circuit Court of Appeals are not considered binding 

precedent; however, they may be cited as persuasive authority. 11th Cir. R. 36-2.

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 4 of 26
5

Cir. 1986). “Once a finding is made that a claimant cannot return to prior work the 

burden shifts to the Secretary to show other work the claimant can do.” Foote v. 

Chater, 67 F.3d 1553, 1559 (11th Cir. 1995) (citation omitted). The Commissioner 

must further show that such work exists in the national economy in significant 

numbers. Id.; Evans, 551 F. App’x at 524.

IV. PLAINTIFF’S HISTORY

Duncan was admitted for treatment on November 8, 2005, to Brookwood 

Medical Center for psychiatric symptoms. He was upset that he was being forced 

to retire from the Army. He “threatened to shoot the people who made this 

decision.” (R. 303). The admission notes state that “[h]e has spells where he has 

rage in which he just screams, hollers and gets uncontrollable. He has talked of 

killing himself. He does not talk to his wife much. He does not sleep much. He 

does not seem right.” (Id.) He admitted to having thoughts of wanting to hurt 

himself and others. (Id.) He was diagnosed with “[m]ajor depressive disorder 

[versus] adjustment disorder with mixed disturbance in emotion and conduct.” (R. 

306). Duncan was discharged on November 22, 2005, in stable condition. (R. 

305).

Duncan was determined to be disabled by the Veteran’s Administration 

(“VA”) with a 90 percent service-connected rating. Seventy percent of his 

disability was determined to be premised on a major depressive disorder and 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 5 of 26
6

twenty percent was premised on degenerative arthritis of the spine. (R. 70, 318). 

According to his VA health summaries, it was “very unlikely” that Duncan “could 

obtain and maintain any meaningful gainful employment requiring any significant 

interaction with other people.” (R. 371). The summaries further report that it 

appears “[Duncan’s] combination of service-connected disabilities make it 

extremely unlikely that he will be able to obtain and maintain meaningful 

employment unless or until he experiences a significant improvement in 

functioning.” (R. 371-72). Additional comments in the summary also note that 

Duncan has “significant problems” with activities of daily living due to physical 

pain, anhedonia,5 and depression. (R. 370). His psycho-socio impairment was 

rated at “moderately severe.” (R. 377). His remote memory and recent memory 

were moderately impaired. (Id.) The notes also reflect that Duncan has moderate 

high frequency hearing loss in the right ear and moderate high frequency hearing 

loss in the left ear. (R. 374).

From March 2010 to November 2013, Duncan received much of his medical 

treatment for various conditions, including back problems, depression, sleep apnea, 

hearing loss, and hip and knee pain, from the VA in Birmingham, Alabama. (R. 

310-573). 

 5 Anhedonia is “a psychological condition characterized by the inability to experience pleasure in 

normally pleasurable acts.” (http://www.meriam-webster.com/disctionary/anhedonia (last 

visited August 29, 2016)). 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 6 of 26
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On March 20, 2010, Duncan was evaluated by Dr. Brian McFarland as part 

of a supplemental compensation and pension examination. Duncan complained he 

was “chronically depressed, [and suffering from] anhedonia, low energy, poor 

concentration, poor sleep, irritability, ruminations, crying spells, nightmares, and 

anxiety.” (R. 71, 556). Dr. McFarland found that Duncan’s “disabilities made it 

extremely unlikely that he would be able to obtain and maintain any meaningful 

employment unless or until he experienced a significant improvement in 

functioning.” (R. 72).

Duncan was seen on May 14, 2010, for a compensation and pension 

examination for a spine disorder. Dr. Isabel M. Baren noted that his “tenderness 

was not severe enough to cause an abnormal gait or spinal contour,” the “spine was 

without painful range of motion,” and “[p]ainful range of motion was produced in 

the thoraco-lumbar spine.” (R. 71). Diagnostic imaging showed minor 

degenerative changes in the cervical and lumbosacral spinal regions. (Id.) Dr. 

Baren diagnosed Duncan with degenerative disc disease that “affected his ability to 

perform physical but not sedentary employment.” (R. 71, 534-35, 543).

Duncan was seen at the VA on July 13, 2012, June 26, 2013, and November 

5, 2013, for complaints of pain in his hip and ankle. (R. 71-72). The examinations 

were unremarkable.

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 7 of 26
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Duncan underwent a physical consultative examination with Dr. Jason 

Markle on December 10, 2013. He complained of pain in his lower back, hips, and 

knees. (R. 575). He further complained of numbness and tingling in his left leg 

along with a burning sensation in his anterior thigh. (R. 73). While noting that

Duncan had pain on his left side during the straight leg raising tests and tenderness 

to palpation and paravertebral muscle spasms in the lumbral sacral spine and 

paravertebral muscles, Dr. Markle concluded that Duncan’s physical examination 

revealed the “severity of complaint appears to be out of the scope of the 

pathology....” (R. 576). Dr. Markle diagnosed Duncan with “[l]umbar 

degenerative disc disease with questionable S1 radiculopathy.” (R. 578). He also 

limited Duncan to siting to a maximum of less than two hours, stating “[for 

a]nybody with a herniated disc, sitting would be very difficult where it would 

increase his pressure on intradiscal pressure.” (R. 579).

Dr. Randall Griffith, a clinical neuro-psychologist, conducted a consultative 

psychological evaluation of Duncan on December 17, 2013. He determined that 

Duncan suffered from a major depressive disorder of moderate severity, 

complicated by his chronic pain. (R. 583). Dr. Griffith found that Duncan’s 

“ability to function independently appeared borderline to mildly limited.” (R. 

584). He also stated:

Despite his impairments, Mr. Duncan appears able to understand and carry 

out reasonably detailed instructions, although his depression and pain would 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 8 of 26
9

likely result in some difficulties with concentration and memory. He has some 

guardedness but otherwise would not respond inappropriately to supervisors, 

coworkers, and the public. His ability to tolerate work stress appears 

moderately reduced.

(R. 582).

Duncan had an MRI on March 27, 2014, due to acute, intractable back pain 

secondary to L5-S1 left sided radiculopathy. (R. 755). It revealed two bulging 

discs. (Id.) He had a microdiscectomy and a left L-4, 5 hemilaminectomy on 

April 8, 2014. (R. 787-88).

On May 7, 2014, Dr. Samuel Saxon conducted a psychological consultation 

evaluation of Duncan. (R. 817). He determined that Duncan suffers from major 

depression with thought disturbance, ADHD, and mixed personality disorder with 

passive aggressive and schizo and paranoid traits. (R. 819). He also found that 

Duncan could not be expected to be reliable in attending work. (R. 821). 

V. DISCUSSION 

Duncan makes three arguments on appeal of the ALJ’s decision. The first is 

that the ALJ improperly determined his RFC by ignoring the weight of the medical 

record. (Doc. 10 at 10-11). Next, Duncan argues that the ALJ failed to consider 

and assign proper weight to both the VA designation of disability and a report by 

Dr. Sam Saxon. (Id. at 11 & 17). Finally, Duncan argues that the ALJ improperly 

discredited his subjective pain testimony. (Id. at 11 & 21). 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 9 of 26
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The Commissioner’s retort to each argument is that: (1) the ALJ’s 

determination of the RFC was supported by substantial evidence throughout the 

record (doc. 14 at 5); (2) “the determination of another governmental agency... is 

not binding on the Commissioner” (id. at 20); and (3) the subjective testimony was 

not supported by the objective medical record, doctor notes, and Duncan’s daily 

living activities (id. at 7-9).

As will be discussed in detail below, because the court finds merit to certain 

of Duncan’s arguments, the case must be remand for further consideration. For the 

sake of organizational clarity, the court will address Duncan’s second issue first

because it implicates other issues as well. 

A. Dr. Sam Saxon’s Report

At the urging of his counsel, Duncan underwent a psychological exam by 

Dr. Sam Saxon on May 7, 2014. (R. 817-24). Dr. Saxon’s report is thorough, 

well-articulated, and detailed. His conclusions appear to be undergirded by 

specific medical testing. (Id.) Duncan asserts the ALJ erred in failing to consider 

this information. (Doc. 10 at 19-20). The Commissioner responds that “[t]he 

objective medical findings and other evidence from the relevant period, ... , 

support the ALJ’s assessment of Plaintiff’s RFC and hypothetical question to the 

VE....” (Doc. 14 at 18-19 (citation omitted)). She also argues the “evidence 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 10 of 26
11

would not change the substantial evidence from the relevant period that supports 

the ALJ’s Assessment....” (Id.)

The Eleventh Circuit Court of Appeals has “recognized that medical 

opinions based on treatment occurring after the date of the ALJ’s decision may be 

chronologically relevant” to the pertinent period. See Washington v. Comm’r of 

Soc. Sec., 806 F.3d 1317, 1322-23 (11th Cir. 2015) (citing Boyd v. Heckler, 704 

F.2d 1207, 1211 (11th Cir. 1983) (considering a “treating physician’s opinion” 

even though “he did not treat the claimant until after the relevant determination 

date”), superseded on other grounds by statute, 42 U.S.C. § 423(d)(5)); see also

Demandre v. Califano, 591 F.2d 1088, 1090 (5th Cir. 1979) (“a claimant must 

prove his disability existed prior to the last month in which this ‘20 out of 40’ test 

is met. If a claimant becomes disabled [a]fter he has lost insured status, his claim 

must be denied despite his disability.”); 20 C.F.R. § 404.1513. However, a 

showing that an impairment became disabling after the expiration of the claimant’s 

insured status is insufficient to establish eligibility for DIB. See Hughes v. Comm’r 

of Soc. Sec, 486 F. App’x 11, 13 (11th Cir. 2012) (“In order to qualify for DIB, an 

individual must prove that her disability existed prior to the end of her insured 

status period, and, after insured status is lost, a claim will be denied despite her 

disability.”) (citing Demadre, 591 F.2d at 1090). 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 11 of 26
12

Duncan acknowledges that December 31, 2013, was the last date he was 

insured. (Doc. 10 at 2). Similarly, it is agreed that the date of Dr. Saxon’s report 

was approximately four months after that date. The report provides that “[t]here is 

no reason to assume that [Duncan] could do anything very successfully at this 

point in time without active treatment of his [severe acquired Attention Deficit 

Hyperactivity Disorder].” (R. 819). Dr. Saxon also states that Duncan’s test 

results show the following:

He had extreme elevation on the depression scale and the 

schizophrenia scale in a way to suggest clearly that he has major 

depression with, most likely, thought disturbance. Secondarily, a 

diagnosis of Obsessive-Compulsive Disorder is very likely the case. 

He does also appear to be a very paranoid and passive aggressive 

individual, and I suspect a lot of the ideas that he has reflecting his 

hypersensitivity and suspiciousness could very well be delusional. At 

this point in time his superego functions seem to be rather reduced and 

he is clearly experiencing a weak ego strength, feeling very vulnerable 

and very likely to act out and possibly in a very unusual fashion. 

Therefore, effort to get him involved in a major way with a 

psychiatrist who is willing to follow him fairly closely for a while 

with anti-depressants, as well as benzothianzines may be able [to] 

help him. [T]o say the very least this gentleman should not be 

working anywhere anytime soon. Not only does he not have the 

mental stability to do it, he doesn’t have the capacity to focus, attend, 

and concentrate either.

(R. 46, 819). In the comment section, Dr. Saxon states:

This gentleman will be very difficult to treat, though he is in 

desperate need of it. In fact, one of the content scales called Negative 

Treatment Indicators is one of [the] highest Content Scales besides 

Depression and it really reflects the tendency on the part of these 

patients to have a variety of personality traits such as paranoia that 

causes them to resist significant treatment. The chronicity of this 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 12 of 26
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profile would suggest to this examiner also that his treatment should 

be ongoing, and even the resolution, this conflict between the VA 

disability statements and the social security ones, while obviously 

necessary and should be forthcoming, he will continue to have 

significant problems that would dictate continued involvement from a 

psychological point of view.

(R. 46-47, 819-20 (bold added)). Finally, Dr. Saxon found that Duncan had no 

ability work an eight-hour day, forty-hour week, week after week due to his 

depression, distraction, and pain; Duncan had no ability to concentrate, persist in 

his endeavors, or pace himself; he had no ability to adapt to stressful circumstances 

at work; he had poor to no ability to understand, remember and carry out complex 

instructions; he had poor ability to carry out detailed, but not complex instructions; 

he had poor ability to carry out simple instructions; and he had no ability to behave 

in an emotionally stable way or relate predictability in social situations. (R. 48-51, 

824).

At the administrative hearing before the ALJ on June 24, 2014, the 

vocational expert indicated that if Dr. Saxon opined that Duncan could not work an 

eight-hour day, a forty-hour week, week-after-week, in view of his symptoms –

depression, distraction and pain – that would preclude gainful employment. (R. 

137-40).

After closely examining the record, the undersigned is troubled by the fact 

that Dr. Saxon’s opinion evidence, which was discussed at the administrative 

hearing, was not addressed by the ALJ. The court recognizes that the evaluation 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 13 of 26
14

and opinion were rendered four months after the insured period expired and by a 

non-treating physician, but Dr. Saxon’s use of the work “chronicity” along with the 

depth of the issues identified and assessed by the VA and various doctors 

concerning Duncan’s mental health make the opinion relevant to the period at 

issue. The report and opinions therein should have been addressed by the ALJ.

The failure to address the report requires that this case be remanded for further 

examination.

The Commissioner argues that “[t]he objective medical findings and other 

evidence from the relevant period, ... , support the ALJ’s assessment” and the 

additional “evidence would not change the substantial evidence from the relevant 

period...” (Doc. 14 at 18-19). This court is not so convinced. The court believes 

that because Dr. Saxon’s report is sufficiently detailed and substantive it is 

particularly relevant to the insured period and Duncan’s persistent complaints, and

should have been examined by the ALJ. Whether the report impacts the prior 

determination is a matter best left for the ALJ under the circumstances. 

B. The VA Disability Designation 

Duncan next argues that the ALJ failed to properly assign great weight to his 

VA Disability Rating. (Doc. 10 at 17). The Commissioner responds that Duncan

has failed to meet his burden to show that he was disabled under the standards of 

the Social Security Act. (Doc. 14 at 20).

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 14 of 26
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As noted previously, Duncan has a 70 percent disability rating from the VA 

due to major depression and a 20 percent disability rating due to degenerative 

arthritis of the spine. (R. 318, 320, 325). The VA further determined Duncan was 

unemployable. (R. 370). After explaining that “a decision by ... any other 

governmental agency about whether a claimant is disabled ... is based on its rules 

and is not our decision,” the ALJ stated in his decision that he “carefully 

considered the [VA] determination as well as the opinions of Drs. Baren and 

McFarland, but d[id] not regard them as dispositive.” (R. 78).

Social Security regulations state that a “decision by .... any other 

governmental agency about whether you are disabled... is based on its rules and is 

not our decision about whether you are disabled.” 20 C.F.R. § 404.1504. “A 

determination made by another agency that you are disabled ... is not binding on 

[the Commissioner].” Id. Nevertheless, an ALJ is required to give great weight to 

a VA disability finding and, if it is rejected, the ALJ should provide adequate 

explanation as to why the disability finding was rejected. See Rodriguez v. 

Schweiker, 640 F.2d 682, 686 (5th Cir. 1979) (per curium) (“Although the ALJ 

mentioned the Veterans Administration disability rating on Rodriguez, he 

obviously refused to give it much weight. A VA rating is certainly not binding on 

the Secretary, but it is evidence that should be considered and is entitled to great 

weight. A VA rating of 100% disability should have been more closely scrutinized 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 15 of 26
16

by the ALJ”) (internal citations omitted); see also Ostborg v. Comm’r of Soc. Sec., 

610 F. App’x 907, 915 (11th Cir. 2015) (“The ALJ’s specific reasons for 

discounting the VA’s determination show he considered and closely scrutinized 

that determination; consequently, the ALJ did not misapply the law in discounting 

it.”); Barraza v. Barnhart, 61 F. App’x 917 (5th Cir. 2003) (“ALJs need not give 

great weight to a VA disability determination if they adequately explain the valid 

reasons for not doing so.”).

The issue before the court at this juncture is whether the ALJ provided an 

adequate explanation for finding the VA disability determination – and, by proxy, 

the opinions of Drs. Baren and McFarland – not “dispositive.” (R. 78). In his 

opinion, the ALJ provides three reasons for why he rejected the conclusions of the 

VA and its doctors: (1) “treating records from the Veterans’ Administration fail to 

corroborate the alleged degree of severity prior to December 2013” (R. 77); (2) 

“the claimant maintained the ability to attend church and participate in 2 model 

railroad clubs by attending monthly meetings during the period of time at issue” 

(id.); and (3) the assessments of Drs. Markle and Griffith are both consistent with 

the record and inconsistent with the VA’s conclusion that Duncan was disabled (id.

at 78). Because the undersigned finds that the second and third reasons articulated 

by the ALJ necessitate further review of the larger issue by him, they will be 

addressed first.

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 16 of 26
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i. The stated daily living activities do not provide substantial 

evidence to reject the VA’s disability determination.

It is well established in the Eleventh Circuit that “participation in everyday 

activities of short duration, such as housework or fishing, [does not disqualify] a 

claimant from disability.” Lewis v. Callahan, 125 F.3d 1436, 1441 (11th Cir. 

1997). Daily activities are dispositive when they indicate that a claimant could 

handle the stress of a daily occupation. See Bennett v. Barnhart, 288 F. Supp. 2d 

1246, 1252 (N.D. Ala. 2003) (“It is the ability to engage in gainful employment 

that is the key, not whether a plaintiff can perform minor household chores or drive 

short distances.”). Duncan’s ability to participate in limited and minimal activities

of daily living is not adequate to discard the VA’s disability determination without 

additional explanation.

6

 However, this evidence should be reconsidered when the 

ALJ assesses Dr. Saxon’s evaluation and opinions. See Harwell v. Heckler, 735 

F.2d 1292, 1293 (11th Cir. 1984) (“the ALJ properly considered a variety of 

factors, including the claimant’s use of pain-killers and his daily activities, in 

making the finding about pain”); Moore v. Barnhart, 405 F.3d 1208, 1212 (11th 

Cir. 2005) (“the ALJ questioned Moore’s contentions that she could not maintain 

 6 The court is not impressed by the fact that Duncan attends church and monthly meetings of two 

model railroad clubs. The skill set required to participate in such activities does not equate well 

to consideration of whether Duncan could adequately perform at work in view of his purported 

mental limitations. The Commissioner also notes in her brief that “Plaintiff shops for groceries, 

reads, drives his granddaughter to school ... watches TV, unloads the dishwasher, occasionally 

mows the lawn, wipes down the counters, ... cares for his pets ... [and] help[ed] care for his 

granddaughter.” (Doc. 14 at 10 (citing R. 77, 113, 258-62, 582)). Again, the court is not 

convinced these additional activities equate well to the work situation in this instance.

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 17 of 26
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consciousness or perform light work, in light of her ability to drive, provide 

childcare, bathe and care for herself, exercise, and perform housework”).

ii. The assessments of Drs. Markle and Griffith alone are not good 

cause to reject the VA’s disability determination.

Dr. Baren, a VA doctor, examined Duncan on May 13, 2010. (R. 520-44). 

After her physical examination, Dr. Baren concluded that Duncan suffered from 

“degenerative joint disease [of the] lumbar spine” and of the “cervical spine.” (R. 

543). Both diseases impacted Duncan’s ability to perform chores. (Id.) Both 

situations were found to affect “[Duncan’s] ability to perform physical but not 

sedentary employment.” (Id.)

Dr. Markle examined Duncan on December 10, 2013. (R. 574-79). Like Dr. 

Baren, Dr. Markle focused on Duncan’s physical impairments. (R. 575). Dr. 

Markle opined that “[t]here are inconsistencies based off medical review of records 

and the minor degenerative changes seen throughout his imaging over recent films 

and the severity of complaint appears to be out of the scope of the pathology seen 

on report.” (R. 576). Dr. Markle diagnosed Duncan with “Lumbar degenerative 

disease with questionable S1 radiculopathy.” (R. 578). Dr. Markle concluded his 

examination by opining:

Maximum standing and walking: Up to four hours.

Maximum sitting: Less than two hours given focal findings on 

examination. Anybody with a herniated disc, sitting would be very 

difficult where it would increase his pressure on intradiscal 

pressure. 

Case 2:14-cv-02338-JEO Document 17 Filed 08/31/16 Page 18 of 26
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Assistive devices: None needed or used.

Maximum lifting: Occasionally 10-20 pounds, and frequently 5-10 

pounds. 

Gross/fine manipulative activities: Reaching, handling, fingering or 

feeling no limitations.

Postural limits: steps, stairs, ladders, scaffolds, ropes, stoops, crouch, 

kneel or crawl frequently to occasionally. Postural limits may 

exacerbate radiculopathy. 

Workplace environment: hearing, speaking, traveling or hazards no 

limitations.

(R. 579 (bold added)).

While Dr. Markle’s opinion tends to support the ALJ’s finding that Duncan 

was not disabled due to his back and hip pain, there is no discussion or analysis of 

the fact that Dr. Markle has a concern that Duncan would be limited in his ability 

to sit. Dr. Baren states that Duncan could only perform sedentary work while Dr. 

Markle indicates that sedentary work should be avoided because of Duncan’s 

herniated disk. This discrepancy is complicated by the fact that one of Duncan’s 

discs apparently ruptured in January 2014, requiring surgery in April 2014. (R. 76, 

100). There is, however, no discussion or analysis of these events and their impact 

on Duncan’s RFC. Accordingly, the undersigned finds that the circumstances 

require that the case be remanded for further consideration on this issue as well.

Concerning Duncan’s mental health, Dr. McFarland performed a mental 

health exam on Duncan for the VA on March 23, 2010. (R. 365). Dr. McFarland 

noted that Duncan “[c]ontinues to report and exhibit chronically depressed mood, 

anhedonia, low energy, poor energy, poor concentration, poor sleep, irritability, 

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ruminations, crying spells, nightmares, and anxiety.” (R. 367). Duncan’s mood 

was described as “Hopeless, Depressed, Labile,” though he was both attentive and 

properly oriented. (R. 368-69). Duncan’s thought process was unremarkable and 

his impulse control was fair. (R. 369). Dr. McFarland noted that Duncan had 

“[s]ignificant problems with ADLS due to physical pain, anhedonia, and 

depression.” (R. 370). Duncan’s recent memory was described as “mildly 

impaired” even though he was found to be “capable of managing financial affairs.” 

(Id.) Dr. McFarland concluded by opining:

Medical records indicate that this veteran’s service-connected general 

medical disabilities would make it extremely difficult for him to 

obtain and maintain any meaningful gainful employment requiring 

any level of physical exertion. Medical records, and this examination, 

indicate that it would be very unlikely that this veteran could obtain 

and maintain any meaningful gainful employment requiring any 

significant interaction with other people. 

Overall, it appears that the veteran’s combination of [mild chronic 

pain] make it extremely unlikely that he will be able to obtain and 

maintain any meaningful employment unless or until he experiences a 

significant improvement in functioning. 

(R. 371-72). 

Dr. Griffith performed a mental health examination of Duncan in December 

2013. (R. 581-84). Dr. Griffith noted that Duncan’s “mood was ‘normal’ although 

he admitted to having no joy. Affect at times was flat and dysphoric.” (R. 582). 

Dr. Griffith reported that Duncan was fully oriented and held mostly normal

attention and concentration. (R. 583). Duncan’s short term memory “appeared 

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intact.” (R. 583). Duncan “appeared to be a fair to reasonable personal historian,” 

and “gave marginally abstract responses to items of similarity.” (R. 583). 

Duncan’s thought processes were described as “logical and goal oriented,” though 

his thought content appeared to contain “[p]assive suicidal thoughts.” (R. 583).

From the medical records and personal examination, Dr. Griffith diagnosed 

Duncan with “Major depressive disorder, moderate severity.” (R. 583). In 

explaining Duncan’s prognosis, Dr. Griffith wrote:

Mr. Duncan’s prognosis appears guarded to poor. Mr. Duncan 

presented evidence of a major depressive disorder of moderate 

severity. However, he appears to have limited insight into the nature 

of his depression and likely has little motivation for treatment of his 

depression, although he might benefit from treatment of his 

depression over the next 3 to 6 months. As well, a complicating 

factor is Mr. Duncan’s chronic pain.

Mr. Duncan’s ability to function independently appeared borderline to 

mildly limited. He has limited to no motivation for activities, likely 

partly due to depression as well as chronic pain. He has very few 

social or recreational interests. Although Mr. Duncan has experience 

in the past with management of finances, his wife is currently doing 

so. He might need short-term assistance with management of 

financial benefits. 

Despite his impairments, Mr. Duncan appears able to understand and 

carry out reasonably detailed instructions, although his depression and 

pain would likely result in some difficulties with concentration and 

memory. He has some guardedness but otherwise would not respond 

inappropriately to supervisors, coworkers, and the public. His ability 

to tolerate work stress appears moderately reduced. 

The impact of the claimant’s physical symptoms on her/his cognitive 

and psychiatric symptoms was considered in this formulation. 

However, direct evaluation of the claimant’s physical symptoms and 

chronic medical conditions is beyond this examiner’s expertise. 

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(R. 583-84). 

While the reports of Drs. McFarland and Griffith contain differences of 

opinion on some issues,7 there are disturbing similarities. Both doctors conclude 

that Duncan suffers from a major depressive disorder, which is exacerbated by his 

chronic pain, and that Duncan would have at least some concentration and 

memorization difficulties while employed. Thus, the court finds that the analysis 

and reliance on either report, without consideration of Dr. Saxon’s opinions,

warrants a remand for additional review. See Cowart v. Schweiker, 662 F.2d 731, 

735 (11th Cir. 1981) (“What is required is that the ALJ state specifically the weight 

accorded to each item of evidence and why he reached that decision. In the 

absence of such a statement, 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.”).

iii. VA treating records fail to corroborate the severity of Duncan’s 

limitations prior to December 2013.

The ALJ found that the treating records from the VA fail to corroborate the 

alleged degree of severity prior to December 2013. (R. 77). In view of the court’s 

determinations on the foregoing issues, it will be necessary to remand this case. 

 7 Dr. McFarland expresses some concern with Duncan’s memory while Dr. Griffith does not; Dr. 

Griffith expresses concern over Duncan’s ability to manage his finances, while Dr. McFarland 

does not.

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That will allow for further evaluation of the VA records along with the other, 

previously unconsidered evidence. Accordingly, the court pretermits any further 

discussion concerning whether the VA records support the severity of Duncan’s 

limitations during the relevant period. 

C. Complaints of Pain

Duncan alleges that the ALJ improperly discredited his testimony 

concerning the amount of his pain. (Doc. 10 at 10). Specifically, he asserts “the 

ALJ made no finding whatsoever as to whether [his] medically determinable 

impairments could reasonably be expected to cause the alleged symptoms.” (Id. at 

22). He then concludes “that the presence of 2 bulging discs and left-sided 

radiculopathy could reasonably be expected to cause the symptoms of pain as 

alleged.” (Id.) The Commissioner responds that the ALJ properly considered 

Duncan’s subjective complaints of pain and other symptoms. (Doc. 14 at 6 (citing 

R. 76-79)). 

In evaluating a disability claim involving subjective complaints such as 

pain, United States District Judge L. Scott Coogler has stated:

In order to establish a disability on the basis of subjective testimony of 

pain and other symptoms, the claimant must present evidence to 

support the Eleventh Circuit’s pain standard. Under this standard, a 

plaintiff must present (1) evidence of an underlying medical 

condition; and (2) either a) objective medical evidence confirming the 

severity of the alleged symptoms or b) that the objectively determined 

medical condition is of such a severity that it can reasonably [be] 

expected to give rise to the alleged pain. See 20 C.F.R. § 404.1529(a) 

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(2011); Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1991) (citing 

Holt v. Sullivan, 921 F.2d 1221, 1225 (11th Cir. 1991)). If the 

claimant established an impairment that could reasonably be expected 

to cause his alleged symptoms, the ALJ is obligated to evaluate the 

claimant’s subjective complaints, including intensity and persistence 

of the alleged symptoms and their effect on the claimant’s ability to 

work. Hogard v. Sullivan, 733 F. Supp. 1465, 1469 (M.D. Fla. 1990). 

The ALJ may discredit this type of pain testimony only by articulating 

“explicit and adequate reasoning” based on substantial evidence from 

the record. Foote, 67 F.3d at 1561; Wilson, 284 F.3d at 1225.

Parker ex rel. Parker v. Colvin, 2013 WL 2635696, *3 (N.D. Ala. June 10, 2013). 

A reversal is warranted if the decision of the ALJ contains no indication of proper 

application of the three-part standard. Holt, 921 F.2d at 1223. If the ALJ’s 

reasoning is not supported by substantial evidence, the pain testimony of the 

plaintiff must be accepted as true. Hale v. Bowen, 831 F.2d 1007, 1012 (11th Cir. 

1987).

In assessing credibility, the ALJ should consider the following factors: (1) the 

individual’s daily activities; (2) the location, duration, frequency, and intensity of 

the pain; (3) any precipitating and aggravating symptoms; (4) the medications 

taken to alleviate pain, and their side effects and effectiveness; (5) other treatment 

to relieve pain; (6) other measures to relieve pain; and (7) other factors concerning 

functional limitations and restrictions. 20 C.F.R. § 404.1529(c)(3); SSR 96-7p, 

1996 WL 374186, *3. These factors are to be evaluated in light of all the other 

evidence of record in making the necessary credibility choices. 20 C.F.R. § 

404.1529(c)(4).

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Duncan’s primary complaint concerning pain is related to his back. At his 

administrative hearing, Duncan testified that he experienced a bulging spinal disc 

in 1997. (R. 76). Over many years, he received medical treatment including pain 

management, physical therapy, injections, and recommendations that he exercise 

and lose weight. (Id.) Overall, his complaints were moderate and the treatment 

was modest. (R. 355, 360-62, 535-43). Physical examinations typically 

demonstrated that he had normal gait and posture with normal range of motion of 

the lumbar and cervical spine. (R. 78, 345, 351, 357, 360-61, 526, 537, 541-43). 

X-rays in May 2010 showed only mild to minor degenerative changes in the 

cervical and lumbrosacral spinal regions. (R. 361-62, 542-43). However, in 

December 2013, Duncan reported to Dr. Griffith that his “back pain never stops 

and that he usually will lay [sic] down in the bed to try not to hurt. On a good day 

his back pain is a 3 or 4/10 but on a bad day his back will ‘go out.’”8

 (R. 581). 

Shortly thereafter, in January 2014, one of Duncan’s discs ruptured. This resulted 

in Duncan having back surgery in April 2014.

Because the ALJ appears to have under-assessed Duncan’s pain during 

December 2013 and because he did not discuss the impact of the medical records 

concerning Duncan’s back from January through April 2014 (see R. 744-814, 826-

 8 The ALJ’s decision simply recites that Duncan’s “back pain was no greater than 3 or 4 on a 10-

point scale.” (R. 78). The ALJ also makes no mention of the fact that Dr. Griffith stated in the 

prognosis section of his report that Duncan’s prognosis is “guarded to poor” and is complicated 

by the fact that he is in “chronic pain.” (R. 583).

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41), the matter is due to be remanded for further consideration. This is particularly 

necessary in view of the fact that the ALJ afforded significant weight to the 

opinion of Dr. Griffith, which includes the reference to significant pain during the 

relevant period.

9

 D. The ALJ’s RFC Findings.

Duncan’s counsel argues that the ALJ improperly determined Duncan’s 

RFC. In view of the court’s findings above, it will be necessary to remand this 

case for further review and evaluation. Depending upon the ALJ’s determinations 

as to the foregoing matters, there will be a need to review Duncan’s RFC 

determination. 

VI. CONCLUSION

For the reasons set forth above, the undersigned finds that the decision of the 

Commissioner is not supported by substantial evidence and this case should be 

remanded for further review and evaluation.

DATED, this 31st day of August, 2016.

_________________________________

JOHN E. OTT

Chief United States Magistrate Judge

 9 To the extent the Commissioner argues that the activities of daily living lend support to the 

ALJ’s credibility and RFC findings as they relate to Duncan’s physical limitations, the court 

notes this evidence is more probative on this issue than on the mental health issue discussed 

previously. (See footnote 6 herein). 

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