Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_14-cv-00018/USCOURTS-alsd-1_14-cv-00018-0/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)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

MONEKE LATASHA NELMS, *

 *

 Plaintiff, * CIVIL ACTION NO. 14-00018-B

 *

vs. *

 *

CAROLYN W. COLVIN, *

Commissioner of Social Security,*

* 

Defendant. *

ORDER

Plaintiff Moneke Latasha Nelms (hereinafter “Plaintiff”)

brings this action seeking judicial review of a final decision 

of the Commissioner of Social Security denying her claim for a 

period of disability, disability insurance benefits, and 

supplemental security income under Titles II and XVI of the 

Social Security Act, 42 U.S.C. §§ 401, et seq., and 1381, et 

seq. On October 15, 2014, the parties waived oral argument, and 

on October 21, 2014, they consented to have the undersigned 

conduct any and all proceedings in this case. (Docs. 16, 18). 

Thus, the action was referred to the undersigned to conduct all 

proceedings and order the entry of judgment in accordance with 

28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73. Upon 

careful consideration of the administrative record and the 

memoranda of the parties, it is hereby ORDERED that the decision 

of the Commissioner be AFFIRMED. 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 1 of 23
2

I. Procedural History

Plaintiff filed an application for a period of disability, 

disability insurance benefits and supplemental security income 

on March 3, 2011. 1 (Tr. 173). Plaintiff alleged that she had

been disabled since November 10, 2010, due to a “slipped disc in 

back[;] right leg is numb[;] [and] diabetic.” (Id. at 172, 175).

Plaintiff’s applications were denied, and upon timely request, 

she was granted an administrative hearing before Administrative 

Law Judge Kim McClain-Leazure (hereinafter “ALJ”) on May 11, 

2012. (Id. at 30). Plaintiff attended the hearing with her

counsel and provided testimony related to her claims. (Id. at 

33). A vocational expert (“VE”) also appeared at the hearing 

and provided testimony. (Id. at 45). On July 16, 2012, the ALJ 

issued an unfavorable decision finding that Plaintiff is not

disabled. (Id. at 23). The Appeals Council denied Plaintiff’s 

request for review on November 20, 2013. (Id. at 1). Thus, the 

ALJ’s decision dated July 16, 2012, became the final decision of 

the Commissioner. 

Having exhausted her administrative remedies, Plaintiff 

timely filed the present civil action. (Doc. 1). The parties 

agree that this case is now ripe for judicial review and is 

 1 Plaintiff filed a prior claim on April 3, 2009, which was 

denied and was pending at the Appeals Council level at the time 

that she filed the instant claim. (Tr. 174).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 2 of 23
3

properly before this Court pursuant to 42 U.S.C. §§ 405(g) and 

1383(c)(3).

II. Issue on Appeal

Whether the ALJ erred in giving “little 

weight” to the opinions of Plaintiff’s

treating physician?

III. Factual Background

Plaintiff was born on March 4, 1980, and was thirty-two

years of age at the time of her administrative hearing on May 

11, 2012. (Tr. 30, 33, 172). She completed the twelfth grade 

in school and last worked in 2008 as a housekeeper at a 

hospital. (Id. at 33, 176). 

Plaintiff testified that she suffers from diabetes, 2 high 

blood pressure,3 back pain, and right leg numbness. (Id. at 35-

36). She described her pain as constant, and she rated it as a 

seven on a ten-point pain scale. (Id. at 36-37). She stated 

that she takes pain medication, which makes her drowsy and 

 2 Plaintiff testified that her blood sugar, on average, tends to 

run “around 280,” but it has shot up as high as 498 and dropped 

as low as 40. (Tr. 39). A normal fasting blood glucose target 

range for an individual without diabetes is 70-100 mg/dL (3.9-

5.6 mmol/L). The American Diabetes Association recommends a 

fasting plasma glucose level of 70–130 mg/dL (3.9-7.2 mmol/L) 

and after meals less than 180 mg/dL (10 mmol/L). See

http://www.mayoclinic.org/diseases-conditions/diabetes/expertblog/blood-glucose-target-range/bgp-20056575.

3 Plaintiff testified that her high blood pressure is fairly well 

controlled with medication. (Tr. 40).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 3 of 23
4

dizzy. 4 (Id. at 36, 42). She has also had repeated epidurals 

for pain, but they only made her condition worse. (Id. at 42). 

Plaintiff testified that she cannot work because of her 

medical conditions and the side effects of her medications. 

(Id. at 35-36, 42). According to Plaintiff, she spends the 

majority of her day lying down. (Id. at 37). She takes care of 

her four-year old daughter alone, except that her mother comes 

over and helps approximately three days a week. (Id. at 37-38). 

She can shop, but she has to do it quickly. (Id. at 41). 

Plaintiff testified that she cannot clean, sweep, mop, bathe her 

child, or put on her child’s clothes. (Id. at 38). 

IV. Analysis

A. Standard of Review 

In reviewing claims brought under the Act, this Court’s 

role is a limited one. The Court’s review is limited to 

determining 1) whether the decision of the Secretary is 

supported by substantial evidence and 2) whether the correct 

legal standards were applied. 5 Martin v. Sullivan, 894 F.2d 

1520, 1529 (11th Cir. 1990). A court may not decide the facts 

anew, reweigh the evidence, or substitute its judgment for that 

 4 Plaintiff listed her medications as Glipizide (for diabetes), 

Integra Plus (for low iron), Percocet (for pain), and Xanax (for 

panic attacks). (Tr. 199). 

5 This Court’s review of the Commissioner’s application of legal 

principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th 

Cir. 1987).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 4 of 23
5

of the Commissioner. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th 

Cir. 1986). The Commissioner’s findings of fact must be 

affirmed if they are based upon substantial evidence. Brown v. 

Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v. 

Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983) (holding 

substantial evidence is defined as “more than a scintilla, but 

less than a preponderance” and consists of “such relevant 

evidence as a reasonable person would accept as adequate to 

support a conclusion.”). In determining whether substantial 

evidence exists, a court 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); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4

(S.D. Ala. June 14, 1999).

B. Discussion

An individual who applies for Social Security disability 

benefits must prove his or her disability. 20 C.F.R. §§ 

404.1512, 416.912. Disability is defined 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); see also 20 C.F.R. §§ 

404.1505(a), 416.905(a). The Social Security regulations 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 5 of 23
6

provide a five-step sequential evaluation process for 

determining if a claimant has proven his disability.6 20 C.F.R. 

§§ 404.1520, 416.920. 

In the case sub judice, the ALJ determined that Plaintiff 

has not engaged in substantial gainful activity since November 

10, 2010, the alleged onset date, and that she has the severe 

impairments of disorders of the back, diabetes, hypertension, 

 6 The claimant must first prove that he or she has not engaged in 

substantial gainful activity. The second step requires the 

claimant to prove that he or she has a severe impairment or 

combination of impairments. If, at the third step, the claimant 

proves that the impairment or combination of impairments meets 

or equals a listed impairment, then the claimant is 

automatically found disabled regardless of age, education, or 

work experience. If the claimant cannot prevail at the third 

step, he or she must proceed to the fourth step where the 

claimant must prove an inability to perform their past relevant 

work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In 

evaluating whether the claimant has met this burden, the 

examiner must consider the following four factors: (1) objective 

medical facts and clinical findings; (2) diagnoses of examining 

physicians; (3) evidence of pain; and (4) the claimant’s age, 

education and work history. Id. Once a claimant meets this 

burden, it becomes the Commissioner’s burden to prove at the 

fifth step that the claimant is capable of engaging in another 

kind of substantial gainful employment which exists in 

significant numbers in the national economy, given the 

claimant’s residual functional capacity, age, education, and 

work history. Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 

1985). If the Commissioner can demonstrate that there are such 

jobs the claimant can perform, the claimant must prove inability 

to perform those jobs in order to be found disabled. Jones v. 

Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v. 

Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v. 

Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 6 of 23
7

osteoarthritis, and general myalgias. 7 (Tr. 17). The ALJ 

further found that Plaintiff does not have an impairment or 

combination of impairments that meets or medically equals any of 

the listed impairments contained in 20 C.F.R. Part 404, Subpart 

P, Appendix 1. (Id. at 18).

The ALJ concluded that Plaintiff retains the residual 

functional capacity (hereinafter “RFC”) to perform a full range 

of light work. (Id.). The ALJ also determined that while 

Plaintiff’s medically determinable impairments could reasonably 

be expected to produce the alleged symptoms, her statements 

concerning the intensity, persistence and limiting effects of 

the alleged symptoms were not credible to the extent that they 

were inconsistent with the RFC. (Id. at 19).

Given Plaintiff’s RFC, the ALJ found that Plaintiff is

unable to perform any past relevant work. (Id. at 22). 

However, utilizing the testimony of a VE, the ALJ concluded that 

considering Plaintiff’s age, education, work experience, and 

residual functional capacity for a full range of light work, a 

finding of “not disabled” was directed by Medical–Vocational 

Rule 202.20. (Id. at 22). 

In addition to the foregoing, the ALJ summarized 

 7 The ALJ concluded that Plaintiff’s headaches and anxiety 

disorder were non-severe. (Tr. 18). Plaintiff has not 

challenged these findings. 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 7 of 23
8

Plaintiff’s testimony as follows: 

The representative’s theory indicates the 

claimant is disabled due to back problems, 

uncontrolled diabetes, hypertension, and 

osteoarthritis with some anxiety. At the 

hearing, claimant testified she has not 

worked since the alleged onset date, 

November 10, 2010. The claimant testified 

she is unable to work due to “slipped disc,” 

right leg numbness, and diabetes, which she 

states includes sugar readings that are both 

high and low, and hand cramps. She 

testified that her pain averages seven on a 

scale of 1-10, and stated she frequently has 

to lie down because of pain, but gets up to 

take her medicine. The claimant testified 

she has a four-year old daughter to care 

for, but indicates her mother assists in 

caring for the child. The claimant 

reportedly has “bad days” three times a 

week, despite medication. She testified 

that her diabetes escalates out of control, 

about five times a week. She indicated her 

hypertension is controlled with medication, 

but escalates on “bad days” due to pain. 

She described cramping in her hands and 

legs, which she relieves by shaking them 

constantly to prevent pain and stiffness. 

The claimant reported she is unable to run 

errands on “bad days.” She also reported 

having undergone at least 25 epidurals in 

the past by a pain management (sic), which 

only made her pain worse. The claimant 

stated that a doctor wanted to perform back 

surgery, but she decided against surgery 

because of her daughter’s young age. The 

claimant indicated she was seeing Dr. 

Yearwood before she started seeing Dr. 

Barnes, and explained she had difficulty 

getting appointments to see Dr. Barnes. . . 

. 

(Tr. 19)

In discussing the relevant medical evidence, the ALJ stated 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 8 of 23
9

as follows:

Turning to the medical evidence, records 

from Barnes Family Medical reflect a visit 

on February 23, 2010, with the claimant 

requesting pain medication for back pain and 

myalgias. Treating physician, Stanley 

Barnes, M.D., prescribed Celestone, Toradol 

injections, Percocet, and Xanax. On April 

1, 2010, the claimant returned, with 

complaints of pain in the right leg, back, 

arm and right shoulder. However, she was 

seen lifting and holding her daughter on her 

right side and was noted as easily weighing 

20 pounds (Exhibit B5F). Outpatient records 

from Evergreen Medical Center reflect 

treatment for bilateral lower leg pain on 

January 5, 2011 after the claimant explained 

that a metal shelf had fallen, striking her 

legs and feet. However, on examination, 

there was no evidence of bruising, swelling,

or redness noted. On January 25, 2011, 

returned to the hospital and was diagnosed 

with chronic low back pain; however, a 

lumbar MRI showed only mild degenerative 

facet hypertrophy at L4-5 and L5-S1.

Claimant was prescribed Prednisone 10 mg and 

Mobic 25 mg (Exhibit B4F). The claimant 

returned to Dr. Barnes on March 21, 2011, 

with persistent pain, including abdominal 

complaints. He referenced the earlier MRI, 

and diagnosed cervical spine disc disease, 

osteoarthritis, lower back pain and 

abdominal pain (probably from diabetic 

hypertensive medication). The claimant 

presented to Barnes Medical Center on June 

6, 2011, complaining of back pain, left hand 

right leg pain, but denied injury. A nurse 

practitioner noted there was evidence of 

cause for the claimant’s hand pain. All 

vital signs were stable, and claimant was 

advised to continue on current medicines 

(Exhibit B10F). On January 30, 2012, she 

returned to Barnes Family Medical with 

additional pain complaints, but indicated 

her pain level overall was 5/10. The 

claimant was administered a B12 and a 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 9 of 23
10

Toradol injection for pain (Exhibit B11F). 

A follow up visit the following month for 

back and leg pain referenced emergency 

hospital treatment for a fractured right 

great toe. On March 8, 2012, the claimant 

presented to Barnes Family Medical, with 

complaints of pain and myalgias involving 

her back, leg and shoulders, but on 

questioning, acknowledged she had been 

moving furniture around a lot at home, and 

that her shoulder had been bothering her for 

the last few days. On examination, the 

claimant exhibited painful range of motion 

of the left shoulder, but there was no 

evidence of popping, crepitus, heat, redness 

or swelling. The claimant was prescribed 

Prednisone for seven days, and Flexeril 10 

mg. She was given refills of Percocet, and 

Xanax, and told to return in one to three 

months, or as necessary (Exhibit B11F). 

Although diagnostic imaging in January 2011 

showed facet joint hypertrophy at L4-5 and 

L5-S-1, those findings were mild in severity 

(Exhibit B4F). Since then, the claimant has 

not been observed to have ongoing neurologic 

deficits in the upper or lower extremities, 

such as reflex and sensory abnormalities, 

motor incoordination, or significant 

decreased muscle strength. Finally, there 

is no indication of joint deformities, gait 

abnormalities, muscle atrophy, or 

substantial limited range of motion 

documented in the record.

As for the claimant’s alleged diabetes and 

hypertension, an assessment of July 14, 2010 

from Barnes Family Medical shows the 

claimant was started on medication for 

elevated blood pressure without hypertension 

(Exhibit B5F). On February 21, 2011, Dr. 

Barnes diagnosed benign hypertension in 

addition to diabetes as part of his 

assessment. The claimant indicated her 

blood sugar had been dropping; but on 

examination, there was no indication of 

fever, chills, sweats, nausea or vomiting; 

all of which are character symptoms (Exhibit 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 10 of 23
11

B5F). Shortly thereafter, the claimant 

began having recurring abdominal pain. Dr. 

Barnes noted on March 21, 2011, that the 

claimant was a diabetic hypertensive and 

indicated her medications were perhaps

responsible for the recurring abdominal 

pain. The evidence shows where the 

claimant’s medicines were adjusted several 

times over the course of treatment with Dr. 

Barnes, who concluded, based on his 

established treating relationship with the 

claimant that she was an “outpatient 

management failure” (Exhibit B10F). 

Subsequently, the claimant admitted to 

excessive use of Goody powders along with 

her prescribed medicines, which ultimately 

lead (sic) to noncompliance as contributing 

to the claimant’s abdominal and related 

symptoms (Exhibit B11F). Dr. Barnes’ nurse 

practitioner noted during follow-up on 

November 28, 2011, that the claimant’s 

vital signs were stable, including a blood 

pressure of 120/70 (Exhibit B10F). On 

February 21, 2012, the claimant’s vital 

signs were again stable, and her blood 

pressure was 130/70 (Exhibit B11F). There 

is no indication that diabetes or 

hypertension resulted in any end-organ 

damage causing a significant functional 

impairment, or evidence that either 

impairment failed to respond appropriately 

to properly administered conservative 

treatment. Medical records have 

consistently shown that treatment for the 

impairments has been effective when properly 

administered. Moreover, the claimant 

acknowledged at the hearing, that while her 

diabetes, treated by Dr. Yearwood remains 

uncontrolled, her blood pressure was 

controlled with medication.

Although the claimant testified that Dr. 

Yearwood is her current treating physician, 

the record is void of evidence until April 

24, 2012, when Amrita Yearwood, M.D., a 

primary care physician, advised she had 

treated the claimant for several years. In 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 11 of 23
12

referencing the claimant’s history of 

hypertension, uncontrolled type II diabetes, 

and back pain, Dr. Yearwood opined that, 

“due to her multiple medical problems, Ms. 

Nelms is unable to work” (Exhibit B13F). On 

May 11, 2012, Dr. Yearwood completed a 

Physical Capacities Evaluation, indicating 

that during an 8-hour workday, the claimant 

can lift/carry 5 pounds occasionally to 1 

pound frequently. She can sit, stand, walk 

for a total of two hours out of eight. 

Occasionally, the claimant can perform 

pushing/pulling movements with arms and/or 

legs; can climb, balance, and can perform 

gross and fine manipulations, and operate 

motor vehicles. Dr. Yearwood opined that, 

on rare occasions, the claimant could bend, 

stoop, reach in all directions, and work 

with environmental problems, such as 

allergies, dust, etc. She indicated the 

claimant could never work with or around 

hazardous machinery. She would likely miss 

more than four days per month from work 

because of impairments or treatment. A 

Clinical Pain Assessment indicates that the 

claimant’s pain is severe enough to cause 

distraction of daily activities or work, 

cause total abandonment of task, and 

indicated that medication side effect were 

severe enough to limit effectiveness due to 

distraction, inattention, drowsiness, etc. 

(Exhibit B15F).

As for the claimant’s subjective 

allegations, based on the history of 

conservative treatment, essentially

consisting of routine physical examinations 

and medication adjustments and refills, the 

allegations are not fully credible. The 

claimant testified that her medicines make 

her drowsy and sleepy[;] however, these 

complaints are not substantiated in the 

evidentiary record. Rather, the current 

medications fail to support any disabling 

conditions. I find the claimant is not 

credible at all, as she basically does as 

she pleases; then complains to doctors about 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 12 of 23
13

her back, which does not seem to stop her 

from doing all kinds of activities, such as 

moving furniture “a lot” (Exhibit B11F). 

Evidence from Evergreen Medical Center, 

including emergency room records in January

2011, document treatment for various 

complaints (Exhibit B4F), but includes no 

records from Dr. Yearwood, albeit her report 

of April 24, 2012, states she had treated 

the claimant for several years prior 

(Exhibit B13F). Overall, medical evidence 

from Dr. Barnes, the established primary 

physician from April 2010 through February 

2011, consistently references the claimant’s 

complaints of back pain, but totally, the 

subjective complaints resulted in 

assessments that showed little more than 

generalized myalgias, benign hypertension, 

and diabetes, capable of being managed 

conservatively (Exhibits BSF, B10F, BllF).

In considering the alleged limitations 

assigned by Dr. Yearwood, she notes the 

claimant is able to climb ladders and stairs 

one-third of a workday, yet indicates the 

claimant can only stand for two hours and 

can sit for two hours; and can rarely be 

exposed to environmental factors (Exhibit 

B15F); however, there is no medically 

documented basis for the limitations. 

Nevertheless, in considering Dr. Yearwood’s 

opinion that the claimant is unable to work 

(Exhibit B13F); even if her records were 

available, her opinion is completely 

internally inconsistent with the other

substantial evidence of record. It is 

unfortunate in that Dr. Yearwood failed to 

provide any basis to support the assigned 

limitations, particularly since her records, 

which includes a brief one-page report at 

Exhibit B15F and the physical/pain 

assessments, consisting of two-pages at 

Exhibit B13F, certainly do not support her 

opinion, which is given little weight. 

Although Dr. Barnes has not offered a 

specific opinion regarding the claimant’s 

functional limitations, his statements merit 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 13 of 23
14

significant weight. Based on Dr. Barnes’ 

longstanding treating relationship with the 

claimant; and his familiarity (along with 

that of his nurse practitioner) with the

Claimant’s overall medical condition and 

limitations, based on his clinical findings; 

observations; and consistent treatment 

notes, are all factors that give weight to 

his opinion statements, which also supports 

the residual functional capacity finding.

In sum, the above residual functional 

capacity assessment is supported by the 

preponderance of the most credible objective 

evidence of record, including the claimant’s 

conservative treatment history and physician 

treatment notes.

(Tr. 19-22).

The Court now considers the foregoing in light of the 

record in this case and the issue on appeal.

1. Issue

Whether the ALJ erred in giving “little 

weight” to the opinions of Plaintiff’s 

treating physician? 

Plaintiff argues that the ALJ erred in “arbitrarily 

substituting her own opinion for that of the treating physician, 

Amrita Yearwood, M.D., without following proper legal standards

and without support of substantial evidence for her opposite 

conclusion.” 8 (Doc. 13 at 3). The Commissioner counters that 

 8 As discussed herein, the record shows that the ALJ gave “little

weight” to the opinions of Dr. Yearwood set forth in the April 

24, 2012 letter opining that Plaintiff “is unable to work” and 

in the May 2012 Physical Capacities Evaluation (“PCE”) and 

Clinical Assessment of Pain (“CAP”) forms. (Tr. 22, 342, 347-

48).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 14 of 23
15

the ALJ had good cause to reject Dr. Yearwood’s opinions because 

they are wholly unsupported and inconsistent with the record 

evidence in this case and that the ALJ’s determination that 

Plaintiff is not disabled is supported by substantial evidence. 

(Doc. 14 at 3-4). Having carefully reviewed the record, the 

Court agrees with Defendant that Plaintiff’s claim is without 

merit. 

Generally speaking, “[i]f a treating physician’s opinion on 

the nature and severity of a claimant’s impairments is wellsupported by medically acceptable clinical and laboratory 

diagnostic techniques, and is not inconsistent with the other 

substantial evidence in the record, the ALJ must give it 

controlling weight.” 9 Roth v. Astrue, 249 Fed. Appx. 167, 168 

(11th Cir. 2007) (citing 20 C.F.R. § 404.1527(d)(2)).

“An administrative law judge must accord substantial or 

considerable weight to the opinion of a claimant’s treating 

physician unless good cause is shown to the contrary.”

Broughton v. Heckler, 776 F.2d 960, 961 (11th Cir. 

1985)(citations and internal quotation marks omitted). “The 

requisite ‘good cause’ for discounting a treating physician’s 

opinion may exist where the opinion is not supported by the 

 9 “Controlling weight” is defined as a medical opinion from a 

treating source that must be adopted. See SSR 96–2P, 1996 SSR 

LEXIS 9, *3, 1996 WL 374188, *1 (1996). 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 15 of 23
16

evidence, or where the evidence supports a contrary finding.” 

Hogan v. Astrue, 2012 U.S. Dist. LEXIS 108512, *8, 2012 WL 

3155570, *3 (M.D. Ala. 2012). “Good cause may also exist where 

a doctor’s opinions are merely conclusory, inconsistent with the 

doctor’s medical records, or unsupported by objective medical 

evidence.” Id. “[T]he weight afforded a treating doctor’s 

opinion must be specified along with ‘any reason for giving it 

no weight, and failure to do so is reversible error.’” Williams 

v. Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1

(M.D. Fla. 2009); see also Phillips v. Barnhart, 357 F.3d 1232, 

1241 (11th Cir. 2004) (“When electing to disregard the opinion 

of a treating physician, the ALJ must clearly articulate [his or 

her] reasons.”).

The record in this case shows that Dr. Yearwood saw

Plaintiff on November 10, 2010, in the hospital emergency room 

when Plaintiff sought treatment for uncontrolled hypertension, 

low back pain, and right leg pain. (Id. at 248, 252). Dr. 

Yearwood discharged Plaintiff approximately one hour later in 

stable condition with Clonidine (for high blood pressure) and 

Lortab (for pain). (Id. at 248, 253). The record next shows 

that Dr. Yearwood treated Plaintiff on five occasions in 2012

(through the hospital emergency room or in her office) for 

various complaints including hypertension, diabetes, back pain, 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 16 of 23
17

cough, congestion, bronchitis, and medication refills. 10 (Tr. 

347-48, 364, 367-69, 379-80). After an office visit on April 

16, 2012, for treatment of leg and back pain, Dr. Yearwood 

drafted a letter for Plaintiff on April 24, 2012, addressed “to 

whom it may concern,” in which Dr. Yearwood opined that “due to 

[Plaintiff’s] multiple medical problems, [she] is unable to 

work.”11 (Id. at 342, 380). Approximately two weeks later, on 

May 11, 2012, Dr. Yearwood completed a Physical Capacities 

Evaluation (“PCE”) form in which she opined that Plaintiff could 

lift/carry only five pounds occasionally and one pound 

frequently, that she could sit for only two hours in an eighthour day, and that she could stand/walk for only two hours in an 

eight-hour day. (Id. at 347). In addition, Dr. Yearwood

completed a Clinical Assessment of Pain (“CAP”) form in which 

she stated that Plaintiff’s pain is “present to such an extent 

 10 On April 1, 2012, Dr. Yearwood treated Plaintiff in the 

emergency room for back pain and elevated diabetes and 

discharged her approximately one and a half hours later with 

Lortab and instructions to follow up with her family physician. 

(Tr. 364-65). Three days later, on April 4, 2012, Dr. Yearwood 

admitted Plaintiff to the hospital for two days for treatment of 

bronchitis. (Id. at 368-70).

11 The letter, in full, consisted of five sentences and stated: 

“Moneke Nelms has been a patient of mine for several years. She 

has hypertension and uncontrolled type II Diabetes. She has a 

history of back pain, having had many epidurals done to relieve 

her pain. Due to her multiple medical problems, Ms. Nelms is 

unable to work. If you have any questions, or if you need any 

additional information, please contact my office.” (Tr. 342). 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 17 of 23
18

as to be distracting to adequate performance of daily 

activities;” that physical activity will “greatly” increase the 

pain “to such an extent as to cause distraction from tasks or 

total abandonment of task[s];” and that “drug side effects can 

be expected to be severe and to limit effectiveness due to 

distraction, inattention, drowsiness, etc.” (Id. at 348). 

Having reviewed the record at length, the Court finds, as the 

ALJ found, that Dr. Yearwood’s opinions are not supported by the 

record. 

First, as the ALJ articulated, there is absolutely nothing 

in Dr. Yearwood’s treatment records to support the debilitating 

limitations assigned to Plaintiff in the April 24, 2012 letter 

and the May 11, 2012 PCE and CAP forms. Dr. Yearwood’s

treatment records reflect nothing more than occasional, 

conservative treatment of Plaintiff’s hypertension, diabetes, 

and back pain. (Id. at 248, 364, 367, 380, 379). 

In addition to being inconsistent with her own treatment 

records, Dr. Yearwood’s opinions are inconsistent with the 

findings and opinions of Plaintiff’s other treating physician, 

Dr. Stanley Barnes, M.D. The record shows that Dr. Barnes

treated Plaintiff from 2008 to 2012 for diabetes, hypertension, 

and back pain. His records reflect regular, conservative 

treatment of Plaintiff’s medical conditions with medications. 

(Id. at 265, 272-94, 336-39). Nothing in Dr. Barnes’ treatment 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 18 of 23
19

notes reflects that Plaintiff’s medical conditions resulted in 

debilitating limitations. To the contrary, on February 21, 

2011, Dr. Barnes assessed Plaintiff with “benign hypertension, 

osteoarthritis, generalized myalgias, and diabetes,” for which 

he simply adjusted her medications. (Id. at 272). Nothing in 

Dr. Barnes’ records reflects any significant functional 

impairment caused by Plaintiff’s hypertension12 or diabetes.

As for Plaintiff’s back pain, on June 9, 2009, Dr. Barnes’

treatment notes reflect that Plaintiff was reporting

“nonspecific pain” “in one place or another,” for which he 

prescribed pain medication. (Id. at 280). Thereafter, Dr. 

Barnes frequently noted that Plaintiff requested refills on her 

pain medication too “early.” 13 (Id. at 277, 290-94, 328).

 12 As noted previously, at her hearing, Plaintiff acknowledged 

that her hypertension is controlled with medication. (Tr. 40).

13 On May 6, 2008, Dr. Barnes stated that he saw no reason to 

keep Plaintiff on any pain medication and that he would “give 

her [an] anti-inflammatory or something to that effect.” (Tr. 

285). On August 3, 2009, Dr. Barnes’ nurse practitioner noted 

that Plaintiff “went to the ER over the weekend with leg pain 

but they just gave her a Toradol shot and she didn’t get any 

pain medicine so I told her she shouldn’t have needed any as it 

is still early for her last pain medication.” (Id. at 290). On 

January 25, 2010, Dr. Barnes stated, “Dr. Rainer [has] 

recommended no further therapy. He’s not really sure what’s 

going to help her out. Now I want to put her on some Mobic and 

before I could even get the words out of my mouth she claimed it 

wouldn’t work so I don’t think she’s interested in getting any 

kind of help or anything like that. Unfortunately she has 

succumbed to taking the narcotic analgesics. She’s here early.” 

(Id. at 292). On June 21, 2010, Dr. Barnes stated, “She needs 

her pain medicine refilled. She is about 4 days early. I have 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 19 of 23
20

Plaintiff claimed that repeated epidural injections for pain

were ineffective. (Id. at 42, 281, 289, 291). She also 

testified that one of her doctors wanted to perform back 

surgery, but she decided against surgery because of her 

daughter’s young age. (Id. at 43). However, on March 18, 2009, 

Dr. Barnes noted that Plaintiff wanted to be put in the hospital 

for her back pain, but he “[saw] no medical reason to do that.” 

(Id. at 282). Dr. Barnes stated, “[h]er MRI Scan14 didn’t show 

much of anything so putting her in the hospital is certainly not 

even a remote option.” (Id.). On July 6, 2009, Dr. Barnes 

further noted that Plaintiff had “no back pain with straight leg 

raises,” “no crepitus in the joints,” and “no evidence of 

swelling or edema.” (Id. at 290). On February 23, 2010, Dr. 

Barnes noted that the orthopedist to whom he had referred 

Plaintiff for her back pain, Dr. Clay Rainer, M.D., had 

 

told her that she is not to come in early. It is going to be 30 

days or not at all.” (Id. at 294). 

14 On July 2, 2008, Dr. Barnes noted, “This patient comes in with 

right hip pain. I’m not really sure what’s going on. We did a 

scan on her. Nothing bad.” (Tr. 284). On October 27, 2009, 

Dr. Clay Rainer, M.D., the orthopedist to whom Dr. Barnes had 

referred Plaintiff, noted that Plaintiff’s June 2008 MRI showed 

“minimal facet degeneration at L4-5 and L5-S1.” (Id. at 220)

(emphasis added). Almost three years later, on January 25, 

2011, an MRI of Plaintiff’s lumbar spine again showed “mild

degenerative facet hypertrophy at L4-5 and L5-S1.” (Id. at 270) 

(emphasis added).

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 20 of 23
21

“basically released” her. 15 (Id. at 277). Thus, as the ALJ 

articulated, in addition to being inconsistent with her own 

treatment notes, Dr. Yearwood’s opinions are inconsistent with 

the treatment notes of Dr. Barnes and Dr. Rainer and the MRI’s 

taken in June 2008 and January 2011.16 

Last, as the ALJ articulated, the record shows that Dr. 

Yearwood’s opinions are inconsistent with the evidence of 

Plaintiff’s activities of daily living. Dr. Barnes observed on 

April 1, 2010, that, despite Plaintiff’s complaints of leg, 

back, arm, and shoulder pain, she was able to lift and hold her 

daughter who “[was] probably a good 20 lbs. easily.” (Id. at 

293). At the hearing, Plaintiff testified that she alone cares

for her four-year-old daughter, with the exception of help from 

her mother approximately three days a week. (Id. at 38). 

Also, on March 8, 2012, Plaintiff reported to Dr. Barnes’ nurse 

practitioner that her left shoulder was bothering her because 

 15 As noted, Dr. Rainer found on October 27, 2009 that Plaintiff 

had only “minimal facet degeneration at L4-5 and L5-S1.” (Tr. 

220). Dr. Barnes’ treatment notes on January 25, 2010, reflect 

that “Dr. Rainer [has] recommended no further therapy. He’s not 

really sure what’s going to help her out.” (Id. at 292).

16 Dr. Yearwood’s opinions are also inconsistent with the 

treatment notes of Dr. Stephen West, M.D., one of Dr. Barnes’ 

partners, who on March 11, 2009, noted that Plaintiff “wanted me 

to write her a letter so that she could get out of community 

service but I refused to. There is nothing that she has that 

would prevent her from doing it. She can do all her community 

service. (Tr. 282). 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 21 of 23
22

she had been “mov[ing] furniture around a lot at home.” (Id. at 

338). This evidence is inconsistent with Dr. Yearwood’s 

opinions, as discussed herein, particularly her opinion in the 

PCE form that Plaintiff could only occasionally lift five pounds 

and frequently lift one pound. (Id. at 347). 

Based on the foregoing evidence, the Court finds that Dr. 

Yearwood’s opinions set forth in the April 24, 2012 letter and 

the May 2012 PCE and CAP forms are inconsistent with the record 

evidence in this case. Therefore, the ALJ did not err in 

failing to give controlling weight to those opinions. The 

substantial medical evidence in this case supports the ALJ’s 

finding that Plaintiff can perform a full range of light work.17 

 17 The Court also rejects Plaintiff’s argument that the ALJ’s 

determination is not supported by substantial evidence because, 

without Dr. Yearwood’s opinions, the record contains no opinion 

from a consultative examiner or other medical expert as to 

Plaintiff’s RFC. (Doc. 13 at 8). To the contrary, the ALJ has 

the discretion to order a consultative examination where the 

record establishes that such is necessary to enable the ALJ to 

render a decision. Holladay v. Bowen, 848 F.2d 1206, 1210 (11th 

Cir. 1988). The ALJ is not required to order a consultative 

examination where the record contains sufficient evidence to 

permit the ALJ’s RFC determination. Ingram v. Commissioner of 

Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (“The 

administrative law judge has a duty to develop the record where 

appropriate but is not required to order a consultative 

examination as long as the record contains sufficient evidence 

for the administrative law judge to make an informed 

decision.”). Likewise, “[t]he ALJ’s RFC assessment may be 

supported by substantial evidence, even in the absence of an 

opinion from an examining medical source about Plaintiff’s 

functional capacity.” Saunders v. Astrue, 2012 U.S. Dist. LEXIS 

39571, *10, 2012 WL 997222, *4 n.5 (M.D. Ala. March 23, 2012) 

(citing Green v. Soc. Sec. Admin., 223 Fed. Appx. 915, 923 (11th 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 22 of 23
23

Therefore, Plaintiff’s claim is without merit.

V. Conclusion 

For the reasons set forth herein, and upon careful 

consideration of the administrative record and memoranda of the 

parties, it is hereby ORDERED that the decision of the 

Commissioner of Social Security denying Plaintiff’s claim for a 

period of disability, disability insurance benefits, and 

supplemental security income be AFFIRMED.

DONE this 26th day of March 2015.

 /s/ SONJA F. BIVINS 

 UNITED STATES MAGISTRATE JUDGE

 

Cir. 2007) (unpublished)); see also Packer v. Astrue, 2013 U.S. 

Dist. LEXIS 20580, *7, 2013 WL 593497, *2 (S.D. Ala. February 

14, 2013) (the fact that no treating or examining medical source 

submitted a physical capacities evaluation “does not, in and of 

itself, mean that there is no medical evidence, much less no 

‘substantial evidence,’ to support the ALJ’s decision.”). Thus, 

Plaintiff’s contention that the absence of a physical RFC 

evaluation by a medical source means that the ALJ’s RFC 

assessment is not based on substantial evidence is simply 

incorrect. Moreover, as noted supra, the record contains 

substantial evidence, including the treatment records of Dr. 

Barnes, from which the ALJ was able to render a decision. 

Case 1:14-cv-00018-B Document 20 Filed 03/26/15 Page 23 of 23