Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_15-cv-00490/USCOURTS-alsd-1_15-cv-00490-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

JASON A. CAFFEY, )

Plaintiff, )

)

v. ) CIVIL ACTION NO. 15-00490-N

)

CAROLYN W. COLVIN, Acting )

Commissioner of Social Security, )

Defendant. )

MEMORANDUM OPINION AND ORDER

Plaintiff Jason A. Caffey has brought this action under 42 U.S.C. § 405(g) 

seeking judicial review of a final decision of the Defendant Commissioner of Social 

Security (“the Commissioner”) denying his application for a period of disability and 

disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 

U.S.C. § 401, et seq. With the consent of the parties, the Court has designated the 

undersigned Magistrate Judge to conduct all proceedings and order the entry of 

judgment in this civil action, in accordance with 28 U.S.C. § 636(c), Federal Rule of 

Civil Procedure 73, and S.D. Ala. GenLR 73. (See Docs. 15, 16).

Upon consideration of the parties’ briefs (Docs. 11, 12) and those portions of

the administrative record (Doc. 10) (hereinafter cited as “(R. [page number(s) in 

lower-right corner of transcript])”) relevant to the issues raised,1 the Court finds 

that the Commissioner’s decision is due to be REVERSED and REMANDED 

under sentence four of § 405(g) for further proceedings consistent with this decision.

 1 With the Court’s consent, the parties jointly waived the opportunity for oral argument. 

(See Docs. 14, 17).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 1 of 36
I. Procedural Background

On May 29, 2012, Caffey filed an application for a period of disability and

DIB with the Social Security Administration (“SSA”).2 Caffey initially alleged 

disability beginning October 3, 2003, but subsequently amended his alleged onset 

date to January 1, 2008. 3 After his application was initially denied, Caffey

requested a hearing, which was held before an Administrative Law Judge (“ALJ”) 

for the SSA’s Office of Disability Adjudication and Review on August 7, 2013, with a 

supplemental hearing held on February 3, 2014. On March 20, 2014, the ALJ 

issued an unfavorable decision on Caffey’s application, finding him “not disabled” 

under the Social Security Act and thus not entitled to benefits. (See R. 54 – 79). 

The Commissioner’s decision on Caffey’s application became final when the 

Appeals Council for the Office of Disability Adjudication and Review denied Caffey’s

request for review of the ALJ’s decision on August 20, 2015. (R. 1 – 6). On October 

2, 2015, Caffey filed this action under § 405(g) for judicial review of the 

Commissioner’s final decision. (Doc. 1). See 42 U.S.C. § 405(g) (“Any individual, 

after any final decision of the Commissioner of Social Security made after a hearing

to which he was a party, irrespective of the amount in controversy, may obtain a 

review of such decision by a civil action commenced within sixty days after the 

mailing to him of notice of such decision or within such further time as the 

 2 The Social Security Act’s general disability insurance benefits program provides income to 

individuals who are forced into involuntary, premature retirement, provided they are both 

insured and disabled, regardless of indigence. See 42 U.S.C. § 423(a).

3 “For DIB claims, a claimant is eligible for benefits where she demonstrates disability on or 

before the last date for which she were insured. 42 U.S.C. § 423(a)(1)(A) (2005).” Moore v. 

Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005) (per curiam).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 2 of 36
Commissioner of Social Security may allow.”); Ingram v. Comm'r of Soc. Sec. 

Admin., 496 F.3d 1253, 1262 (11th Cir. 2007) (“The settled law of this Circuit is that 

a court may review, under sentence four of section 405(g), a denial of review by the 

Appeals Council.”).

II. Standard of Review

“In Social Security appeals, [the Court] must determine whether the 

Commissioner’s decision is ‘ “supported by substantial evidence and based on proper 

legal standards. 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) (quoting 

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

(internal citation omitted) (quoting Lewis v. Callahan, 125 F.3d 1436, 1439 (11th 

Cir. 1997))). However, the Court “ ‘may not decide the facts anew, reweigh the 

evidence, or substitute our judgment for that of the [Commissioner].’ ” Id. (quoting 

Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir. 2004) (alteration in 

original) (quoting Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983))). “ 

‘Even if the evidence preponderates against the [Commissioner]’s factual findings, 

we must affirm if the decision reached is supported by substantial evidence.’ ” 

Ingram, 496 F.3d at 1260 (quoting Martin v. Sullivan, 894 F.2d 1520, 1529 (11th 

Cir. 1990)).

 “Yet, within this narrowly circumscribed role, [courts] do not act as 

automatons. [The court] must scrutinize the record as a whole to determine if the 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 3 of 36
decision reached is reasonable and supported by substantial evidence[.]” 

Bloodsworth, 703 F.2d at 1239 (citations and quotation omitted). See also Owens v. 

Heckler, 748 F.2d 1511, 1516 (11th Cir. 1984) (per curiam) (“We are neither to 

conduct a de novo proceeding, nor to rubber stamp the administrative decisions that 

come before us. Rather, our function is to ensure that the decision was based on a 

reasonable and consistently applied standard, and was carefully considered in light 

of all the relevant facts.”). “In determining whether substantial evidence exists, [a 

court] must...tak[e] into account evidence favorable as well as unfavorable to the 

[Commissioner’s] decision.” Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986).

However, the “substantial evidence” “standard of review applies only to 

findings of fact. No similar presumption of validity attaches to the [Commissioner]’s 

conclusions of law, including determination of the proper standards to be applied in 

reviewing claims.” MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986)

(quotation omitted). Accord, e.g., Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th 

Cir. 1982) (“Our standard of review for appeals from the administrative denials of 

Social Security benefits dictates that ‘(t)he findings of the Secretary as to any fact, if 

supported by substantial evidence, shall be conclusive ....’ 42 U.S.C.A. s 405(g) 

(West Supp. 1982) (emphasis added). As is plain from the statutory language, this 

deferential standard of review is applicable only to findings of fact made by the 

Secretary, and it is well established that no similar presumption of validity attaches 

to the Secretary’s conclusions of law, including determination of the proper 

standards to be applied in reviewing claims.” (footnote and some citations and 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 4 of 36
quotation marks omitted)). This Court “conduct[s] ‘an exacting examination’ of 

these factors.” Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996) (per curiam) 

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

[Commissioner]’s failure to apply the correct law or to provide the reviewing court 

with sufficient reasoning for determining that the proper legal analysis has been 

conducted mandates reversal.’” Ingram, 496 F.3d at 1260 (quoting Cornelius v. 

Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991)). Accord Keeton v. Dep't of Health 

& Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).

In sum, courts “review the Commissioner’s factual findings with deference 

and the Commissioner’s legal conclusions with close scrutiny.” Doughty v. Apfel, 

245 F.3d 1274, 1278 (11th Cir. 2001). See also Moore v. Barnhart, 405 F.3d 1208, 

1211 (11th Cir. 2005) (per curiam) (“In Social Security appeals, we review de novo

the legal principles upon which the Commissioner's decision is based. Chester v. 

Bowen, 792 F.2d 129, 131 (11th Cir. 1986). However, we review the resulting 

decision only to determine whether it is supported by substantial evidence. 

Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158–59 (11th Cir. 2004).”).

Eligibility for DIB ... requires that the claimant be disabled. 42 U.S.C. 

§[] 423(a)(1)(E) ... A claimant is disabled if she is unable “to engage in 

any substantial gainful activity by reason of a medically determinable 

physical or mental impairment ... 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)...

Thornton v. Comm’r, Soc. Sec. Admin., 597 F. App’x 604, 609 (11th Cir. 2015) (per 

curiam) (unpublished).4

 4 In this Circuit, “[u]npublished opinions are not considered binding precedent, but they 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 5 of 36
The Social Security Regulations outline a five-step, sequential 

evaluation process used to determine whether a claimant is disabled: 

(1) whether the claimant is currently engaged in substantial gainful 

activity; (2) whether the claimant has a severe impairment or 

combination of impairments; (3) whether the impairment meets or 

equals the severity of the specified impairments in the Listing of 

Impairments; (4) based on a residual functional capacity (“RFC”) 

assessment, whether the claimant can perform any of his or her past 

relevant work despite the impairment; and (5) whether there are 

significant numbers of jobs in the national economy that the claimant 

can perform given the claimant's RFC, age, education, and work 

experience.

Winschel, 631 F.3d at 1178 (citing 20 C.F.R. §§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-

(v); Phillips, 357 F.3d at 1237-39).5

“These regulations place a very heavy burden on the claimant to demonstrate 

both a qualifying disability and an inability to perform past relevant work.” Moore, 

405 F.3d at 1211 (citing Spencer v. Heckler, 765 F.2d 1090, 1093 (11th Cir. 1985)). 

“In determining whether the claimant has satisfied this initial burden, the 

examiner must consider four factors: (1) objective medical facts or clinical findings; 

(2) the diagnoses of examining physicians; (3) evidence of pain; and (4) the 

claimant’s age, education, and work history.” Jones v. Bowen, 810 F.2d 1001, 1005 

(11th Cir. 1986) (per curiam) (citing Tieniber v. Heckler, 720 F.2d 1251, 1253 (11th 

Cir. 1983) (per curiam)). “These factors must be considered both singly and in 

combination. Presence or absence of a single factor is not, in itself, conclusive.” 

Bloodsworth, 703 F.2d at 1240 (citations omitted).

 

may be cited as persuasive authority.” 11th Cir. R. 36-2. See also Henry v. Comm'r of Soc. 

Sec., 802 F.3d 1264, 1267 n.1 (11th Cir. 2015) (per curiam) (“Cases printed in the Federal 

Appendix are cited as persuasive authority.”).

5 The Court will hereinafter use “Step One,” “Step Two,” etc. when referencing individual 

steps of this five-step sequential evaluation.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 6 of 36
If, in Steps One through Four of the five-step evaluation, a claimant proves 

that he or she has a qualifying disability and cannot do his or her past relevant 

work, it then becomes the Commissioner’s burden, at Step Five, to prove that the 

claimant is capable—given his or her age, education, and work history—of engaging 

in another kind of substantial gainful employment that exists in the national 

economy. Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999); Sryock v. Heckler, 

764 F.2d 834, 836 (11th Cir. 1985). Finally, although the “claimant bears the 

burden of demonstrating the inability to return to [his or] her past relevant work, 

the Commissioner of Social Security has an obligation to develop a full and fair 

record.” Shnorr v. Bowen, 816 F.2d 578, 581 (11th Cir. 1987). See also Ellison v. 

Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003) (per curiam) (“It is well-established 

that the ALJ has a basic duty to develop a full and fair record. Nevertheless, the 

claimant bears the burden of proving that he is disabled, and, consequently, he is 

responsible for producing evidence in support of his claim.” (citations omitted)). 

“This is an onerous task, as the ALJ must scrupulously and conscientiously probe 

into, inquire of, and explore for all relevant facts. In determining whether a 

claimant is disabled, the ALJ must consider the evidence as a whole.” Henry v. 

Comm'r of Soc. Sec., 802 F.3d 1264, 1267 (11th Cir. 2015) (per curiam) (citation and 

quotation omitted).

Where, as here, the ALJ denied benefits and the Appeals Council denied 

review of that decision, the Court “review[s] the ALJ’s decision as the 

Commissioner’s final decision.” Doughty, 245 F.3d at 1278. “[W]hen the [Appeals 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 7 of 36
Council] has denied review, [the Court] will look only to the evidence actually 

presented to the ALJ in determining whether the ALJ’s decision is supported by 

substantial evidence.” Falge v. Apfel, 150 F.3d 1320, 1323 (11th Cir. 1998). If the 

applicant attacks only the ALJ’s decision, the Court may not consider evidence that 

was presented to the Appeals Council but not to the ALJ. See id. at 1324. 

III. Claims on Judicial Review

1. “The ALJ’s mental residual functional capacity assessment is inconsistent 

with the evidence upon which it purports to rely.”

2. “The ALJ’s physical residual functional capacity assessment is inconsistent 

with the evidence upon which it purports to rely.”

3. “The ALJ erred in failing to properly assess Mr. Caffey’s testimony of 

medication side effects.”

(Doc. 11 at 2).6

IV. Analysis

At Step One, the ALJ determined that Caffey had “not engaged in substantial 

gainful activity during the period from his amended alleged onset date of January 1, 

2008 through his date last insured of December 31, 2012...” (R. 59). At Step Two, 

 6 Generally, claims of error not raised in the district court are deemed waived. See Stewart 

v. Dep’t of Health & Human Servs., 26 F.3d 115, 115 – 16 (11th Cir. 1994) (“As a general 

principle, [the court of appeals] will not address an argument that has not been raised in 

the district court ... Because Stewart did not present any of his assertions in the district 

court, we decline to consider them on appeal.” (applying rule in appeal of judicial review 

under 42 U.S.C. §§ 405(g), 1383(c)(3)); Hunter v. Comm’r of Soc. Sec., 651 F. App'x 958, 962 

(11th Cir. 2016) (per curiam) (unpublished) (same); In re Pan Am. World Airways, Inc., 

Maternity Leave Practices & Flight Attendant Weight Program Litig., 905 F.2d 1457, 1462 

(11th Cir. 1990) (“[I]f a party hopes to preserve a claim, argument, theory, or defense for 

appeal, she must first clearly present it to the district court, that is, in such a way as to 

afford the district court an opportunity to recognize and rule on it.”).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 8 of 36
the ALJ determined that Caffey had the following severe impairments: arthritis in 

the wrists, knees, hips, and lower back; anxiety; depression; and polysubstance 

dependence. (R. 59 – 60). At Step Three, the ALJ found that Caffey did not have an 

impairment or combination of impairments that meets or equals the severity of one 

of the specified impairments in the relevant Listing of Impairments. (R. 60 – 61). 

At Step Four,

the ALJ must assess: (1) the claimant's residual functional capacity 

(“RFC”); and (2) the claimant's ability to return to her past relevant 

work. 20 C.F.R. § 404.1520(a)(4)(iv). As for the claimant's RFC, the 

regulations define RFC as that which an individual is still able to do 

despite the limitations caused by his or her impairments. 20 C.F.R. § 

404.1545(a). Moreover, the ALJ will “assess and make a finding about 

[the claimant's] residual functional capacity based on all the relevant 

medical and other evidence” in the case. 20 C.F.R. § 404.1520(e). 

Furthermore, the RFC determination is used both to determine 

whether the claimant: (1) can return to her past relevant work under 

the fourth step; and (2) can adjust to other work under the fifth 

step...20 C.F.R. § 404.1520(e).

If the claimant can return to her past relevant work, the ALJ will 

conclude that the claimant is not disabled. 20 C.F.R. § 

404.1520(a)(4)(iv) & (f). If the claimant cannot return to her past 

relevant work, the ALJ moves on to step five.

In determining whether [a claimant] can return to her past relevant 

work, the ALJ must determine the claimant's RFC using all relevant 

medical and other evidence in the case. 20 C.F.R. § 404.1520(e). That 

is, the ALJ must determine if the claimant is limited to a particular 

work level. See 20 C.F.R. § 404.1567. Once the ALJ assesses the 

claimant’s RFC and determines that the claimant cannot return to her 

prior relevant work, the ALJ moves on to the fifth, and final, step.

Phillips, 357 F.3d at 1238-39 (footnote omitted).

The ALJ determined that Caffey had the RFC “to perform a range of light 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 9 of 36
work as defined in 20 CFR 404.1567(b),[ 7] in function by function terms (SSRs 83-10 

and 06-8p, with certain non-exertional restrictions associated with that level of 

exertion. The claimant’s specific capabilities during the period of adjudication have 

been the ability to lift 20 pounds occasionally and 10 pounds frequently; sit at least 

6 hours in an 8 hour workday; and stand/walk in combination with at least 6 hours 

in an 8 hour workday. The claimant would have manipulative limitations resulting 

in the ability to frequently handle bilaterally. He would have postural limitations 

resulting in the ability to occasionally climb ramps/stairs, stoop, kneel, crouch and 

crawl and never climb ladders/ropes/scaffolds. The claimant should never work at 

unprotected heights or with dangerous machinery. The claimant would have 

residual mental restrictions resulting in a need for simple tasks with short simple 

instructions; occasional contact with the general public; and only casual supervisors 

and coworkers with casual meaning the claimant could work in proximity to others 

but should avoid team type work activity.” (R. 61 – 77).

Based on this RFC, the ALJ determined that Caffey was unable to perform 

any past relevant work. (Doc. 77). At Step Five, the ALJ determined that there 

 7 “To determine the physical exertion requirements of different types of employment in the 

national economy, the Commissioner classifies jobs as sedentary, light, medium, heavy, and 

very heavy. These terms are all defined in the regulations ... Each classification ... has its 

own set of criteria.” Phillips, 357 F.3d at 1239 n.4. “Light work involves lifting no more 

than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 

pounds. Even though the weight lifted may be very little, a job is in this category when it 

requires a good deal of walking or standing, or when it involves sitting most of the time 

with some pushing and pulling of arm or leg controls. To be considered capable of 

performing a full or wide range of light work, [the claimant] must have the ability to do 

substantially all of these activities. If someone can do light work, [the Commissioner] 

determine[s] that he or she can also do sedentary work, unless there are additional limiting 

factors such as loss of fine dexterity or inability to sit for long periods of time.” 20 C.F.R. §

404.1567(b).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 10 of 36
exist significant numbers of jobs in the national economy that Caffey can perform 

given his RFC, age, education, and work experience. (R. 77 – 78). Thus, the ALJ 

found that Caffey was not disabled under the Social Security Act. (R. 78).

In her Step Four RFC assessment, the ALJ considered a good deal of 

evidence, consisting of Caffey’s subjective testimony given in his administrative 

filings and at his administrative hearings (his “statements concerning the intensity, 

persistence and limiting effects of [his] symptoms” were found “not entirely 

credible”), the reports of two state agency consultants (“little weight” given to both), 

and the treatment notes and medical opinions of:

1. one-time examining physician Dr. David Kim, who performed an orthopedic 

evaluation of Caffey on June 24, 2011, in connection with Caffey’s workers’ 

compensation case (findings and opinion given “considerable weight”); 

2. one-time examining neurologist Dr. Kenneth Nudleman, who evaluated 

Caffey on June 23, 2011, in connection with the workers’ compensation case

(opinion given “some weight); 

3. treating family physician Dr. Michael Rowland, who treated Caffey from May 

12, 2012, until April 13, 2013 (opinions given “little weight”); 

4. treating physician Dr. Bobby Wrights, who began seeing Caffey on April 22, 

2013 (opinions given “little weight”); 

5. consultative examining psychologist Dr. Kenneth Starkey, who evaluated 

Caffey on July 27, 2012 (opinion given “significant weight”); and

6. consultative examining psychologist Dr. John Davis, who evaluated Caffey on 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 11 of 36
September 24, 2013 (opinion given “significant weight”).

(See R. 61 – 77).

A. Claim 1 (Mental RFC)

A mental RFC determination includes an assessment of mental abilities such 

as the ability to understand, remember, and carry out instructions, and to respond

appropriately to supervision, coworkers, and work pressure. 20 C.F.R. § 

404.1545(c); Luterman v. Comm'r of Soc. Sec., 518 F. App'x 683, 689 (11th Cir. 2013) 

(per curiam) (unpublished). See also SSR 96-8P, 1996 WL 374184, at *6 (S.S.A. 

July 2, 1996) (“Work-related mental activities generally required by competitive, 

remunerative work include the abilities to: understand, carry out, and remember 

instructions; use judgment in making work-related decisions; respond appropriately 

to supervision, co-workers and work situations; and deal with changes in a routine 

work setting.”). Claim 1 asserts that the ALJ’s mental RFC determination failed to 

account for key portions of the medical opinions of Dr. Starkey and Dr. Davis, 

despite giving them “significant weight” (R. 76).

“Medical opinions are statements from physicians and psychologists or 

other acceptable medical sources that reflect judgments about the

nature and severity of [the claimant’s] impairment(s), including [the 

claimant’s] symptoms, diagnosis and prognosis, what [the claimant] 

can still do despite impairment(s), and [the claimant's] physical or 

mental restrictions.” 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2) ...

[T]he ALJ must state with particularity the weight given to different 

medical opinions and the reasons therefor. Sharfarz v. Bowen, 825 

F.2d 278, 279 (11th Cir. 1987) (per curiam). “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.” Cowart v. Schweiker, 662 F.2d 731, 

735 (11th Cir. 1981). Therefore, when the ALJ fails to “state with at 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 12 of 36
least some measure of clarity the grounds for his decision,” we will 

decline to affirm “simply because some rationale might have supported 

the ALJ’s conclusion.” Owens v. Heckler, 748 F.2d 1511, 1516 (11th Cir.

1984) (per curiam). In such a situation, “to say that [the ALJ’s] 

decision is supported by substantial evidence approaches an abdication 

of the court's duty to scrutinize the record as a whole to determine 

whether the conclusions reached are rational.” Cowart, 662 F.2d at 735 

(quoting Stawls v. Califano, 596 F.2d 1209, 1213 (4th Cir. 1979)) 

(internal quotation marks omitted).

Winschel, 631 F.3d at 1178-79.

At Step Four, after discussing the record evidence relevant to Caffey’s mental 

impairments, including the notes and opinions of Dr. Starkey and Dr. Davis, the 

ALJ made the following determinations:

In terms of the claimant’s alleged anxiety, depression and 

polysubstance dependence, the preponderance of the documentary 

evidence reflects that his level of mental functioning is only moderately 

impaired by his alleged mental health symptomatology. The record 

reflects no actual formal mental health treatment since 2003. 

(Exhibits 15F, 16F and 27F). He has only been prescribed Xanax for 

anxiety by his general treating physicians; and the record does not 

contain any evidence that the claimant has sought or was referred to a 

mental health specialist for treatment of his anxiety/depression during 

the period at issue. The claimant has reported no depression 

symptoms to his treatment providers during the period at issue. The 

claimant has reported no depression symptoms to his treatment 

providers during the period at issue, and Dr. Davis diagnosed him with 

depression secondary to a general medical condition. Dr. Davis 

commented that “This diagnosis is an Axis III diagnosis which 

recognizes ‘normal depression’ associated with their medical problems. 

It is not the same as an Axis I diagnosis of Depression.” (Exhibit 27F).

The claimant testified that Xanax is helpful for his anxiety, and he has 

not had a panic attack since he stared taking his medication. Indeed, 

Dr. Rowland noted the claimant was calm, in no acute distress and had 

normal mood/affect during all office visits. (Exhibits 19F, 20F and 

25F). When the claimant saw Dr. Wrights on April 22, 2013, he 

complained of anxiety symptoms including feelings of losing control 

and palpitations. Dr. Wrights noted previous reported treatment 

includes benzodiazepines (Xanax 2 mg), which the claimant said he 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 13 of 36
takes 3-4 daily. The claimant complained of no side effects from the 

treatment. The claimant had a normal mood and affect. His behavior 

was normal and he was alert and oriented to person, place and time. 

His judgment and thought content was also normal. Dr. Wrights 

diagnosed the claimant with anxiety and continued him on Xanax at a 

2 mg dosage. (Exhibit 22F). During the claimant’s follow up with Dr. 

Wrights on June 27 and July 16, 2013, no psychiatric/behavioral 

complaints were noted during the review of systems or in the 

diagnosis. (Exhibits 26F and 28F). The review of systems on August 

27, 2013 was positive for agitation; but the psychiatric exam reflected a 

normal mood and affect. Dr. Wrights refilled the claimant’s Xanax at 2 

mg to be taken 3-4 times a day for anxiety. (Exhibit 28F).

Overall, it appears that the claimant’s mental condition is generally 

controlled with his medication regimen based on his testimony and 

normal mental status exams with his treating physicians. The 

undersigned finds that he is capable of performing simple tasks with 

short simple instructions; occasional contact with the general public; 

and only casual supervisors and coworkers with casual meaning the 

claimant could work in proximity to others but should avoid team type 

work activity.

Polysubstance dependence related to opioids and benzodiazepines was 

addressed by the consultative examiners in Exhibits 16F and 27F. The 

undersigned finds this condition is not material, as the record does not 

document maladaptive use of his prescription medications ongoing 

throughout the period at issue (SSR 13-2p). The record does contain 

some indications that the claimant has not taken these medications 

exactly as prescribed. Dr. Starkey noted the claimant had “NO Lortab 

pills remaining in the bottle from a prescription of 168 such pills filled 

20 days prior to our meeting, and only 6 Xanax pills from a 

prescription of 112 such pills prescribed 20 days prior to our meeting.” 

(Exhibit 16F). Dr. Rowland discharged the claimant from his practice 

in April 2013 due to violating the pain management contract. (Exhibit 

25F). The claimant also testified that he is supposed to take Xanax 3-4 

times a day, but he had been taking it more often recently. However, 

as noted above, the alleged sedative side effects related to his 

medications have been accounted for in the residual functional 

capacity with the mental and environmental limitations. 

(R. 73 – 74).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 14 of 36
The ALJ then proceeded to weigh “the opinion evidence,” discussing the 

opinions of Dr. Starkey and Dr. Davis as follows:

The opinions of Dr. Starkey and Dr. Davis are given significant weight 

as they are generally consistent with the mental residual functional 

capacity above. Dr. Starkey opined that the claimant can understand, 

remember and carry out simple/concrete instructions. However, his 

ability to work independently (versus with close supervision[)]; to work 

with supervisors, co-workers and general public; and his ability to deal 

with work pressures appeared marginal at the time. (Exhibit 16F). 

Dr. Davis opined that the claimant’s ability to understand, remember 

and carry out complex instructions and make judgments on complex 

work-related decisions is moderately impaired. Dr. Davis also said the 

claimant has moderate impairment in the ability to interact 

appropriately with the public, supervisors and co-workers and respond 

appropriately to usual work situations and to changes in routine 

setting. (Exhibit 27F). As a result, the claimant would have moderate 

difficulties in maintaining social functioning and concentration, 

persistence or pace.

(R. 76 – 77). 

Caffey argues that the ALJ reversibly erred in failing to sufficiently explain 

“the reasons therefore” in assigning “significant weight” to the opinions of Dr. 

Starkey and Dr. Davis. Caffey notes that the RFC “provides no specific limitation 

regarding Mr. Caffey’s ability to deal with work pressure[,]” which Dr. Starkey 

opined was “marginal,” and his ability “to respond appropriately to usual work 

situations and changes in routine settings[,]” which Dr. Davis opined was 

“moderately impaired.” (Doc. 11 at 9). Caffey also asserts that the RFC’s limitation 

to tasks with “casual supervisors and coworkers with casual meaning the claimant 

could work in proximity to others but should avoid team type work activity” is 

inconsistent with Dr. Starkey’s opinion that Caffey’s ability to work independently 

(versus with close supervision) was “marginal.” (Id.). He further argues that, 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 15 of 36
because these limitations were not included in the ALJ’s hypothetical questions to 

the vocational expert (“VE”) at Step Five, the VE’s testimony that there exist 

significant numbers of jobs that Caffey can perform does not constitute substantial 

evidence.8 See (id. at 9, 11 – 12); Winschel, 631 F.3d at 1180 (“In order for a 

vocational expert’s testimony to constitute substantial evidence, the ALJ must pose 

a hypothetical question which comprises all of the claimant’s impairments.” 

(quotation omitted)).

As Caffey notes in his brief, the undersigned, observing that “medical 

opinions are generally multifaceted” and that, “in the course of determining a 

plaintiff’s residual functional capacity (‘RFC’), an ALJ may choose to accept some 

conclusions-or recommended related restrictions-made within an opinion while 

rejecting others[,]” has stated:

If such a choice is made, in addition to explaining the overall weight 

given to a particular medical opinion, the ALJ also must explain with 

at least some measure of clarity the grounds for a decision to adopt 

particular aspects of a medical opinion. Any failure to explain his or 

her rationale in this regard will result in a reviewing court declining to 

affirm simply because some rationale might have supported the ALJ's 

conclusion. []Picking some restrictions while rejecting others without 

explanation is clearly grounds to find that an ALJ's decision is not 

supported by substantial evidence and, therefore, order that it be 

remanded for further consideration.

 8 “At step five, the Commissioner must determine that significant numbers of jobs exist in 

the national economy that the claimant can perform. An ALJ may make this determination 

either by applying the Medical Vocational Guidelines or by obtaining the testimony of a 

vocational expert.” Winschel, 631 F.3d at 1180 (citations omitted). However, where, as 

here, “nonexertional impairments exist, the ALJ may use Medical–Vocational Guidelines as 

a framework to evaluate vocational factors, but must also introduce independent evidence, 

preferably through a vocational expert’s testimony, of existence of jobs in the national 

economy that the claimant can perform.” Wilson v. Barnhart, 284 F.3d 1219, 1227 (11th 

Cir. 2002) (per curiam).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 16 of 36
Smith v. Colvin, Civil Action No. 2:13-00275-N, 2014 WL 518057, at *3 (S.D. Ala. 

Feb. 10, 2014) (citations, quotations, and footnote omitted).9

Nevertheless, the RFC assessment is ultimately the ALJ’s responsibility.10 

At least where the opinion is not from a treating source,11 the Eleventh Circuit 

imposes no rigid requirement that an ALJ, in crediting a medical opinion, must 

repeat it word for word in the RFC determination. See Lewen v. Comm'r of Soc. 

Sec., 605 F. App'x 967, 968-69 (11th Cir. 2015) (per curiam) (unpublished) (“Lewen’s 

contention, that the ALJ did not properly consider the medical opinions, lacks 

merit. The mental limitations imposed in the ALJ’s determination of Lewen’s 

residual functional capacity were consistent with the medical opinions, even the 

portions that the ALJ did not specifically quote in her order. The ALJ 

limited Lewen to simple tasks and instructions, occasional interaction with the 

 9 Smith’s reasoning relied primarily on the reasoning of non-binding district court and 

Tenth Circuit Court of Appeals opinions, while simply noting that “the Eleventh Circuit ... 

has not held otherwise...” Smith, 2014 WL 518057, at *3 & n.4. Though not binding, see

United States v. Cerceda, 172 F.3d 806, 812 n.6 (11th Cir. 1999) (en banc) (per curiam)

(“The opinion of a district court carries no precedential weight, even within the same 

district.”), Smith is instructive.

10 See 20 C.F.R. §§ 404.1527(d)(2) (“Although we consider opinions from medical sources on 

issues such as whether your impairment(s) meets or equals the requirements of any 

impairment(s) in the Listing of Impairments in appendix 1 to this subpart, your residual 

functional capacity (see §§ 404.1545 and 404.1546), or the application of vocational factors, 

the final responsibility for deciding these issues is reserved to the Commissioner.”), 

404.1546(c) (“If your case is at the administrative law judge hearing level ... , the 

administrative law judge ... is responsible for assessing your residual functional capacity.”); 

Moore v. Soc. Sec. Admin., Com'r, 649 F. App'x 941 (11th Cir. 2016) (per curiam) 

(unpublished) (“[T]he task of determining a claimant’s residual functional capacity and 

ability to work rests with the administrative law judge, not a doctor.” (citing 20 C.F.R. § 

404.1546(c))).

11 “Absent good cause, an ALJ is to give the medical opinions of treating physicians 

substantial or considerable weight.” Winschel, 631 F.3d at 1179 (quotation marks omitted). 

Neither Dr. Davis nor Dr. Starkey is a treating physician for Caffey.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 17 of 36
public, and occasional routine interaction with supervisors. Lewen was further 

limited to tasks and instructions that were ‘consistent with unskilled work.’ There 

is no indication that these limitations do not account for the doctors’ opinions in 

their entireties. Rather, any need to limit Lewen’s ability to concentrate, deal with 

stress, or maintain a regular schedule on the job—opinions that Lewen argues are 

omitted from the ALJ’s decision—is accounted for by the ALJ limiting her to simple 

tasks and unskilled work with little interaction with the public and supervisors. 

Moreover, there is no indication that the doctors, by opining that Lewen might have 

difficulties dealing with stress, concentrating, or maintaining a schedule, meant 

that these limitations would limit her ability to work a full work day/week. These 

doctors opined that, despite these limitations, she could perform simple routine 

tasks. Finally, while the ALJ is required to state the weight afforded to each 

medical opinion, the ALJ is not required to discuss every piece of evidence.” 

(citations omitted) (emphasis added)); Adams v. Comm'r, Soc. Sec. Admin., 586 F. 

App'x 531, 534 (11th Cir. 2014) (per curiam) (unpublished) (“[T]he ALJ did not err 

by failing to specifically address Adams’s neurologist’s opinion that she should avoid 

frequent overhead reaching, and that she needed to take 5–minute breaks every 45 

minutes, as his written decision made clear that he considered both the 

neurologist's opinion and Adams's medical condition as a whole.” (citing Dyer v. 

Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (per curiam))); Hunter v. Comm'r of 

Soc. Sec., 609 F. App'x 555, 558 (11th Cir. 2015) (per curiam) (unpublished) (“To the 

extent that an administrative law judge commits an error, the error is harmless if it 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 18 of 36
did not affect the judge’s ultimate determination. See Diorio v. Heckler, 721 F.2d 

726, 728 (11th Cir. 1983) (applying the harmless error doctrine in a Social Security 

appeal after finding that an administrative law judge made ‘erroneous statements 

of fact’).”); Shaw v. Astrue, 392 F. App'x 684, 687 & n.1 (11th Cir. 2010) (“Shaw 

argues that the ALJ did not address Dr. Muller’s opinion that she had poor abilities 

to interact with supervisors or to deal with work stress when making the RFC 

finding. []The ALJ did not reject Dr. Muller's opinions explicitly or implicitly. 

Rather, he made two references to Dr. Muller's opinions, both of which were 

positive. The ALJ noted that he found several statements made by Shaw to Dr. 

Muller that were in direct conflict with statements made to Dr. Naqvi, and 

therefore not credible. Ultimately, however, he relied on Dr. Muller’s opinions in 

making an RFC limiting Shaw to light exertional work, including work with simple 

instructions and no more than limited public contact. Although he did not 

specifically address the findings regarding poor functionality in dealing with 

supervisors or stress, his RFC finding was not inconsistent with this ... Thus, even 

if the ALJ erred in failing to mention every finding made by Dr. Muller, any such 

error was harmless. See Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983).” 

(record citations omitted)); Brothers v. Colvin, No. 3:14-CV-108 (CAR), 2015 WL 

4977300, at *1 & n.1 (M.D. Ga. Aug. 20, 2015) (Royal, J.) (“Plaintiff argues the 

Magistrate Judge did not address the ALJ’s failure to account for the examining 

psychologist's finding that Plaintiff is extremely limited in her ability to deal with 

supervisors, and the ALJ's failure to do so constitutes reversible error. The Court 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 19 of 36
disagrees. As noted by the Magistrate Judge, the record shows the ALJ limited 

Plaintiff’s RFC to work with only occasional interaction with the public and 

coworkers and gave weight to the examining psychologist’s opinion. Indeed, the 

ALJ’s RFC assessment is not inconsistent with the opinion that Plaintiff is limited 

in her ability to get along with supervisors.” (citing Shaw, 392 F. App’x at 686)), 

aff'd, Brothers v. Comm'r of Soc. Sec., 648 F. App'x 938 (11th Cir. 2016) (per curiam) 

(unpublished).

Though Caffey does not specifically identify this issue, the undersigned 

initially observes that the ALJ’s stated reason for assigning “significant weight” to 

these opinions was because they were “generally consistent with [Caffey’s] mental 

residual functional capacity above.” (Doc. 76). Indeed, the very sequence of the 

ALJ’s written decision indicates that she formulated the mental RFC prior to 

weighing the medical opinions of record. See supra. However, an RFC is to be 

“assess[ed] based on all the relevant evidence in [a claimant’s] case record.” 20 

C.F.R. § 404.1545(a)(1), (3). Thus, medical opinions, which are relevant evidence, 

see 20 C.F.R. §§ 404.1512(b)(1)(ii), 404.1527(a)(2), are to be examined and weighed 

as part of the RFC assessment, rather than as post hoc justification for an RFC predetermined without consideration of “all the relevant evidence.” In other words, at 

Step Four the evidence is supposed to justify the RFC, not vice versa. 

Moreover, it is not clear how, or why, the ALJ synthesized the specific mental 

limitations in the two opinions into the more general determination that Caffey 

“would have moderate difficulties in maintaining social functioning and 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 20 of 36
concentration, persistence or pace,” especially when such limitations were not 

stated in the RFC. These factors appear to be more relevant at Steps Two and 

Three, as “social functioning” and “concentration, persistence, or pace” are two of 

the “four broad functional areas” used to “rate the degree of [a claimant’s] functional 

limitation” as part of the Psychiatric Review Technique (“PRT”) used to evaluate the 

severity of mental impairments. See 20 C.F.R. § 404.1520a(c)(3).12 Indeed, the 

Commissioner has recognized that PRT findings “are not an RFC assessment” and 

that “[t]he mental RFC assessment used at steps 4 and 5 of the sequential 

evaluation process requires a more detailed assessment by itemizing various 

functions contained in the broad categories” of the PRT. Social Security Ruling 

(SSR) 96-8P, 1996 WL 374184, at *4 (July 2, 1996). 13

The record supports the conclusion that the ALJ reversibly erred in failing to

clearly address Dr. Starkey’s opinion assigning Caffey a marginal ability to work 

independently. As noted previously, Caffey had two hearings with the ALJ. At his

 12 The other two “broad functional areas” are “activities of daily living” and “episodes of 

decompensation.” 20 C.F.R. § 404.1520a(c)(3).

13 Agreeing with other circuits, the Eleventh Circuit has recognized that, “[t]hough the PRT 

and RFC evaluations are undeniably distinct, see 20 C.F.R. §§ 404.1520a(d)(3), 

416.920a(d)(3), nothing precludes the ALJ from considering the results of the former in his 

determination of the latter.” Winschel, 631 F.3d at 1180 (citing Ramirez v. Barnhart, 372 

F.3d 546, 554 (3d Cir. 2004) (“While [Social Security Ruling] 96–8p does state that the 

[PRT] findings are ‘not an RFC assessment’ and that step four requires a ‘more detailed 

assessment,’ it does not follow that the findings on the [PRT] play no role in steps four and 

five, and [Social Security Ruling] 96–8p contains no such prohibition.”)). In Winschel, 

however, the claimant had argued (successfully) that the ALJ’s hypothetical to the VE 

failed to account for his moderate limitations in maintaining concentration, persistence, 

and pace identified in Steps Two and Three, with the Commissioner countering that to 

include such limitations in the hypothetical “would inappropriately conflate independent 

inquiries” (an assertion the court rejected). See id. Caffey is not asserting such an 

argument here.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 21 of 36
initial administrative hearing on August 7, 2013, the ALJ asked the VE whether 

jobs were available for a hypothetical individual with similar age, education, and 

prior work history as Caffey “who had a marginal ability to work with supervisors, 

co-workers or the general public and who would have a marginal ability to work 

independently” (both limitations included in Dr. Starkey’s opinion), with such 

limitations resulting “in an inability to sustain activity, remain on task, remain on 

target for two hour periods at a time eight hours during each work day 40 hours 

during each work week.” (R. 119 (emphasis added)). Notably, the ALJ did not 

incorporate any of Caffey’s RFC into this hypothetical, as she did with the first two 

hypotheticals. The first VE responded that no jobs would be available for such an 

individual. (R. 119).

A different VE gave testimony at the supplemental hearing held February 3, 

2014. The ALJ’s third hypothetical to the second VE again asked whether jobs 

were available for a hypothetical individual with similar age, education, and prior 

work history as Caffey who is “unable to sustain activity, remain on task, remain on 

target for two hour periods of a time over the course of an eight hour work day for 

40 hours during each work week either given residual side effects from medication, 

residual pain or residual psychiatric symptoms.” Again, the ALJ did not 

incorporate any of Caffey’s RFC into this hypothetical. (R. 94 – 95). The second VE 

also responded that no jobs would be available for such an individual. (R. 94 – 95).

The ALJ did not specifically mention Caffey’s “marginal ability to work 

independently” in her third hypothetical to the second VE. However, the third 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 22 of 36
hypothetical to the first VE reveals the ALJ’s reasoning that such a limitation 

would result in the limitations of being “unable to sustain activity, remain on task, 

remain on target for two hour periods of a time over the course of an eight hour 

work day for 40 hours during each work week either given residual side effects from 

medication, residual pain or residual psychiatric symptoms[,]” which was included 

in the third hypothetical to both VEs. (Compare R. 94 – 95 with R. 119). Moreover, 

the third hypothetical to the second VE included the additional detail that 

limitations would be based on the “residual side effects of medication, residual pain 

or residual psychiatric symptoms.” Dr. Starkey’s opinion attributed Caffey’s 

marginal ability to work independently “to adverse effects of too much addictive 

medication.” (R. 572 – 573). 

At Step Five in her decision, the ALJ made note of her third hypothetical to 

the second VE, and that VE’s answer, but conclusorily stated that she “has 

accounted for these factors in the residual functional capacity, as explained in detail 

above.” (R. 78). It is unclear, however, how “account[ing] for these factors” at Step 

Four somehow renders them non-disabling at Step Five when two VEs each 

testified that the presence of those factors, and indeed only those factors (that is, 

without any of the other limitations in his RFC), rendered Caffey unable to find 

work. 

An ALJ is “not required to include findings in the hypothetical that the ALJ 

had properly rejected as unsupported.” Crawford v. Comm'r Of Soc. Sec., 363 F.3d 

1155, 1161 (11th Cir. 2004) (per curiam). Here, however, the ALJ, in assigning 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 23 of 36
“significant weight” to Dr. Starkey’s opinion, specifically mentioned the limitation 

that Caffey had a “marginal” ability to work independently. (See R. 76). The ALJ’s 

decision gives no indication that she gave less weight to this particular limitation 

than to the others mentioned in Dr. Starkey’s opinion. Rather, the ALJ aggregated

those limitations into the general determination that Caffey would have “moderate 

difficulties in maintaining social functioning and concentration, persistence or 

pace.” (R. 76 – 77).

“An administrative law judge may not ask a vocational expert a hypothetical 

question based on substantial evidence and then ignore unfavorable answers.” 

Campbell v. Bowen, 822 F.2d 1518, 1523 n.6 (10th Cir. 1987). Accord Angel v. 

Barnhart, 329 F.3d 1208, 1212 (10th Cir. 2003) (“In performing his step four 

analysis, the ALJ ignored and failed to address Dr. Schneider’s testimony at the 

hearing, which is supported by her medical records, that Angel needs a sterile 

environment in which to catheterize herself due to the risk of infection. This 

omission is significant because, following Dr. Schneider’s testimony, the vocational 

expert (VE) testified, in response to a hypothetical question posed by Angel’s 

counsel, that the requirement of providing Angel with a sterile environment, which 

would basically require that she have a personal, or private, bathroom, ‘would have 

a negative impact ... [and] would [not] preclude all employment, but it would be 

rather significant in reducing the occupational base.’ []Dr. Schneider's testimony, 

and the related testimony of the VE, is supported by substantial medical evidence 

in the record showing that Angel is at high risk of contracting recurrent urinary 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 24 of 36
tract infections. We therefore agree with Angel that the ALJ’s failure to address the 

testimony is reversible error.” (citing, inter alia, Campbell, 822 F.2d at 1523 n.6) 

(record citations omitted)); Arrington v. Apfel, 185 F.3d 873 (10th Cir. 1999) (per 

curiam) (unpublished) (“[T]he hypothetical questions posed to the VE were 

problematic. The first question, based on Dr. Standefer’s findings and plaintiff’s 

condition as of shortly after plaintiff's accident, elicited a series of jobs the VE 

thought plaintiff could perform, most of which were at least semiskilled. With the 

additional restrictions of numbness in her dominant hand, however, the VE in his 

answers to the second and third questions stated there were no jobs she could 

perform. We have held that an ALJ may not ask a VE a hypothetical question based 

on substantial evidence and then ignore unfavorable answers. See Campbell v. 

Bowen, 822 F.2d 1518, 1523 n 6 (10th Cir. 1987).”)).14

 14 Similar errors involving multi-faceted medical opinions were found to merit remand 

in Smith v. Colvin, 2014 WL 518057, and Dempsey v. Commissioner of Social Security, 454 

F. App'x 729 (11th Cir. 2011) (per curiam) (unpublished). In Smith, the ALJ clearly relied 

on some parts of a medical opinion to support her determinations at Step Two and Step 

Four, but did not acknowledge rejecting, or even considering, a portion of that opinion 

reflecting that the claimant would have to miss 1 – 2 days of work a month due to her 

psychiatric symptoms. 2014 WL 518057, at *4. This omission was deemed “significant” 

because, in response to the ALJ’s hypothetical that incorporated that particular limitation, 

the VE had testified that employers would not tolerate such a rate of absenteeism. Id.

In Dempsey, the ALJ addressed and discounted one opinion, regarding the number 

of days of work per month the claimant would miss due to her impairments, contained in a 

treating physician’s questionnaire, but did not mention another opinion, regarding the 

claimant’s ability to concentrate, contained in the same questionnaire. 454 F. App’x at 733. 

The Eleventh Circuit held that the “ALJ erred when he failed to mention, much less 

consider, [the treating physician]’s opinion of Dempsey’s ability to concentrate” because the 

opinion was “contrary to the ALJ’s finding in his RFC assessment that Dempsey had no 

significant mental limitations[,]” and because “[w]hether or not Dempsey has an inability to 

concentrate [wa]s significant because the vocational expert testified that an individual with 

all of Dempsey’s physical limitations whose pain and other symptoms would interfere with 

the attention and concentration needed to perform simple work tasks would be precluded 

from performing any work.” Id. at 733 & n.6.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 25 of 36
Accordingly, the Court SUSTAINS Caffey’s assertion in Claim 1 that the 

ALJ reversibly erred in failing to address with particularity Dr. Starkey’s opinion 

that his ability to work independently was marginal. Thus, the Court need not 

decide whether the ALJ’s alleged failure to sufficiently address the other aspects of 

Dr. Davis and Dr. Starkey’s opinions identified by Caffey in Claim 1 also constitute 

reversible error. On remand, however, the Commissioner should consider the need 

to further explain with particularity the weight given to those portions of the 

medical opinions and the reasons therefor. Winschel, 631 F.3d at 1179.

B. Claim 2 (Physical RFC)

Caffey’s assertions of error in Claim 2 are similar to those in Claim 1, 

alleging that, despite giving “considerable weight to the findings and opinion of 

[examining orthopedist] Dr. Kim” (R. 74), the ALJ’s physical RFC “differs from the 

assessment of Dr. Kim in several important ways” with regard to Caffey’s wrist and 

knee impairments (Doc. 11 at 15).

After a thorough discussion of Dr. Kim’s report (SSA Ex. 15F), as well as 

medical records from several other physicians regarding Caffey’s physical 

impairments, including treating physicians Dr. Rowland and Dr. Wrights, the ALJ 

then discussed how this evidence influenced the various physical limitations in her 

RFC assessment. Discussing Caffey’s wrist and knee impairments, among others, 

the ALJ stated as follows:

In terms of the claimant’s alleged arthritis in the wrists, knees, hips 

and lower back, although the claimant has received treatment for the 

allegedly disabling impairment, that treatment has been essentially 

routine and/or conservative in nature since the alleged onset date ...

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 26 of 36
Based on the claimant’s knee condition, Dr. Kim recommended work 

restrictions precluding repeated ascending and descending 

stairs/ladders, repeated squatting, kneeling, crawling and no prolonged 

weightbearing. He said the claimant’s bilateral knee symptomatology 

can be characterized as intermittent slight to moderate pain, 

increasing to moderate on prolonged weightbearing and on repetitive 

range of motion. Objective factors identified included crepitus in the 

bilateral knees; limitation on range of motion in the bilateral knees; 

and abnormal findings on MRIs of the bilateral knees. (Exhibit 15F). 

The other physical exams have also shown mild crepitance, decreased 

range of motion and 4-5/5 strength of flexion/extension of the knees at 

times, tenderness of the knees, and a normal gait. (Exhibits 19F, 20F 

and 22F). The claimant’s knee condition is accounted for in the 

residual functional capacity above with the limitation to occasionally 

climbing ramps/stairs, stooping, kneeling, crouching and crawling and 

never climbing ladders/ropes/scaffolds.

Dr. Kim described the symptomology with regard to claimant’s hips, as 

intermittent and slight. He also said the claimant’s left shin 

symptoms were described as occasional slight pain and the claimant 

had no subjective complaints referable to the ankles. (Exhibit 15F). 

Dr. Rowland noted the claimant had 3-4/5 strength of dorsi/plantar 

flexion at the ankles in September 2012 that improved to 4/5 in 2013 

and 4/5 flexion at the hips once in January 2013. (Exhibits 20F and 

25F). The limitation to standing/walking in combination at least 6 

hours in an 8 hour workday also accounts for the claimant’s back and 

knees, as well as his hip and ankle impairments. 

Dr. Kim said the claimant’s symptomatology with regard to his wrists 

and hands/thumbs is best described as intermittent slight pain, 

increasing to slight to moderate pain on repetitive gripping and 

grasping. He noted he would characterize the claimant’s right middle 

finger pain as intermittent slight pain. Based on the claimant’s 

bilateral wrists/hands and thumb, work restrictions are recommended 

precluding repeated gripping and grasping activities. (Exhibit 15F). 

The claimant also told Dr. Nudleman that he had some difficulties 

with hand grasping secondary to a fractured ring finger (See Exhibit 

13F), and Dr. Rowland noted the claimant had 4/5 grip strength in 

Exhibit 19F. The undersigned has accounted for the claimant’s upper 

extremity impairments with the manipulative limitations resulting in 

the ability to frequently handle bilaterally.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 27 of 36
(R. 68 – 69). Considering the foregoing, the Court disagrees with Caffey’s assertion 

that the decision “does not link the conclusions about Mr. Caffey’s assessed 

capabilities to medical any opinions in the record evidence.” (Doc. 11 at 17). 

Caffey argues the ALJ’s determination that Caffey could stand and/or walk 

for at least 6 hours per 8-hour workday is inconsistent with Dr. Kim’s opinion that 

Caffey should engage in “no prolonged weightbearing” (R. 547). (See Doc. 11 at 16). 

Similarly, Caffey asserts that the ALJ’s allowance for frequent bilateral handling in 

the RFC (R. 61) is inconsistent with Dr. Kim’s opinion that “precluded Mr. Caffey 

from repeated gripping and grasping activities.”15 (Doc. 11 at 15 (citing (R. 545)). 

However, the ALJ made reasonably clear that she considered the opinions of Dr. 

Kim, derived from a one-time examination in 2011, in conjunction with the more 

recent treatment notes of Caffey’s two treating physicians.

Moreover, any alleged inconsistencies between the RFC and Dr. Kim’s 

opinions identified by Caffey appear to be harmless. Caffey argues that his 

bilateral wrist limitations and hand impairments “significantly impact Mr. Caffey’s 

ability to engage in work at the ‘light’ level of physical exertion,” and that “no 

prolonged weightbearing” would not allow for standing/walking for six hours in an 

eight hour workday. (See Doc. 11 at 15 – 16). However, at Step Five, the ALJ noted 

that she had ask the VE a hypothetical limiting Caffey to “the sedentary exertion 

level with the ability [to] stand/walk in combination for 2 hours in an 8 hour 

 15 Caffey also complains that the RFC ignores Dr. Kim’s notation “that Mr. Caffey’s pain 

increased when he engaged in repeated use of his hands.” (Doc. 11 at 15 (citing R. 529)). 

However, this notation was made in the section of Dr. Kim’s notes documenting Caffey’s 

subjective complaints of pain and other symptoms. (See R. 529). It is not a medical 

diagnosis.

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 28 of 36
workday[,]” for which the VE “identified a representative sample of jobs...” (R. 78). 

Thus, even if Caffey were limited to “sedentary” work instead of “light” work, and 

even if his ability to stand/walk was significantly reduced, substantial evidence 

indicates that Caffey would still be able to find work despite his physical 

impairments.

Accordingly, the Court OVERRULES Caffey’s assertions of reversible error 

in Claim 2.

C. Claim 3 (Credibility Determination)

Finally, Caffey asserts that the ALJ reversibly erred in failing to sufficiently 

credit his testimony regarding his medications’ side effects. 

In Holt v. Sullivan, 921 F.2d 1221 (11th Cir. 1991), [the Eleventh 

Circuit] articulated the “pain standard,” which applies when a 

disability claimant attempts to establish a disability through his own 

testimony of pain or other subjective symptoms. 921 F.2d at 1223. The 

pain standard requires

(1) evidence of an underlying medical condition and either (2) 

objective medical evidence that confirms the severity of the 

alleged pain arising from that condition or (3) that the 

objectively determined medical condition is of such a severity 

that it can be reasonably expected to give rise to the alleged 

pain.

921 F.2d at 1223 (internal citation omitted). If a claimant testifies as to 

his subjective complaints of disabling pain and other symptoms ... , the 

ALJ must clearly “articulate explicit and adequate reasons” for 

discrediting the claimant's allegations of completely disabling 

symptoms. Foote[ v. Chater], 67 F.3d [1553,] 1561–62[ (11th Cir. 1995) 

(per curiam)]. “Although this circuit does not require an explicit 

finding as to credibility, ... the implication must be obvious to the 

reviewing court.” 67 F.3d at 1562 (quoting Tieniber v. Heckler, 720 

F.2d 1251, 1255 (11th Cir. 1983)). The credibility determination does 

not need to cite “ ‘particular phrases or formulations' ” but it cannot 

merely be a broad rejection which is “ ‘not enough to enable [the 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 29 of 36
district court or this Court] to conclude that [the ALJ] considered her 

medical condition as a whole.’ ” Foote, 67 F.3d at 1561 (quoting 

Jamison v. Bowen, 814 F.2d 585, 588–90 (11th Cir. 1987)).

Dyer v. Barnhart, 395 F.3d 1206, 1210-11 (11th Cir. 2005) (per curiam). 

“[C]redibility determinations are the province of the ALJ, Moore v. Barnhart, 405 

F.3d 1208, 1212 (11th Cir. 2005), and [a court] will not disturb a clearly articulated 

credibility finding supported by substantial evidence, Foote v. Chater, 67 F.3d 1553, 

1562 (11th Cir. 1995).” Mitchell v. Comm'r, Soc. Sec. Admin., 771 F.3d 780, 782 

(11th Cir. 2014).

At his first administrative hearing, Caffey testified that “he has looked for 

work and has had job offers; however, he has not been hired because his 

medications cause drowsiness.” Caffey also testified that his medications (Lortab, 

Xanax, muscle relaxers, anti-inflammatories) were “ ‘knock out meds’ that make 

him drowsy or put him to sleep” and that “he is asleep from his medications for 7 

hours a day between 8:00 a.m. and 5:00 p.m.” Additionally, he reported that his 

“doctors told him not to drive due to his medications[,] that he has fallen asleep at 

red lights before and burned himself the last time he cooked because he was on 

Lortab and fell asleep.” At his supplemental administrative hearing, Caffey 

“reiterated his previous testimony that his medications sedate him and make him 

sleep 70% of the day. Otherwise, he is groggy, stays to himself and does not like to 

be around a lot of people.” (R. 62 – 63).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 30 of 36
The ALJ found that Caffey’s “statements concerning the intensity, 

persistence and limiting effects of [his] symptoms are not entirely credible...” (R. 

63). The ALJ then explained:

The undersigned has taken into account the claimant’s alleged side 

effects from the use of medications and his testimony that his 

medications cause him to sleep for most of the day. The undersigned 

notes that the claimant’s description of his sleep pattern since he 

started taking his current pain management regimen contrasts with 

the information in Dr. Nudleman [sic] narrative report in Exhibit 13F. 

Dr. Nudleman said the claimant had a sleep disorder that is 

“intermittent and halfway between minimal and slight secondary to 

nonrestorative sleep and joint pains.” Dr. Nudleman said the claimant 

should not work in an environment where he has to do constant 

multitasking or where he has to do phase shifts of work. (Exhibit 13F). 

The undersigned has considered the potential for residual side effects 

from medication and/or residual pain in the residual functional 

capacity with the limitation to performing simple tasks with short 

simple instructions, which takes Dr. Nudleman’s findings into 

account.[16] The claimant also testified that he uses a cane when he is 

on medications to maintain balance. Therefore, the undersigned finds 

the claimant should never work at unprotected heights or with 

dangerous machinery due to the potential for medication side effects 

and/or pain and due to his musculoskeletal impairments.

Overall, the record supports the finding that the claimant is capable of 

performing light work ... Of particular note, the claimant has alleged 

an inability to do many things, including a denial of exercising and 

running in hearing testimony. However, the claimant has provided 

inconsistent information regarding daily activities. The most recent 

records from his treating physician, Dr. Wrights, indicates that he 

suffered from an injury to his right calf that occurred while running. 

(Exhibit 28F). The other medical evidence also contains references to 

various physical activities that are inconsistent with his testimony 

regarding what he is able to do and with his alleged medication side 

effects. For example, Dr. Kim noted the claimant “works out on an 

almost daily basis in the swimming pool and also does deep water 

 16 In the portion of her decision evaluating the medical opinion evidence, the ALJ gave Dr. 

Nudleman’s assessment “some weight” and repeated that she had “considered the potential 

for residual side effects from medication and/or residual pain in the residual functional 

capacity with the limitation to performing simple tasks with short simple instructions.” (R. 

75).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 31 of 36
jogging. He also performs bench-pressing exercises.” (Exhibit 15F). 

Dr. Dimmick also noted that since “has kept active” and “tries to do 

some weightlifting” since retiring from basketball. (Exhibit 14F). The 

claimant told Dr. Rowland that the increase in the Lortab “allows him 

to get back into the gym to exercise with his kids.” He later said that 

taking a Soma with a Lortab allows him “to be able to shoot a little 

hoop,” and allows him to be more active. Indeed, on March 16, 2013, 

the claimant said he was doing some training to help raise some 

money, and Dr. Rowland noted the claimant “works out with his 

clients, so it puts a demand on him.” (Exhibits 19F, 20F and 25F). Dr. 

Wrights also noted the claimant “is active in basketball but limited in 

certain movement secondary to pain.” (Exhibit 22F).

(R. 69 – 70).

Considering the above, the Court disagrees with Caffey’s assertion that “the 

ALJ failed to provide a reasoned explanation for discrediting [his] testimony...” 

(Doc. 11 at 19). Caffey also argues “the limitation to only unskilled work fails to 

adequately allow for Mr. Caffey’s medication side effects.” (Doc. 11 at 17 – 18). 

However, he cites no authority in support this contention, nor does he directly 

address the ALJ’s stated reasons for declining to fully credit Caffey’s testimony (i.e. 

that it was not bolstered by Dr. Nudleman’s report or by evidence of Caffey’s 

reported life activities), instead insisting that his testimony must be accepted as 

true because other record evidence supports it.17 These “contentions misinterpret 

 17 For instance, Caffey asserts that his testimony is “supported by the opinions of two 

treating physicians, Dr. Wrights and Dr. Rowland...” (Doc. 11 at 19). However, the ALJ 

explicitly addressed the opinions of these physicians in regards to Caffey’s claimed side 

effects of his medication, as follows:

The undersigned gives little weight to the notes submitted by both Dr. 

Rowland in Exhibit 23F and Dr. Wrights in Exhibit 24F. Both doctors noted 

the claimant’s medications (Lortab, Xanax and Robaxin) can make the 

claimant sleepy. Therefore, they advised him that if any of his medications 

interfere with his ability to remain alert, he should not drive while on any of 

the “offending medications.” These statements are merely advising him not 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 32 of 36
the narrowly circumscribed nature of [judicial] review, which precludes [the Court] 

from ‘re-weigh[ing] the evidence or substitut[ing] our judgment for that [of the 

Commissioner] ... even if the evidence preponderates against’ the decision.” Moore 

v. Barnhart, 405 F.3d 1208, 1213 (11th Cir. 2005) (per curiam) (quoting 

Bloodsworth, 703 F.2d at 1239). See also Mitchell v, 771 F.3d at 782 (“The ALJ 

made a clearly articulated credibility finding and pointed to specific reasons for 

discrediting Mitchell’s subjective complaints of disabling pain. That finding was 

supported by substantial evidence in the record. Furthermore, contrary to Mitchell’s 

contention that the ALJ ignored evidence favorable to Mitchell, ‘there is no rigid 

requirement that the ALJ specifically refer to every piece of evidence in his decision, 

so long as the ALJ's decision ... is not a broad rejection which is not enough to 

enable [a reviewing court] to conclude that the ALJ considered [the claimant's] 

medical condition as a whole.’ Dyer, 395 F.3d at 1211 (quotation and brackets 

omitted).”).

Accordingly, the Court OVERRULES Caffey’s assertions of reversible error 

in Claim 3. 

V. Conclusion

Caffey has requested that his case be remanded to the Commissioner with 

 

to drive while on any medication that makes him sleepy. As noted above, the 

claimant has reported engaging in activities such as exercising to both 

doctors while taking these medications. However, the limitation to 

performing simple tasks with short simple instructions and the 

environmental limitations have been provided to account for any medication 

side effects.

(R. 76).

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 33 of 36
instructions that he be awarded benefits, while alternatively requesting remand for 

further proceedings on his application for benefits. Generally, remand to the 

Commissioner “is warranted where the ALJ has failed to apply the correct legal 

standards.” Davis v. Shalala, 985 F.2d 528, 534 (11th Cir. 1993). This Court may enter 

an order “awarding disability benefits where the [Commissioner] has already 

considered the essential evidence and it is clear that the cumulative effect of the 

evidence establishes disability without any doubt.” Id. See also Carnes v. Sullivan, 936 

F.2d 1215, 1219 (11th Cir. 1991) (“The credibility of witnesses is for the Secretary to 

determine, not the courts...The decision of the Secretary here, however, rests not so 

much on the credibility of the ‘history of pain’ presented by Carnes, as on the adoption 

of a legal standard improper under Listing 10.10(A). []The record in this case is fully 

developed and there is no need to remand for additional evidence. Based on the facts 

adduced below and after application of the proper legal standard, we hold that claimant 

met the requirements of Listing 10.10(A) as early as 1982.”). Here, however, reversal is 

based upon the Commissioner’s failure to adequately explain her reasoning in weighing 

different aspects of medical opinions. It is not clear that the cumulative effect of the 

evidence establishes disability without any doubt.18 Thus, the Court will reverse and 

 18 Cf. Broughton v. Heckler, 776 F.2d 960, 962 (11th Cir. 1985) (per curiam) (“Though we 

have found that the ALJ erred in his application of the legal standards, at this time we 

decline to enter an order requiring entitlement to disability benefits. While it is true that 

the opinions of Drs. Todd and Raybin provide strong evidence of disability, it is at least 

arguable that the report of Dr. Morse is to the contrary. Consequently, it is appropriate that 

the evidence be evaluated in the first instance by the ALJ pursuant to the correct legal 

standards.”); Hildebrand v. Comm'r of Soc. Sec., No. 6:11-CV-1012-ORL-31, 2012 WL 

1854238, at *7 (M.D. Fla. May 4, 2012) (“The errors noted here compel a return of the case 

to the Commissioner to evaluate the evidence and make findings in the first instance. For 

the reasons set forth above, the Court finds that certain of the conclusions of the ALJ were 

not made in accordance with proper legal standards and are not supported by substantial 

evidence. The Court does not find that only one conclusion can be drawn from the evidence; 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 34 of 36
remand this action to the Commissioner for further proceedings.

In accordance with the foregoing analysis, it is ORDERED that the 

Commissioner’s August 20, 2015 final decision denying Caffey’s application for a 

period of disability and DIB is REVERSED and REMANDED to the 

Commissioner under sentence four of 42 U.S.C. § 405(g), see Melkonyan v. Sullivan, 

501 U.S. 89 (1991), for further proceedings consistent with this decision. This 

remand under sentence four of § 405(g) makes Caffey a prevailing party for 

purposes of the Equal Access to Justice Act, 28 U.S.C. § 2412, see Shalala v. 

Schaefer, 509 U.S. 292 (1993), and terminates this Court’s jurisdiction over this 

matter.

Under Federal Rule of Civil Procedure 54(d)(2)(B), should Caffey be awarded 

Social Security benefits on the subject application following this remand, the Court 

hereby grants Caffey’s counsel an extension of time in which to file a motion for fees 

under 42 U.S.C. § 406(b) until thirty days after the date of receipt of a notice of 

award of benefits from the SSA.19 Consistent with 20 C.F.R. § 422.210(c), “the date 

 

but that the conclusion that was drawn did not meet the standard of review. Under such a 

circumstance, it would not be appropriate for this Court to substitute its opinion of the 

weight to be given the evidence for that of the Commissioner. While the Court has the 

power to do just that in an appropriate case, the Court finds this is not such a case.”), report 

and recommendation adopted, No. 6:11-CV-1012-ORL-31, 2012 WL 1854249 (M.D. Fla. May 

21, 2012).

19 See Bergen v. Comm'r of Soc. Sec., 454 F.3d 1273, 1277 (11th Cir. 2006) (per curiam) 

(“Fed. R. Civ. P. 54(d)(2) applies to a § 406(b) attorney's fee claim.”); Blitch v. Astrue, 261 F. 

App'x 241, 242 n.1 (11th Cir. 2008) (per curiam) (unpublished) (“In Bergen v. Comm'r of Soc. 

Sec., 454 F.3d 1273 (11th Cir. 2006), we suggested the best practice for avoiding confusion 

about the integration of Fed. R. Civ. P. 54(d)(2)(B) into the procedural framework of a fee 

award under 42 U.S.C. § 406 is for a plaintiff to request and the district court to include in 

the remand judgment a statement that attorneys fees may be applied for within a specified 

time after the determination of the plaintiff's past due benefits by the Commission. 454 

Case 1:15-cv-00490-N Document 18 Filed 10/28/16 Page 35 of 36
of receipt of notice ... shall be presumed to be 5 days after the date of such notice, 

unless there is a reasonable showing to the contrary.” If multiple award notices are 

issued, the time for filing a § 406(b) fee motion shall run from the date of receipt of 

the latest-dated notice.

Final judgment shall issue separately in accordance with this Order and 

Federal Rule of Civil Procedure 58.

DONE and ORDERED this the 28th day of October 2016.

/s/ Katherine P. Nelson

KATHERINE P. NELSON

UNITED STATES MAGISTRATE JUDGE

 

F.3d at 1278 n.2.”).

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