Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_14-cv-00671/USCOURTS-almd-2_14-cv-00671-0/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

APRIL JOHNSON, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:14CV671-SRW

)

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

Plaintiff appeals the Commissioner’s final decision denying plaintiff’s applications

for benefits under Titles II and XVI of the Social Security Act. The parties have consented

to proceeding before the undersigned Magistrate Judge. (Doc. ## 9, 10). Upon consideration

of the administrative record and the arguments of the parties, the court concludes that the

Commissioner’s decision is due to be reversed. 

Single Decision-maker

Plaintiff asserts that the ALJ erred by giving “great weight” to the opinion expressed 1

by S.P. Cooper, a single decision-maker (“SDM”), as to plaintiff’s residual functional

capacity; she contends that this error is not harmless and requires that the Commissioner’s 2

The Appeals Council denied review (R. 1-7) and, thus, the ALJ’s decision is the final 1

decision of the Commissioner. 

The “harmless error” doctrine applies to review of the Commissioner’s decisions. See 2

Diorio v. Heckler, 721 F.2d 726 (11th Cir. 1983)(finding ALJ’s misstatement of facts relating to

vocational factors to be harmless, where those factors were irrelevant because the ALJ had found no

severe impairment). 

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 1 of 9
decision be reversed. (Doc. # 15). The Commissioner agrees that “the ALJ erroneously

referred to SDM Cooper as a state agency medical consultant and gave SDM Cooper’s

‘opinion’ great weight. (Tr. 27).” (Doc. # 16, 7). However, she contend that, “[t]o the extent

this was error, it was harmless.” (Id.).3

In reaching his RFC finding, the ALJ summarized plaintiff’s testimony, her records

of treatment, and the reports of consultative examiners (R. 25-27). He assigned weight to the

medical opinion evidence as follows:

Pursuant to 20 CFR § 404.1527 and Social Security Rulings 06-03p, 96-6p,

and 96-2p, the undersigned has considered the medical opinions, which are

statements fromacceptable medical sources which reflect judgments about the

nature and severity of the impairment and resulting limitations, of the

claimant’s treating physicians, evaluating physicians, and the state agency

medical consultants. Regarding medical opinion of the state agency medical

consultant, the undersigned has accorded the opinion great weight (Exhibit

5A); however, found the claimant’s ability to climb ramps and stairs not as

limited as the state agency consultant determined based on examinations that

show that the claimant had a normal gait and full lower extremity strength.

Regarding the psychiatric review technique (Exhibit 9F), the undersigned finds

that the claimant has no more than mild limitations in social functioning as

opposed to moderate. There are no opinions from any treating physicians.

(R. 27)(emphases added). The ALJ then assigned “some weight” to the opinion of the 4

See SSR 06-03p, 2006 WL 2329939 at *2 (“only ‘acceptable medical sources’ can give us 3

medical opinions”)(citing 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2)); POMS DI 24510.050

(physical RFC forms completed by the single decision-maker (“SDM”) “are not opinion evidence

at the appeal levels”).

The Commissioner argues that, “[n]otably, Plaintiff’s treating physician, E. Shane 4

Cunningham, indicated she could not engage in ‘heavy’ lifting but could lift and carry over 23

pounds ‘on a regular basis’ with proper lifting technique (Tr. 492).” (Doc. # 16, p. 6). Dr.

Cunningham noted:

2

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 2 of 9
consultative clinical psychologist, Dr. Moyer. (R. 27-28). 

Plaintiff argues:

The present record does not contain a medical source opinion from a treating

physician. The ALJ acknowledged this in the decision. Additionally, the

examining physician Dr. May did not render a medical opinion and the ALJ

does not articulate what if any weight he gave Dr. May’s report in reaching his

decision. Based on this record, we cannot discern whether the ALJ’s error in

giving “great weight” to S.P. Cooper’s opinion was harmless, given the

absence of any other medical opinion upon which the ALJ could have relied.

(Doc. # 15, pp. 11-12) (footnotes omitted).5

The patient does have a little bit of muscle spasm of her lower back today with some

mild decreased ROM and some pain on ROM. We will give her a short course of the

Flagyl and the Lortab again for the discomfort. The patient is advised to avoid heavy

lifting[.] The patient does have a young child and does have to lift the young child

that weighs 23 pounds plus all the equipment to help carry the child on a regular

basis. I did tell her to try to use proper lifting technique[.]

(R. 492). There is no indication in the treatment note that Dr. Cunningham ascribed the

Commissioner’s definition of “heavy” work to the word as used in his advice to his patient. 

Additionally, the ALJ was aware of the cited treatment note, but – with good reason – did not

interpret it to mean what counsel now contends that it does. (See R. 27) (ALJ’s statement, in

summarizing Dr. Cunningham’s treatment note, that “[o]n examination, she was noted to have a little

bit of muscle spasm of her lower back with mild decreased range of motion. ... Her discomfort was

attributed to her lifting her child who weighs about 23 pounds as well as all the equipment to help

carry the child on a regular basis.).

The Commissioner argues that both Dr. Cunningham and Dr. May rendered “medical

5

opinions,” as the term is defined in the Commissioner’s regulations. (Doc. # 16, p. 8). While this is

true, it is clear to the court that plaintiff’s argument is that they provided no medical source

statements about plaintiff’s physical capacities. The Commissioner is also correct that an ALJ’s RFC

finding may be supported by substantial evidence even in the absence of such a medical source

opinion. (Id.; see Castle v. Colvin, 557 F. App’x. 849, 853 (11th Cir. 2014)). However, the absence

of such an opinion from an acceptable medical source is relevant, certainly, to the determination of

whether the ALJ’s error in giving “great weight” to what he mistakenly believed to be a physical

RFC assessment rendered byan acceptable medical source is harmless. See Cooper v. Commissioner

of Soc. Sec., 521 F. App’x. 803, 806-07 (11th Cir. 2013) (in a case in which the evidence included

RFC opinions from both plaintiff’s treating physician and a non-examining agency physician, and

in which the ALJ found the claimant to be more limited than reflected in the SDM’s assessment,

3

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 3 of 9
The Commissioner responds that “[t]he task for this Court is ... to determine whether

there was adequate evidence supporting the ALJ’s conclusion that Plaintiff could perform

a reduce[d] range of light work, even in the absence of SDM Cooper’s findings. The

Commissioner respectfully submits there was more than adequate evidence in the formof Dr.

Cunningham’s treatment notes, Dr. May’s examination findings, and objective imaging.” 

(Doc. # 16, p. 9). In other words, the Commissioner invites the court to re-weigh the evidence

that was before the ALJ (excluding the SDM’s opinion, which is not entitled to any

evidentiary weight) and find that the claimant is not disabled. The “harmless error” doctrine

neither requires nor allows this court to do as the Commissioner asks. 

While an ALJ’s consideration of an SDM opinion may very well be harmless in some

cases – for example, where the SDM opinion is substantially similar to an opinion of record

from an acceptable medical source, or the ALJ’s opinion makes clear that he did not give 6

the SDM opinion much weight – this is not such a case. As noted previously, the ALJ 7

observed that “[t]here are no opinions from any treating physicians.” (R. 27). Like the

plaintiff (see Doc. # 16, pp. 11-12), the court understands the ALJ to mean – as is in fact the

holding that the ALJ’s error in referring to the SDM as a doctor and giving weight to her opinion was

“harmless because the ALJ stated that he considered all of the evidence in the record, which also

included opinions by Cooper’s treating physician and the non-examining physician, both of whom

were medical doctors and there is nothing to indicate that the opinion of the SDM was anything

more than cumulative of other evidence, let alone dispositive.”) (emphasis added). 

 See Cooper, 521 F. App’x. at 806-07; n. 5, supra. 

6

 See e.g., Carter v. Astrue, 2012 WL 2135471, *4 (M.D. Ala. Jun. 13, 2012). 7

4

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 4 of 9
case – that no treating physician completed a medical source statement regarding plaintiff’s

physical capacities. As plaintiff contends, neither did Dr. May, the consultative examiner. 8

(See R. 440-43). The ALJ’s decision makes clear that he believed the SDM’s opinion to be

that of a “state agency medical consultant,” and he expressly “accorded the opinion great

weight.” (R. 27). Taking the ALJ at his word, the court cannot conclude that the SDM’s

opinion did not affect the ALJ’s RFC formulation. And if it affected his RFC formulation

in any respect, it necessarily affected his step five conclusion, which rested on vocational

expert testimony regarding other jobs plaintiff can perform with the specified RFC. (See R.

29). 

This case presents the converse of the situation before the Eleventh Circuit in Nyberg

v. Commissioner of Social Security, 179 F. App’x. 589 (11th Cir. 2006). In that case, the

ALJ failed to consider evidence he is required to consider – the opinion of the claimant’s

treating physician. The Commissioner argued that any such error was harmless because,

“even if the ALJ had considered [the treating doctor’s] opinion, the outcome of the case

could not reasonably have changed.” Id. at 592. The Eleventh Circuit reasoned:

The instant case ... is not one where the unmentioned physician’s opinion

merelysupported the ALJ’s conclusion, and was thus unnecessary. See Wilson

v. Comm’r of Soc. Sec., 378 F.3d 541, 547 (6th Cir. 2004). On the contrary,

the potential impact of Dr. Trowbridge’s opinion is strongly and reasonably

disputed by the parties. Thus, we cannot say that the failure to address Dr.

Trowbridge’s opinion was harmless without re-weighing the evidence and

engaging in conjecture that invades the province of the ALJ. See Moore [v.

Barnhart, 405 F.3d 1208, 1214 (11th Cir. 2005)](stating that, where ALJ failed

 See n. 5, supra.

8

5

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 5 of 9
to consider certain factors and indicate their impact on his ultimate conclusion

as to claimant’s residual functional capacity, we “[could not] even evaluate the

Commissioner’s contention that the ALJ’s error was harmless”); Wiggins [v.

Schweiker, 679 F.2d 1387, 1390 (11th Cir. 1982)](remanding where we were

“unable to determine whether the ALJ applied the proper legal standard and

gave the treating physician’s evidence substantial or considerable weight or

found good cause not to do so”)[.]

(Id.)(footnotes omitted; emphasis added). 

While “an estimation of the likelihood that the result would have been different” is

relevant to the harmless error analysis, so is “an awareness of what body (jury, lower court,

administrative agency) has the authority to reach that result[.]” Shinseki v. Sanders, 556 U.S.

396, 411 (2009). This court cannot find that the ALJ’s error in giving “great weight” to the 9

SDM’s opinion was harmless “without re-weighing the evidence and engaging in conjecture

that invades the province of the ALJ.” Nyberg, 179 F. App’x. at 592. Whether the court

would reach the same ultimate conclusion after re-weighing the evidence is beside the

point. Thus, the court concludes – on the particular record under consideration – that the 10

ALJ committed reversible error by giving “great weight” to the opinion of the SDM.

In Allen v. Barnhart, 357 F.3d 1140 (10th Cir. 2004), the Tenth Circuit rejected the 9

Commissioner’s argument that an ALJ’s failure to make a required finding of fact – that one hundred

of a particular job was “a substantial number” – was harmless error because “the missing fact was

clearly established in the record.” Id. at 1145. While the particular error before this court differs

from that in Allen, the Tenth Circuit’s reluctance to expand the harmless error doctrine was informed

by general concerns also relevant here – i.e., that courts should not “obscure the important

institutional boundary” by usurping the administrative tribunal’s fact-finding responsibility, or

engage in “post hoc justification of administrative action[.]” Id. 

The court expresses no opinion regarding the conclusion the Commissioner should reach 10

upon reevaluation of the medical evidence. 

6

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 6 of 9
Dr. Estock’s Opinion

Plaintiff contends that the ALJ erred by failing to consider the mental RFC opinion

of Dr. Estock, the state agency non-examining psychiatrist, who concluded that the plaintiff

was more limited than assessed by the ALJ. (Doc. # 15, pp. 13-15). Social Security Ruling

96-6p provides that “[f]indings of fact made by State agency medical and psychological

consultants and other programphysicians and psychologists regarding the nature and severity

of an individual’s impairment(s) must be treated as expert opinion evidence of nonexamining sources at the administrative law judge and Appeals Council levels of

administrative review.” SSR 96-6p, 1996 WL 374180, * 1 (July 2, 1996). It further provides

that, while ALJs are not bound by the findings of state agency physicians, “they may not

ignore these opinions and must explain the weight given to the opinions in their decisions”

and that “RFC assessments by State agency medical or psychological consultants or other

program physicians or psychologists are to be considered and addressed in the decision as

medical opinions from nonexamining sources about what the individual can still do despite

his or her impairment(s).” (Id. at **1, 4). Additionally, if an ALJ’s RFC assessment

“conflicts with an opinion from a medical source, the [ALJ] must explain why the opinion

was not adopted.” SSR 96-8p, 1996 WL 374184, *7 (July 2, 1996).

The ALJ referred to Dr. Estock’s opinion only once, as follows:

Regarding the psychiatric review technique (Exhibit 9F), the undersigned finds

that the claimant has no more than mild limitations in social functioning as

opposed to moderate.

7

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 7 of 9
(R. 27). As plaintiff argues, the ALJ did not acknowledge or evaluate the mental RFC

opinion given by Dr. Estock in Exhibit 10F, an exhibit separate from the PRTF. While the

ALJ found plaintiff to be “limited to the performance of simple, routine, repetitive tasks[,]”

he included no other mental limitations in his RFC finding. (R. 24). In addition to a limitation

to simple instructions and tasks, Dr. Estock concluded that plaintiff “would likely miss 1-2

days/month due to psych symptoms,” that “[s]upervision should be tactful and constructive

and non-threatening,” and that “[c]hanges in the workplace should be infrequent and

gradually introduced.” (R. 460). The Commissioner offers post hoc explanations of how the

evidence supports rejecting Dr. Estock’s expert opinion regarding plaintiff’s mental RFC

limitations, and contends that “the ALJ’s alleged error in failing to explicitly discount Dr.

Estock’s opinion is harmless and not a basis for remand.” (Doc. # 16, pp. 9-12). However,

the court cannot discern from the ALJ’s written decision his reasons for rejecting the

additional mental limitations assessed by Dr. Estock. For this additional reason, the 11

Commissioner’s decision is due to be reversed, and this action remanded to the

Commissioner for further proceedings.

CONCLUSION

While the ALJ did not include it in his RFC finding, his hypothetical question to the 11

vocational expert included a limitation that “changes in the work place should be infrequent and

gradually introduced[,]” one of the limitations expressed by Dr. Estock. (See R. 24, 75, 460). 

However, the ALJ’s hypothetical question did not take into account Dr. Estock’s opinion that

plaintiff “would likelymiss 1-2 days/month due to psych symptoms,” and that “[s]upervision should

be tactful and constructive and non-threatening.” (See id.). Thus, the ALJ’s hypothetical question

to the VE does not support a conclusion of harmless error. 

8

Case 2:14-cv-00671-SRW Document 22 Filed 01/29/16 Page 8 of 9
For the foregoing reasons, the Commissioner’s decision is due to be reversed. A

separate judgment will be entered. 

Done, this 29 day of January, 2016. th

/s/ Susan Russ Walker 

SUSAN RUSS WALKER

CHIEF UNITED STATES MAGISTRATE JUDGE

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