Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_14-cv-00373/USCOURTS-alsd-1_14-cv-00373-0/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 UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

CATHY HAMILTON GRIMES, :

Plaintiff, :

vs. : CA 14-0373-C

CAROLYN W. COLVIN, :

Acting Commissioner of Social Security, 

:

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action, pursuant to 42 U.S. C. § 1383(c)(3), seeking judicial 

review of a final decision of the Commissioner of Social Security denying her claim for 

supplemental security income benefits. The parties have consented to the exercise of 

jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings 

in this Court. (Compare Doc. 28 (“In accordance with provisions of 28 U.S.C. §636(c) and 

Fed.R.Civ.P. 73, the parties in this case consent to have a United States magistrate judge 

conduct any and all proceedings in this case, . . . order the entry of a final judgment, and 

conduct all post-judgment proceedings.”) with Doc. 29 (endorsed order referring this 

matter to the undersigned for all proceedings).) Upon consideration of the 

administrative record, plaintiff’s brief, and the Commissioner’s brief, it is determined 

that the Commissioner’s decision denying benefits should be reversed and remanded 

for further proceedings not inconsistent with this decision.

1

 1 Any appeal taken from this memorandum opinion and order and judgment shall 

be made to the Eleventh Circuit Court of Appeals. (See Doc. 28 (“An appeal from a judgment 

entered by a magistrate judge shall be taken directly to the United States court of appeals for 

(Continued)

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 1 of 16
2

Plaintiff alleges disability due to obesity, osteoarthritis, plantar warts/callosity, 

chronic pain syndrome, a learning disability, and anxiety disorder. The Administrative 

Law Judge (ALJ) made the following relevant findings:

1. The claimant has not engaged in substantial gainful activity since 

March 26, 2012, the application date (20 CFR 416.971 et seq.).

2. The claimant has the following severe impairments: obesity, 

osteoarthritis, pain disorder, learning disability, and anxiety disorder 

(20 CFR 416.920(c)).

. . .

3. The claimant does not have an impairment or combination of 

impairments that meets or medically equals the severity of one of the 

listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 

416.920(d), 416.925 and 416.926).

. . .

The severity of the claimant’s mental impairments, considered singly and 

in combination, do not meet or medically equal the criteria of listing 12.06. 

In making this finding, the undersigned has considered whether the 

“paragraph B” criteria are satisfied. To satisfy the “paragraph B” criteria, 

the mental impairments must result in at least two of the following: 

marked restriction of activities of daily living; marked difficulties in 

maintaining social functioning; marked difficulties in maintaining 

concentration, persistence, or pace; or repeated episodes of 

decompensation, each of extended duration. A marked limitation means 

more than moderate but less than extreme. Repeated episodes of 

decompensation, each of extended duration, means three episodes within 

1 year, or an average of once every 4 months, each lasting for at least 2 

weeks.

In activities of daily living, the claimant has mild restriction. She drives 

and has an active driver’s license. She has no problem with her personal 

hygiene matters. She can do laundry and maintain her household chores, 

prepare simple meals, and shop for the things she needs.

 

this judicial circuit in the same manner as an appeal from any other judgment of this district 

court.”))

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 2 of 16
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In social functioning, the claimant has mild difficulties. She lives in an 

apartment with her adult son. She has been married twice and has four 

adult children. . . . She attends church regularly, goes swimming, and to 

the park. She gets along well with authority figures but has been fired fr 

not getting along with others. 

With regard to concentration, persistence or pace, the claimant has 

moderate difficulties. She watches television, can pay bills, count change, 

use checkbooks or money orders, and handles a savings account. She can 

drive and pay attention at church.

As for episodes of decompensation, the claimant has experienced one or 

two episodes of decompensation, each of extended duration. The claimant 

denied any psychiatric hospitalizations other than a single commitment to 

Altapointe in 2011.

Because the claimant’s mental impairments do not cause at least two 

“marked” limitations or one “marked” limitation and “repeated” episodes 

of decompensation, each of extended duration, the “paragraph B” criteria 

are not satisfied.

The undersigned has also considered whether the “paragraph C” criteria 

are satisfied. In this case, the evidence fails to establish the presence of the 

“paragraph C” criteria. The “paragraph C” criteria of 12.06 is not met 

because there is no medical evidence showing the claimant has a complete 

inability to function independently outside the home.

The limitations identified in the “paragraph B” criteria are not a residual 

functional capacity assessment but are used to rate the severity of mental 

impairments at steps 2 and 3 of the sequential evaluation process. The 

mental residual functional capacity 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 found in 

paragraph B of the adult mental disorders listing in 12.00 of the Listing of 

Impairments. Therefore, the following residual functional capacity 

assessment reflects the degree of limitation the undersigned has found in 

the “paragraph B” mental function analysis.

4. After careful consideration of the entire record, the undersigned 

finds that the claimant has the residual functional capacity to perform a 

reduced level of medium work as defined in 20 CFR 416.967(c). She can 

understand, remember, and carry out short simple instructions on an 

unlimited basis and detailed instructions occasionally. She has [] no 

[social] interaction limitations or adaptation limitations. She is 

precluded from climbing ladders, ropes, or scaffolds. She is precluded 

from crawling. She can occasionally stoop, kneel, or crouch. She can 

continuously reach, handle, finger, or feel. 

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 3 of 16
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. . .

The claimant alleges that she cannot work because she is in pain all the 

time. She testified that she cannot stand for long because her feet hurt and 

her back hurts. She testified that her hands hurt and her arm goes numb. 

She testified that she was committed to Altapointe because she got into an 

altercation with someone else at a homeless shelter.

After careful consideration of the evidence, the undersigned finds that the 

claimant’s medically determinable impairments could reasonably be 

expected to cause some symptoms; however, the claimant’s statements 

concerning the intensity, persistence and limiting effects of these 

symptoms are not entirely credible for the reasons explained in this 

decision.

The claimant has the severe physical impairments of obesity and 

osteoarthritis. Both impairments are accommodated in her residual 

functional capacity in that she is precluded from all very heavy and heavy 

work in the national economy and she is precluded from climbing 

ladders, ropes, or scaffolds and from crawling. She can occasionally stoop, 

kneel, or crouch. She can continuously reach, handle, finger, or feel. 

The claimant testified that she is 5’2” and currently weighs 196 pounds. 

Her medical records from Mobile County Health Department from May 6, 

2010, state that she was five feet tall and weighed 188 pounds with a body 

mass index (BMI) of 36.8. She was down from 196 pounds on March 22, 

2010. In March of 2012, she was reported to be 5’0” and weigh 172 pounds 

with a BMI of 33.66. The last half of 2012 and the first part of 2013, the 

claimant’s weight ranged from 186 to 201 pounds. The claimant has 

consistently been shown to be obese; however, no surgical intervention, 

diet medication, or other treatments have been prescribed or 

recommended. Even so, her obesity is accommodated in her residual 

functional capacity.

The claimant has the severe impairment of osteoarthritis; however, 

medical treatment notes from Tri-County Medical Center [i]n February, 

March, and July of 2012 state that she has a normal range of motion, no 

joint tenderness, no joint swelling, normal straight leg raises, and no calf 

tenderness. She was diagnosed with osteoarthritis in 2010 due to pain in 

her knee joints. Range of motion testing performed in January, February, 

March, June and July of 2011 and every month from August of 2012 

through May of 2013 showed the claimant to have normal range of motion 

in the knees and the other joints, no swelling and a normal gait. X-rays 

done on July 28, 2011 showed no acute abnormality in the knees, no 

significant degenerative disc disease, minimal degenerative disease in the 

right hand and a chronic calcification in the left wrist joint. Nonetheless, 

the claimant’s osteoarthritis is accommodated in the claimant’s residual 

functional capacity as noted above.

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 4 of 16
5

On April 3, 2013, Alan Sherman, M.D., performed a consultative medical 

exam and review of the claimant. Dr. Sherman performed a clinical exam 

that showed her fine motor movement normal bilaterally, normal range of 

motion in the wrists, elbows and shoulders, bilaterally with no complaints 

of pain, and upper extremity strength of 5 of 5. She also has had normal 

range of motion of her ankles, knees and hips, bilaterally, straight leg raise 

was negative and lower extremity strength was 5 of 5. The claimant 

denied any back pain whatsoever during the exam and range of motion 

testing done on the back proved to be completely normal with no altered 

gait or speed. Dr. Sherman opined that the claimant has “few physical 

limitations that would preclude gainful employment.[“] Great weight is 

assigned to Dr. Sherman’s physical opinion. He is very credible as a nontreating source. His opinion is well supported by medically acceptable 

clinical and laboratory diagnostic techniques and is consistent with the 

other substantial evidence in the claimant’s case record and the claimant’s 

treatment history.

The claimant has the severe mental impairments of anxiety, chronic pain 

syndrome, and learning disability. Her severe mental impairments are 

accommodated in her residual functional capacity in that she is precluded 

from all very heavy and heavy work in the national economy and she is 

expected to only understand, remember, and carry out short simple 

instructions on an unlimited basis and detailed instructions occasionally.

The claimant was involved in an altercation at a homeless shelter on 

March 25, 2012. She was later committed to Altapointe Health Systems 

due to psychiatric problems based upon a petition filed in Probate Court. 

Her initial diagnoses at Altapointe were psychosis and anxiety disorder. 

She reported that she had never been admitted to any psychiatric 

institution before though she had been on anti-depressants sometime in 

the distant past. She was admitted to Baypointe Hospital for monitoring 

due to her unpredictable behavior and placed on Klonopin for treatment.

The claimant was consistently treated at Altapointe Health Systems from 

April of 2012 until August of 2012. After two months of treatment, on May 

31, 2012, her memory and concentration were found to be unimpaired and 

no symptoms of anxiety were noted throughout the claimant’s remaining 

treatment at Altapointe. The claimant reported no symptoms of 

depression or any other problems. In her consultative medical exam, on 

August 20, 2012, the claimant reported that her only mental problem was 

a history of anxiety.

In January of 2012, the claimant was prescribed Lortab for treatment of 

chronic pain and Xanax for anxiety treatment. She complains regularly of 

pain and is generally prescribed Lortab for treatment though no 

diagnostic testing has shown any basis for the pain. In her consultative 

medical exam, Dr. Sherman diagnosed the claimant with chronic pain 

syndrome.

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 5 of 16
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The claimant was seen at Southwest Alabama Behavioral Health Care 

Systems on November 15, 2012 for psychiatric treatment and 

recommendations were made for various evaluations. Apparently, she did 

not follow through with the recommendations. She next reported to 

Southwest Alabama Behavioral Health Care Systems on February 26, 2013 

and reported that she had not been on her medication in three or four 

months and would like to get back on them because they help her to be 

“more calm”. She was evaluated by John Cranton, M.D., at the visit. Based 

on her evaluation, Dr. Cranton opined that the claimant appears to have 

anxiety issues and a learning disability. He noted that she dropped out of 

school in the seventh grade and had difficulty with the computational 

portions of his clinical evaluation. He further opined that she did not have 

any signs of depression, is probably not schizophrenic, and does not 

appear to have any adverse reaction to the medications previously 

prescribed. Dr. Cranton prescribed Haldol monthly; Cogentin, and 

Trazadone and recommended psychological testing. Significant weight is 

assigned to the opinion of Dr. Cranton. As a treating physician, his 

opinion is very credible. His opinion is consistent with the claimant’s 

treatment history, the diagnostic testing contained in the record[,] and 

with the other substantial evidence in the record.

The claimant was given a Multiphasic Personality Inventory-Second 

Addition (MMPI-2) on May 31, 2013 at Southwest Alabama Behavioral 

Health Care Systems. The results of the exam proved to be invalid. The 

psychologist that administered the exam, Jill Hall, Ph.D., noted that the 

claimant’s results may have been invalid due to an inability to understand 

the questions or in an attempt to over or under report her symptoms. No 

weight is assigned to the test or speculation made by Dr. Hall due to the 

clinically invalid results of the administered test; however, the claimant’s 

credibility is not enhanced by producing the invalid test.

The claimant’s credibility regarding her mental impairments is greatly 

diminished by her lack of treatment and lack of following through with 

recommendations made by her treating physicians. She was without any 

medication at all for several months and only showed signs of anxiety 

when she finally reappeared for treatment. As noted above, she even 

reported only anxiety as a mental health issue in her medical evaluation. 

The claimant’s mental impairments are fully accommodated in her 

residual functional capacity as stated above.

The claimant had a consultative mental evaluation on October 9, 2012 

performed by Robert DeFrancisco, Ph.D. Upon clinical evaluation, Dr. 

DeFrancisco opined that the claimant has a pain-disorder, substanceabuse in remission, probably borderline to average intelligence and a 

learning disability. He opined that she can understand, remember and 

carry out instructions that are within her ability and respond adequately 

to coworkers. Five months later, on March 21, 2013, the claimant hired Dr. 

DeFrancisco to reevaluate her. In the reevaluation, Dr. DeFrancisco 

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 6 of 16
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changes his diagnoses completely. He opined that she has a personality 

disorder with self-defeating tendencies and an anxiety disorder along 

with major depression. He opined that she is in need of intense 

psychotherapy and pharmacotherapy and has marked restrictions in her 

ability to function. No weight is assigned to the opinions expressed by 

DeFrancisco. The opinions are inconsistent with the claimant’s treatment 

history, her own reports, the other clinical testing in the record and even 

internally inconsistent. Dr. DeFrancisco noted that the claimant has low 

normal concentration in the narrative portion of the evaluation then 

indicated that she had a marked restriction in the form for her mental 

residual functional capacity. He indicated in the form that she has marked 

history of decompensation in work setting but no examples or history of 

decompensation in a work setting are contained in the record or in his 

narrative history. The only episode of decompensation in the record is the 

commitment to Baypointe in March of 2012 after the altercation at the 

homeless shelter. Dr. DeFrancisco gave the claimant a marked restriction 

of activities of daily living; however, the claimant wrote in her Function 

Report and the claimant’s mother wrote in her function report that the 

claimant has almost no restrictions in her activities of daily living. The 

marked restriction[s] in social functioning [are] also internally inconsistent 

because a mere moderate restriction was placed on the claimant’s ability 

[to] respond appropriately to supervision. 

In sum, the above residual functional capacity assessment is supported by 

the objective medical evidence, the medical opinions when afforded 

appropriate weight, and the claimant’s subjective complaints during the 

relevant period when taken in proper context. In view of all of the factors 

discussed above, the limitations on the claimant’s capacities that were 

described earlier in this decision are considered warranted, but no greater 

or additional limitations are justified.

5. The claimant is capable of performing past relevant work as a 

cashier. This work does not require the performance of work-related 

activities precluded by the claimant’s residual functional capacity (20 

CFR 416.965).

The position of cashier is described in the Dictionary of Occupational Titles 

at 211.462-010. The job is performed at the light exertional level and is 

unskilled. It requires frequent reaching, handling, fingering, talking, 

hearing, and near acuity. She performed the position beyond the level 

required to reach substantial gainful activity at various places during her 

career for more than enough time to learn the job.

In comparing the claimant’s residual functional capacity with the physical 

and mental demands of this work, the undersigned finds that the claimant 

is able to perform it as actually and generally performed. She is capable of 

performing light work as she is limited only to the medium exertional 

level. She can understand, remember, and carry out short simple 

instructions on an unlimited basis and detailed instructions occasionally.

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 7 of 16
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She has no social interaction limitations or adaptation limitations. She can 

continually reach, handle, finger, or feel. The only additional limitations 

that she has are preclusion from climbing ladders, ropes, or scaffolds, and 

crawling and being limited to only occasionally stooping, kneeling, or 

crouching. These precluded activities are not requirements of the position 

of cashier as described in the Dictionary of Occupational Titles.

6. The claimant has not been under a disability, as defined in the 

Social Security Act, since March 26, 2012, the date the application was 

filed (20 CFR 416.920(f)). 

 

(Tr. 13, 14-15, 15, 15-16, 16 & 16-20 (internal citations omitted; emphasis in original).) 

The Appeals Council affirmed the ALJ’s decision (Tr. 1-3) and thus, the hearing decision 

became the final decision of the Commissioner of Social Security.

DISCUSSION

A claimant is entitled to an award of supplemental security income benefits 

when she is unable to engage in substantial gainful activity by reason of any medically 

determinable physical or mental impairment which can be expected to result in death or 

last for a continuous period of not less than 12 months. See 20 C.F.R. § 416.905(a) (2014). 

In determining whether a claimant has met her burden of proving disability, the 

Commissioner follows a five-step sequential evaluation process. See 20 C.F.R. § 416.920. 

At step one, if a claimant is performing substantial gainful activity, she is not disabled. 

20 C.F.R. § 416.920(b). At the second step, if a claimant does not have an impairment or 

combination of impairments that significantly limits her physical or mental ability to do 

basic work activities, she is not disabled. 20 C.F.R. § 416.920(c). At step three, if a 

claimant proves that her impairments meet or medically equal one of the listed

impairments set forth in Appendix 1 to Subpart P of Part 404, the claimant will be 

considered disabled without consideration of age, education and work experience. 20 

C.F.R. § 416.920(d). At the fourth step, if the claimant is unable to prove the existence of 

a listed impairment, she must prove that her physical and/or mental impairments

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 8 of 16
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prevent her from performing her past relevant work. 20 C.F.R. § 416.920(f). And at the 

fifth step, the Commissioner must consider the claimant’s residual functional capacity, 

age, education, and past work experience to determine whether the claimant can 

perform other work besides past relevant work. 20 C.F.R. § 416.920(g). Plaintiff bears 

the burden of proof through the first four steps of the sequential evaluation process, see 

Bowen v. Yuckert, 482 U.S. 137, 146 n.5, 107 S.Ct. 2287, 2294 n.5, 96 L.Ed.2d 119 (1987), 

and while the burden of proof shifts to the Commissioner at the fifth step of the process

to establish other jobs existing in substantial numbers in the national economy that the 

claimant can perform,

2 the ultimate burden of proving disability never shifts from the 

plaintiff, see, e.g., Green v. Social Security Administration, 223 Fed.Appx. 915, 923 (11th Cir. 

May 2, 2007) (“If a claimant proves that she is unable to perform her past relevant work, 

in the fifth step, ‘the burden shifts to the Commissioner to determine if there is other 

work available in significant numbers in the national economy that the claimant is able 

to perform.’ . . . Should the Commissioner ‘demonstrate that there are jobs the claimant 

can perform, the claimant must prove she is unable to perform those jobs in order to be 

found disabled.’”). 3

The task for the Magistrate Judge is to determine whether the Commissioner’s 

decision to deny claimant benefits, on the basis that she is capable of performing her 

past relevant work as a cashier, is supported by substantial evidence. Substantial 

evidence is defined as more than a scintilla and means such relevant evidence as a 

 2 See, e.g., McManus v. Barnhart, 2004 WL 3316303, *2 (M.D. Fla. Dec. 14, 2004) 

(“The burden [] temporarily shifts to the Commissioner to demonstrate that ‘other work’ which 

the claimant can perform currently exists in the national economy.”).

3 “Unpublished opinions are not considered binding precedent, but they may be 

cited as persuasive authority.” 11th Cir.R. 36-2.

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 9 of 16
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reasonable mind might accept as adequate to support a conclusion. Richardson v. 

Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971). “In determining whether 

substantial evidence exists, we must view the record as a whole, taking into account 

evidence favorable as well as unfavorable to the Commissioner’s] decision.” Chester v. 

Bowen, 792 F.2d 129, 131 (11th Cir. 1986).4 Courts are precluded, however, from 

“deciding the facts anew or re-weighing the evidence.” Davison v. Astrue, 370 Fed. 

App’x 995, 996 (11th Cir. Apr. 1, 2010) (per curiam) (citing Dyer v. Barnhart, 395 F.3d

1206, 1210 (11th Cir. 2005)). And, “[e]ven if the evidence preponderates against the 

Commissioner’s findings, [a court] must affirm if the decision reached is supported by 

substantial evidence.” Id. (citing Crawford v. Commissioner of Social Security, 363 F.3d 

1155, 1158-59 (11th Cir. 2004).

Although the plaintiff’s brief is a bit disjointed (see Doc. 19), the Court considers 

Grimes to be offering two reasons why the Commissioner’s decision to deny her 

supplemental security income benefits is in error (i.e., not supported by substantial 

evidence): (1) the ALJ accorded improper weight to the various doctors’ 

evaluations/examinations contained in the record and/or erred in failing to obtain a 

consultative psychological examination in light of his rejection of the evaluations of Dr. 

Robert DeFrancisco; and (2) the ALJ’s residual functional capacity determination and 

finding that claimant can perform her past relevant work as a cashier is not supported 

by substantial evidence because of the ALJ’s failure to consider relevant evidence and 

testimony of record.

 4 This Court’s review of the Commissioner’s application of legal principles, 

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

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 10 of 16
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A. RFC Determination and Plaintiff’s Ability to Perform her Past Relevant 

Work as a Cashier. Initially, the Court notes that the responsibility for making the 

residual functional capacity determination rests with the ALJ. Compare 20 C.F.R. § 

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

administrative law judge . . . is responsible for assessing your residual functional 

capacity.”) with, e.g., Packer v. Commissioner, Social Security Admin., 542 Fed. Appx. 890, 

891-892 (11th Cir. Oct. 29, 2013) (per curiam) (“An RFC determination is an assessment, 

based on all relevant evidence, of a claimant’s remaining ability to do work despite her 

impairments. There is no rigid requirement that the ALJ specifically refer to every piece 

of evidence, so long as the ALJ’s decision is not a broad rejection, i.e., where the ALJ 

does not provide enough reasoning for a reviewing court to conclude that the ALJ 

considered the claimant’s medical condition as a whole.” (internal citation omitted)). A 

plaintiff’s RFC—which “includes physical abilities, such as sitting, standing or walking, 

and mental abilities, such as the ability to understand, remember and carry out 

instructions or to respond appropriately to supervision, co-workers and work 

pressure[]”—“is a[n] [] assessment of what the claimant can do in a work setting despite 

any mental, physical or environmental limitations caused by the claimant’s 

impairments and related symptoms.” Watkins v. Commissioner of Social Security, 457 Fed. 

Appx. 868, 870 n.5 (11th Cir. Feb. 9, 2012) (citing 20 C.F.R. §§ 404.1545(a)-(c), 416.945(a)-

(c)). And, of course, it is clear that the ALJ’s RFC determination is as important at the 

fourth step of the sequential evaluation process as it is at the fifth. See Phillips v. 

Barnhart, 357 F.3d 1232, 1238-1239 (11th Cir. 2004) (“At the fourth step, the ALJ must 

assess: (1) the claimant’s residual functional capacity []; and (2) the claimant’s ability to 

return to [his] past relevant work. 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 

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 11 of 16
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impairments. 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. Furthermore, the RFC determination is used both to determine whether the 

claimant: (1) can return to [his] past relevant work under the fourth step; and (2) can 

adjust to other work under the fifth step . . . . If the claimant can return to [his] past 

relevant work, the ALJ will conclude that the claimant is not disabled. If the claimant 

cannot return to [his] past relevant work, the ALJ moves on to step 5.” (internal 

citations, quotation marks, and brackets omitted; brackets added)). In this case, the ALJ 

made the following RFC determination: “After careful consideration of the entire 

record, the undersigned finds that the claimant has the residual functional capacity to 

perform a reduced level of medium work as defined in 20 CFR 416.967(c). She can 

understand, remember, and carry out short simple instructions on an unlimited basis 

and detailed instructions occasionally. She has [] no [social] interaction limitations or 

adaptation limitations. She is precluded from climbing ladders, ropes, or scaffolds. 

She is precluded from crawling. She can occasionally stoop, kneel, or crouch. She can 

continuously reach, handle, finger, or feel.” (Tr. 15-16 (emphasis in original).)

To find that an ALJ’s RFC determination is supported by substantial evidence, it 

must be shown that the ALJ has “’provide[d] a sufficient rationale to link’” substantial 

record evidence “’to the legal conclusions reached.’” Ricks v. Astrue, 2012 WL 1020428, 

*9 (M.D. Fla. Mar. 27, 2012) (quoting Russ v. Barnhart, 363 F. Supp. 2d 1345, 1347 (M.D. 

Fla. 2005)); compare id. with Packer v. Astrue, 2013 WL 593497, *4 (S.D.Ala. Feb. 14, 2013) 

(“’[T]he ALJ must link the RFC assessment to specific evidence in the record bearing 

upon the claimant’s ability to perform the physical, mental, sensory, and other 

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 12 of 16
13

requirements of work.’”), aff’d, 542 Fed. Appx. 890 (11th Cir. Oct. 29, 2013)5; see also 

Hanna v. Astrue, 395 Fed. Appx. 634, 636 (11th Cir. Sept. 9, 2010) (per curiam) (“The ALJ 

must state the grounds for his decision with clarity to enable us to conduct meaningful 

review. . . . Absent such explanation, it is unclear whether substantial evidence 

supported the ALJ’s findings; and the decision does not provide a meaningful basis 

upon which we can review [a plaintiff’s] case.” (internal citation omitted)).6

In this case, the undersigned cannot find that the ALJ has provided the required 

“linkage” between the record evidence and his RFC determination necessary to 

facilitate this Court’s meaningful review of his decision. The ALJ specifically 

determined that plaintiff is capable of performing a “reduced range of medium work 

as defined in 20 CFR 416.967(c).” (Tr. 15.) That section of the Commissioner’s 

 5 In affirming the ALJ, the Eleventh Circuit rejected Packer’s substantial evidence 

argument, noting, she “failed to establish that her RFC assessment was not supported by 

substantial evidence[]” in light of the ALJ’s consideration of her credibility and the medical 

evidence. Id. at 892.

6 It is the ALJ’s (or, in some cases, the Appeals Council’s) responsibility, not the 

responsibility of the Commissioner’s counsel on appeal to this Court, to “state with clarity” the 

grounds for an RFC determination. Stated differently, “linkage” may not be manufactured 

speculatively by the Commissioner—using “the record as a whole”—on appeal, but rather, 

must be clearly set forth in the Commissioner’s decision. See, e.g., Durham v. Astrue, 2010 WL 

3825617, *3 (M.D. Ala. Sept. 24, 2010) (rejecting the Commissioner’s request to affirm an ALJ’s 

decision because, according to the Commissioner, overall, the decision was “adequately 

explained and supported by substantial evidence in the record”; holding that affirming that 

decision would require that the court “ignor[e] what the law requires of the ALJ[; t]he court 

‘must reverse [the ALJ’s decision] when the ALJ has failed to provide the reviewing court with 

sufficient reasoning for determining that the proper legal analysis has been conducted’” 

(quoting Hanna, 395 Fed. Appx. at 636 (internal quotation marks omitted))); see also id. at *3 n.4 

(“In his brief, the Commissioner sets forth the evidence on which the ALJ could have relied . . . . 

There may very well be ample reason, supported by the record, for [the ALJ’s ultimate 

conclusion]. However, because the ALJ did not state his reasons, the court cannot evaluate 

them for substantial evidentiary support. Here, the court does not hold that the ALJ’s ultimate 

conclusion is unsupportable on the present record; the court holds only that the ALJ did not 

conduct the analysis that the law requires him to conduct.” (emphasis in original)); Patterson v. 

Bowen, 839 F.2d 221, 225 n.1 (4th Cir. 1988) (“We must . . . affirm the ALJ’s decision only upon 

the reasons he gave.”).

Case 1:14-cv-00373-C Document 30 Filed 06/03/15 Page 13 of 16
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regulations defines medium work as requiring “lifting no more than 50 pounds at a 

time with frequent lifting or carrying of objects weighing up to 25 pounds[,]” id. and it 

is clear that medium work requires prolonged standing, see SSR 83-10 (“In most 

medium jobs, being on one’s feet for most of the workday is critical.”). Although the 

ALJ notes in a conclusory manner that his RFC determination accommodates plaintiff’s 

severe physical impairments “of obesity and osteoarthritis[]”(see Tr. 16), this Court 

cannot find substantial evidence in the record supporting that RFC determination in 

light of the ALJ’s wholesale failure to mention, much less consider, the evidence in the 

record regarding the morbidly obese plaintiff’s numerous plantar warts on both feet, 

including one doctor’s repeated suggestion that she was in need of surgery (see, e.g., Tr. 

291-305, 312, 351-352, 355 & 368), and plaintiff’s testimony that the warts on her feet are 

a big and painful problem and make it impossible for her to stand for prolonged 

periods (see Tr. 30-31, 33-34 & 41-42). Since the ALJ totally ignored the evidence of 

record relative to plaintiff’s plantar warts, as well as her testimony regarding that 

condition (whether plantar “feet” or plantar warts), he obviously failed to set forth 

explicit and adequate reasons for questioning Grimes’ testimony that she cannot stand 

for prolonged periods because of her plantar warts. Accordingly, the Court must accept 

plaintiff’s testimony in this regard as true, see Foote v. Chater, 67 F.3d 1553, 1561 (11th 

Cir. 1995) (“Failure to articulate the reasons for discrediting subjective pain testimony 

requires, as a matter of law, that the testimony be accepted as true.”), and since the

truth of such testimony cannot be reconciled with the ability to perform the physical 

requirements of medium work,

7 this case need be remanded for further proceedings not 

inconsistent with this decision.

8

 7 Although the ALJ noted in a conclusory manner that “no diagnostic testing has 

(Continued)

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On remand, the ALJ should also more specifically explain how plaintiff’s mental 

impairments still allow her to “occasionally” understand, remember, and carry out 

detailed instructions (see Tr. 15), given the evidence or record relied upon by the ALJ in 

denying the claimant benefit (compare, e.g., Tr. 373 (“She is adequately oriented, but she 

does appear to have difficulty with recall. She was able to remember that I am a 

psychiatrist but she could not recall my name even though I wrote it down on a piece of 

paper. Her intellectual functioning appears to be impaired. She subtracted serials seven 

very slowly. She could not multiply. She was not able to abstract proverbs.”); and Tr. 

329 (memory and concentration were noted to be impaired) with Tr. 212 (mother’s 

report that plaintiff “does not take instructions well”)).

Because substantial evidence of record fails to support the Commissioner’s

determination that Grimes can perform the physical and mental requirements of 

medium work as identified by the ALJ (see Tr. 15-16), the Commissioner’s fourth-step 

determination is due to be reversed and remanded for further consideration not 

inconsistent with this decision. See Land v. Commissioner of Social Security, 494 Fed.Appx. 

 

shown any basis for the pain[]” plaintiff complained of during the hearing (see Tr. 18), this 

Court simply observes that plaintiff’s plantar warts are patently apparent and no physician who 

examined plaintiff has given the slightest indication that those warts would not be painful (to 

stand or walk on) or cause pain (see, e.g., Tr. 317).

8 The undersigned recognizes that when Dr. Alan Sherman examined plaintiff on 

August 20, 2012, he noted that “[g]iven ROM there are few physical limitations that would 

preclude gainful employment.” (Tr. 317.) However, this comment has no impact on plaintiff’s 

testimony regarding her feet and plantar warts and, in truth, the undersigned questions 

whether the “few physical limitations” to which Dr. Sherman made implicit reference relate to 

plaintiff’s plantar warts. Certainly, Dr. Sherman did not question that plaintiff was being 

treated for plantar warts (see Tr. 315 (“She also is currently being treated for bilateral foot 

plantar warts which she states increases pain.”)) or that the warts are painful (compare id. with 

Tr. 317 (“CHRONIC PAIN SYNDROME PER MEDICAL RECORDS”)). And since Dr. Sherman 

makes no direct notation that he examined the warts and found that they would not cause any 

physical limitations, Dr. Sherman’s examination notes simply are not contradictory of plaintiff’s 

testimony that her plantar warts prohibit her from engaging in prolonged standing.

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47, 49 & 50 (11th Cir. Oct. 26, 2012) (“[S]tep four assesses the claimant’s RFC to 

determine whether the claimant is capable of performing ‘past relevant work.’ . . . A 

claimant’s RFC takes into account both physical and mental limitations. . . . Because 

more than a scintilla of evidence supported the ALJ’s RFC assessment here, we will not 

second-guess the Commissioner’s determination.”).

B. Weight Afforded the Opinions of the Various Examining Physicians. 

Because this case is due to be remanded for further proceedings for those reasons 

previously identified, this Court has no reason to address this assignment of error at 

any length. However, the undersigned would simply note that given the objections 

raised by the plaintiff, reconsideration of whether to obtain a detailed psychological 

evaluation of the claimant on remand may be appropriate. 

CONCLUSION

In light of the foregoing, it is ORDERED that the decision of the Commissioner 

of Social Security denying plaintiff benefits be reversed and remanded pursuant to 

sentence four of 42 U.S.C. § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct. 2157, 

115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this decision. The 

remand pursuant to sentence four of § 405(g) makes the plaintiff a prevailing party for 

purposes of the Equal Access to Justice Act, 28 U.S.C. § 2412, Shalala v. Schaefer, 509 U.S. 

292, 113 S.Ct. 2625, 125 L.Ed.2d 239 (1993), and terminates this Court’s jurisdiction over 

this matter.

DONE and ORDERED this the 3rd day of June, 2015.

s/WILLIAM E. CASSADY

UNITED STATES MAGISTRATE JUDGE

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