Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_12-cv-01027/USCOURTS-almd-2_12-cv-01027-0/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 DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

NORTHERN DIVISION

CHARLES WILEY RAILEY, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:12cv1027-CSC

) (WO)

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff applied for disabilityinsurance benefits pursuant to Title II ofthe Social

Security Act, 42 U.S.C. §§ 401 et seq. alleging that he was unable to work because of a

disability. His application was denied at the initial administrative level. The plaintiff then

requested and received a hearing before an Administrative Law Judge (“ALJ”). Following

the hearing, the ALJ also denied the claim. The Appeals Council rejected a subsequent

request for review. The ALJ’s decision consequently became the final decision of the

Commissioner of Social Security (Commissioner). See Chester v. Bowen, 792 F.2d 129,

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131 (11th Cir. 1986). The case is now before the court for review pursuant to 42 U.S.C.

§§ 405(g) and 1383(c)(3). The parties have consented to the United States Magistrate

Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L. No. 1

103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social

Security matters were transferred to the Commissioner of Social Security.

Case 2:12-cv-01027-CSC Document 17 Filed 10/18/13 Page 1 of 14
Judge conducting all proceedings in this case and ordering the entry of final judgment,

pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1. Based on the court’s review of

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

the Commissioner should be affirmed.

II. Standard of Review

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

person is unable to

engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result

in death or which haslasted or can be expected to last for a continuous period

of not less than 12 months . . .

To make this determination, the Commissioner employs a five-step, sequential

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

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

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

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

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

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

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

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

answer to any question, other than step three, leadsto a determination of “not

disabled.”

A “physical or mental impairment” is one resulting from anatomical, physiological, or psychological 2

abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.

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

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

must find the Commissioner’s decision conclusive ifit issupported bysubstantial evidence. 

42 U.S.C. § 405(g); Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Substantial

evidence is “more than a scintilla,” but less than a preponderance; it “is such relevant

evidence as a reasonable person would accept as adequate to support a conclusion.”

Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004) (quotation

marks omitted). The court “may not decide the facts anew, reweigh the evidence, or

substitute . . . [its] judgment for that of the [Commissioner].” Phillips v. Barnhart, 357

F.3d 1232, 1240 n. 8 (11th Cir. 2004) (alteration in original) (quotation marks omitted).

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

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

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

conclusions, including determination of the properstandardsto be applied in

evaluating claims.

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

III. The Issues

A. Introduction. The plaintiff was 47 years old on the date of onset of disability.

(R. 118), and 48 years old on the date of the administrative hearing. (R. 13, 32). He has

completed high school and graduated from college. (R. 34). His past work experience

McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986) is a supplemental security income case (SSI). 3

The same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately cited

as authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5th Cir. 1981) (Unit A).

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includes work as police officer and patrol sergeant. (R.34-35, 45). Following the hearing,

the ALJ concluded that the plaintiff has severe impairments of “deep venous thrombosis;

hypertension; and arthritis.” (R. 12). The ALJ determined that “the claimant has the

residualfunctional capacityto performlessthan the fullrange of sedentarywork as defined

in 20 CFR 404.1567(a)” with additional restrictions. (R. 13). Following the hearing, the

ALJ concluded that the plaintiff was unable to perform his past relevant work, but, using

the Medical-Vocational Guidelines, 20 C.F.R. Pt. 404, Subpt. P., App. 2, as a framework

and relying on the testimony of a vocational expert, he also concluded that there were

significant number of jobsin the national economy that the plaintiff could perform. (R. 23).

Accordingly, the ALJ concluded that the plaintiff was not disabled. (R. 23-24).

 B. Plaintiff’s Claims. As stated by the plaintiff, he presents the following issues

for the Court’s review.

I. Whether the Commissioner of Social Security made a proper and just

decision regarding the Plaintiff’s Social Security claim for Disability

Insurance Benefits.

A. Whether the Commissioner of Social Security

erred in rewording pertinent evidence.

B. Whether the Commissioner of Social Security

erred in failing to consider all relevant evidence.

(Doc. # 12, Pl’s Br. at 5).

IV. Discussion

A disability claimant bears the initial burden of demonstrating an inability to return

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to his past work. Lucas v. Sullivan, 918 F.2d 1567 (11th Cir. 1990). In determining

whether the claimant hassatisfied this burden, the Commissioner is guided by four factors:

(1) objective medical facts or clinical findings, (2) diagnoses of examining physicians, (3)

subjective evidence of pain and disability, e.g., the testimony of the claimant and hisfamily

or friends, and (4) the claimant’s age, education, and work history. Tieniber v. Heckler, 720

F.2d 1251 (11th Cir. 1983). The ALJ must conscientiously probe into, inquire of and

explore all relevant facts to elicit both favorable and unfavorable factsfor review. Cowart

v. Schweiker, 662 F.2d 731, 735-36 (11th Cir. 1981). The ALJ must also state, with

sufficient specificity, the reasons for his decision referencing the plaintiff’s impairments.

Any such decision by the Commissioner of Social Security which involves a

determination of disability and which is in whole or in part unfavorable to

such individual shall contain a statement of the case, in understandable

language, setting forth a discussion of the evidence, and stating the

Commissioner’s determination and the reason or reasons upon which it is

based.

42 U.S.C. § 405(b)(1) (emphases added). Within this analytical framework, the court will

address the plaintiff’s claims.

A. Rewording Pertinent Evidence. Railey argues that the ALJ improperly

“changed the wording of Dr. Adediji’s assessment,” and in doing so, “made a false and

unjust error in his decision.” (Doc. # 12 at 8). Of course, this hyperbole is not the standard

for evaluating the decision of the ALJ. Pursuant to the substantial evidence standard, this

court’s review is a limited one; the entire record must be scrutinized to determine the

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reasonableness of the ALJ’s factual findings. Lowery v. Sullivan, 979 F.2d 835, 837 (11th

Cir. 1992).

On August 26, 2011, Dr. Oluyiwka Adediji conducted a medical examination of

Railey at the request of the Social Security Administration. (R. 309-320). He provided a

five (5) page narrative and completed a four (4) page medical source statement of ability.

(Id.) Afterthoroughlydetailing his evaluation, Dr. Adediji wrote that “[t]he claimant is able

to do sedentary activities that would not require prolonged standing sitting or working.”

(R. 313) (emphasis added). After considering Dr. Adediji’s assessment in determining

Railey’s residual functional capacity, the ALJ gave “substantial weight to Dr. Adediji’s

assessment thatreflectsthe claimant is able to do sedentary activitiesthat would notrequire

prolonged standing, sitting or walking.” (R. 21) (emphasis added). Railey seizes on the

difference between Dr. Adediji’s use of the word “working” in his narrative and the ALJ’s

use of the word “walking” to assert that the ALJ erroneously altered Dr. Adediji’s

assessment. Railey parses the ALJ’s determination too finely. This sentence must be

considered in context with the full narrative and medical source determination. Railey’s

attempt to proof text this particular statement disregards Dr. Adediji’s other statements

regarding Railey’s ability to sit, stand and walk. See R. 309 (“Since then he has

experienced increased pain and swelling in the left leg. Pain is moderate to severe and

aggravated by sitting and standing for any period of time as brief as 1 hour. He can walk

but less than 1 mile before he has to stop due to pain and swelling in the left leg”); R. 310

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(“Asfar as occupation, he is not able to perform the duties of police officer he had done for

27 years and likewise any activity requiring prolonged sitting, standing or long walk.”): R.

316 (“SITTING/STANDING/WALKING”). It is apparent that Dr. Adediji’s reference to

Railey’s ability to sit, stand and work is simply a scrivener’s error, occurring perhaps as

the result of faulty transcription.

More importantly, however, the ALJ properly considered Dr. Adediji’s assessment

in determinating the plaintiff’sresidual functional capacity (“RFC”). The ALJ determined

that Railey had the residual functional capacity

to perform a less than the full range of sedentary work as defined in 20 CFR

404.1567(a) he must periodicallyalternate sitting and standing to relieve pain

or discomfort; occasionally elevate left to foot stool height; occasional

pushing and pulling with upper and lower extremities; no climbing ladders,

ropes,scaffolds; occasional climbing ramps and stairs; occasional balancing,

kneeling, crouching, crawling, stooping; no overhead reaching bilaterally;

frequent reaching in other directions; frequent handling, fingering, feeling;

avoid concentrated exposure to extreme heat and cold; avoid all dangerous

machinery and unprotected heights.

(R. 13).

It is the responsibility of the ALJ to independently assess a claimant’s residual

functional capacity “based upon all of the relevant evidence.” 20 CFR § 404.1545(a)(3)

(“We will assess your residual functional capacity based on all of the relevant medical and

other evidence.”); 20 C.F.R. § 404.1546(c) (“Responsibility for assessing residual

functional capacity at the administrative law judge hearing . . . level. If your case is at the

administrative law judge hearing level . . ., the administrative law judge . . . is responsible

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for assessing your residual functional capacity.”) See also Lewis v. Callahan, 125 F.3d

1436, 1440 (11th Cir. 1997) (“The residual functional capacity is an assessment, based

upon all of the relevant evidence, of a claimant’s remaining ability to do work despite his

impairments.”). “Residual functional capacity, or RFC, is a medical assessment of what

the claimant can do in a work setting despite any mental, physical or environmental

limitations caused by the claimant’s impairments and related symptoms. 20 C.F.R. §

416.945(a).” Peeler v. Astrue, 400 Fed. Appx. 492, 494 n.2 (11th Cir. 2010).

The plaintiff’s argument that Dr. Adediji opinion that he could only perform

sedentary activitiesthat did not include working improperly conflatesthe nature of residual

functional capacity with the responsibility for making the residual functional capacity and

disability determination. The Commissioner’sregulations clearly show who isresponsible

for making the residual functional capacity determination when a case has reached the

administrative law judge hearing.

If your case is at the administrative law judge hearing level or at the Appeals

Council review level, the administrative law judge or the administrative

appeals judge at the Appeals Council (when the Appeals Council makes a

decision) is responsible for assessing your residual functional capacity.

20 CFR § 404.1546.

In addition, it is the ALJ’s responsibility to determine disability. See 20 C.F.R. §

404.1527(d) (stating that dispositive issues such as whether the claimant is “unable to

work,” and the claimant’s residual functional capacity, are “issues reserved to the

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Commissioner;” medical source opinions on these matters will not be given “any special

significance”).

B. Failed to consider all relevant evidence. The plaintiff also argues that the

ALJ failed to properly consider all evidence, particularly the evidence from his treating

physicians suggesting that he pursue disability. (Doc. # 12 at 8). Specifically, Railey

complainsthat “[a]lthough [his]treating and examining physicians agreed that the claimant

should qualify for disability benefits, Judge Martin gave only partial credit to Dr. Ben

Smith’s assessment . . . but failed to consider or give weight to any of the other treating or

examining physician’s opinions ofthe claimant’s abilityto performwork related activities.”

(Id. at 8-9).

In essence,Raileyarguesthat the ALJshould have accepted his physicians’ opinions

that he qualified for disability. However, the ALJ was not required to accept his treating

physicians’ opinions that he “should be considered” for disability. First, the ALJ did

consider Railey for disability and found that he did not meet the requirementsfor disability

benefits. Next, the ALJ reviewed and considered all the medical evidence in the record in

determining whether Railey is disabled within the meaning of 42 U.S.C. § 423(d). The

court hasindependently considered the record as a whole and findsthat the record provides

substantialsupportforthe ALJ’s conclusions. Consequently, the court concludesthere was

sufficient medical evidence before the ALJfromwhich he properly could make a disability

determination.

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To the extent that Railey contendsthat the ALJshould have accepted his physicians’

opinions, the court disagrees. Of course, the law in this circuit is well-settled that the ALJ

must accord “substantial weight” or “considerable weight” to the opinion, diagnosis, and

medical evidence ofthe claimant’streating physician unless good cause existsfor not doing

so. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986); Broughton v. Heckler, 776

F.2d 960, 961 (11th Cir. 1985). The Commissioner, as reflected in her regulations, also

demonstrates a similar preference for the opinion of treating physicians.

Generally, we give more weight to opinionsfromyour treating sources,since

these sources are likely to be the medical professionals most able to provide

a detailed, longitudinal picture of your medical impairment(s) and may bring

a unique perspective to the medical evidence that cannot be obtained fromthe

objective medical findings alone or from reports of individual examinations,

such as consultive examinations or brief hospitalizations.

Lewis, 125 F.3d at 1440 (citing 20 CFR § 404.1527 (d)(2)). The ALJ’s failure to give

considerable weight to the treating physician’s opinion isreversible error. Broughton, 776

F.2d at 961-62.

However, there are limited circumstances when the ALJ can disregard the treating

physician’s opinion. The requisite “good cause” for discounting a treating physician’s

opinion may exist where the opinion is not supported by the evidence, or where the

evidence supports a contrary finding. See Schnorr v. Bowen, 816 F.2d 578, 582 (11th Cir.

1987). 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

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evidence. See Jones v. Dep’t. of Health & Human Servs., 941 F.2d 1529, 1532-33 (11th

Cir. 1991); Edwards v. Sullivan, 937 F.2d 580, 584-85 (11th Cir. 1991); Johns v. Bowen,

821 F.2d 551, 555 (11th Cir. 1987). The weight afforded to a physician’s conclusory

statements depends upon the extent to which they are supported by clinical or laboratory

findings and are consistent with other evidence of the claimant’s impairment. Wheeler v.

Heckler, 784 F.2d 1073, 1075 (11th Cir. 1986). The ALJ “may reject the opinion of any

physician when the evidence supports a contraryconclusion.” Bloodsworth v. Heckler, 703

F.2d 1233, 1240 (11th Cir. 1983). The ALJ must articulate the weight given to a treating

physician’s opinion and must articulate any reasons for discounting the opinion. Schnorr,

816 F.2d at 581.

On September 15, 2010, Dr. Ben Smith wrote a letter on Railey’s behalf. (R. 254).

According to Dr. Smith, Railey

has a history of DVT times 2, with chronic leg pain, shortness of breath,

accelerated hypertension, edema, and fatigue. His exercise status is

diminished. He is at increased risk of thromboembolism. He will require life

long coumadin treatment due to his multiple chronic conditions. I feel he

should be considered for permanent disability.

(Id.).

After reviewing the medical evidence, the ALJ gave Dr. Smith’s opinion “some

weight.” (R. 21).

[T]he undersigned givessome weight to Dr. Smith’s opinion that the claimant

needs to keep his leg elevated and continue pain medications and Coumadin

but reject (sic) the portion that he should apply for permanent disability with

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pain and numbness and swelling he is at risk for himself and others (Exhibit

7F). His opinion is supported by his own clinical examinations and testing.

(Id.). After a thorough review of Railey’s treatment records, the ALJ discounted Dr.

Smith’s opinion only in part. His decision to give Dr. Smith’s opinion some weight is

supported by substantial evidence. While it is undisputed that Railey cannot return to work

as a police officer, the evidence does not support Dr. Smith’s opinion that Railey can

perform no work at all.

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Railey testified at the administrative hearing that he does light cooking and general

housework. (R. 38). He takes onlyover-the-counter pain medication of Tylenol and Aleve;

he takes no prescription pain medication. (R. 43). In his application for disability, Railey

indicated that he cares for his two children. He also cooks, washes clothes, prepares food,

and cleans. (R. 164-66). He walks, drives, and rides in a car. (R. 166). He goes shopping

once every two weeksfor approximately two hours each time. (Id.) He also attends church

and sporting events at the local high school and university. (R. 167). The ALJ examined

and evaluated the treatment records for evidence supporting Dr. Smith’s assessment of

Railey’s ability to work, and he considered Railey’s own testimony. Only then did the ALJ

discount Dr. Smith’s opinion that Railey was unable to work. Based upon itsreview of the

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On August 16, 2010, Dr. Keith Thompson opined that he was “certainly concerned about [Railey’s]

4

ability to continue his chosen field of work.” (R. 204). 

The court notes that on June 11, 2012, nine months after Dr. Smith’s letter, Dr. Smith noted that 5

Railey “state[d] injured left leg at work today and takes Coumadin and was concerned about swelling.” (R.

344). This notation contradicts Dr. Smith’s opinion that Railey is disabled.

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ALJ’s decision and the objective medical evidence of record, the court concludes that the

ALJ properly rejected Dr. Smith’s opinion regarding Railey’s eligibility for disability

benefits.

The court finds no legal error in the ALJ’s consideration of the underlying basis of

Dr. Smith’s opinion and the extent to which his opinion was consistent with the record as

a whole. See 20 C.F.R.404.1527(c) (“The more a medical source presents relevant

evidence to support an opinion, particularlymedicalsigns and laboratoryfindings, the more

weight we will give that opinion. The better an explanation a source provides for an opinion,

the more weight we will give that opinion. . . . Generally, the more consistent an opinion is

with the record as a whole, the more weight we will give to that opinion.”). Moreover, while

the ALJ properly considered medical source opinions in considering whether Railey was

disabled, Dr. Smith’s medical opinion was not controlling on that issue. See 20 C.F.R.

404.1527(d)(1) (Opinions on disability are issues reserved to the Commissioner . . . [The

Commissioner is ] responsible for making the determination or decision about whether [a

claimant] meet[s] the statutory definition of disability. . . . A statement by a medicalsource

that[the claimant is] “disabled” or “unable to work” does not mean that[theCommissioner’

will determine that [the claimant is] disabled.”) Consequently, Dr. Smith’s opinion that

Railey qualifies for disability is not dispositive.

It is not the province of this court to reweigh evidence, make credibility

determinations, orsubstitute itsjudgment for that of the ALJ. Instead the court reviewsthe

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record to determine if the decision reached is supported by substantial evidence. Moore

v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). Substantial evidence “is less than a

preponderance, but rather such relevant evidence as a reasonable person would accept as

adequate to support a conclusion.” Id. Given this standard of review, the court concludes

that the ALJ’s disability determination is consistent with the medical evidence as a whole

as well as Railey’s testimony about his impairments and abilities. In short, after a careful

examination of the administrative record, the court concludes that substantial evidence

supports the conclusion of the ALJ concerning Railey’s ability to work.

V. Conclusion

Forthe foregoing reasons, the court concludesthat the decision oftheCommissioner

is due to be affirmed. A separate final judgment will be entered.

Done this 18th day of October, 2013.

/s/Charles S. Coody

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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