Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-5_15-cv-01293/USCOURTS-alnd-5_15-cv-01293-0/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 (SSID)

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UNITED STATES DISTRICT COURT 

FOR THE NORTHERN DISTRICT OF ALABAMA 

NORTHEASTERN DIVISION 

KIMBERLY DIANE FLECK, 

Plaintiff, 

v. 

CAROLYN COLVIN, 

Commissioner, Social Security 

Administration, 

Defendant. 

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Case No.: 5:15-cv-01293-MHH 

MEMORANDUM OPINION 

 This case is before the Court for review of a report and recommendation 

concerning the termination of plaintiff Kimberly Diane Fleck’s disability insurance 

benefits. In the report, the magistrate judge recommended that the Court affirm the 

Commissioner’s decision that Ms. Fleck is no longer disabled. (Doc. 14). Ms. 

Fleck objects to the magistrate judge’s recommendation. (Doc. 15; Doc. 19). This 

opinion addresses Ms. Fleck’s objections. 

STANDARD OF REVIEW 

 A district court “may accept, reject, or modify, in whole or part, the findings 

or recommendations made by the magistrate judge.” 28 U.S.C. § 636(b)(1)(C). 

When a party objects to a report, a district court must “make a de novo

FILED

 2016 Sep-30 PM 10:43

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 1 of 12
2 

determination of those portions of the report or specified proposed findings or 

recommendations to which objection is made.” 28 U.S.C. §§ 636(b)(1)(B)-(C). A 

district court reviews legal conclusions in a report de novo and reviews for plain 

error factual findings to which no objection is made. Garvey v. Vaughn, 993 F.2d 

776, 779 n. 9 (11th Cir. 1993); see also LoConte v. Dugger, 847 F.2d 745, 749 

(11th Cir. 1988); Macort v. Prem, Inc., 208 Fed. Appx. 781, 784 (11th Cir. 2006). 

 Ms. Fleck lodges four objections to the magistrate judge’s recommendation, 

one of which concerns a factual determination regarding malaise, a sign or 

symptom of lupus under listing 14.02. Because the Court sustains this objection 

and remands the case to the Commissioner for further administrative proceedings, 

the Court does not reach Ms. Fleck’s other arguments for relief.1

 

                                                            

1

 For her other objections, Ms. Fleck argues that the magistrate judge did not properly apply the 

law concerning the ALJ’s credibility determination. (Doc. 15, pp. 4-7). In addition, Ms. Fleck 

objects to the holding that the ALJ was not required to explicitly discuss whether Ms. Fleck 

meets a listing. (Doc. 15, pp. 1-2). The magistrate judge properly recited the law regarding an 

ALJ’s obligation to consider the Listings. (See Doc. 14, pp. 7-8). The Eleventh Circuit has 

explained that “[t]he ALJ’s finding as to whether a claimant does or does not meet a listed 

impairment may be implied from the record.” Prince v. Commissioner, Social Sec. Admin., 551 

Fed. Appx. 967, 969 (11th Cir. 2014) (citing Hutchison v. Bowen, 787 F.2d 1461, 1463 (11th 

Cir. 1986)). “Furthermore, while the ALJ must consider the Listings in making its disability 

determination, ‘it is not required that the [ALJ] mechanically recite the evidence leading to her 

determination.’” Id. (quoting Hutchison, 787 F.2d at 1463)). In Hutchison, the Eleventh Circuit 

noted: “There may be an implied finding that a claimant does not meet a listing. Edwards v. 

Heckler, 736 F.2d 625, 629 (11th Cir. 1984). We thus consider it clear that the ALJ, in reaching 

the fourth and fifth steps of the disability analysis, implicitly found that appellant did not meet 

any of the Appendix 1 impairments.” Hutchison, 787 F.2d at 1463. Although an ALJ need not 

make explicit findings regarding listed impairments, an ALJ’s analysis must demonstrate to the 

Court that the ALJ considered evidence relevant to the listing. As explained below, in this case, 

the ALJ’s discussion of the medical evidence does not account for certain diagnoses and reported 

symptoms that support Ms. Fleck’s arguments concerning her impairment of lupus, so the Court 

cannot determine whether the ALJ considered that evidence or the related lupus listing. 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 2 of 12
3 

 In making a de novo review of the factual findings to which Ms. Fleck 

objects, the Court “review[s] the ALJ’s ‘factual findings with deference.’” Riggs 

v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir. 2013) (quoting 

Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)). The Court must 

determine whether there is substantial evidence in the record to support the ALJ’s 

factual findings. “Substantial evidence is more than a scintilla and is such relevant 

evidence as a reasonable person would accept as adequate to support a 

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

2004). In making this evaluation, the Court may not “decide the facts anew, 

reweigh the evidence,” or substitute its judgment for that of the ALJ. Winschel v. 

Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal 

quotations and citation omitted). If substantial evidence supports the ALJ’s factual 

findings, then the Court must accept the magistrate judge’s recommendation and 

“must affirm [the Commissioner’s decision] even if the evidence preponderates 

against the Commissioner’s findings.” Costigan v. Comm’r of Soc. Sec. Admin., 

603 Fed. Appx. 783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158). 

 With respect to the ALJ’s legal conclusions, the Court must determine 

whether the ALJ applied the correct legal standards. If the Court finds an error in 

the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide 

sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis, 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 3 of 12
4 

then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 

1143, 1145-46 (11th Cir. 1991). 

ANALYSIS 

This social security case concerns the termination of Ms. Fleck’s disability 

benefits. Therefore, as the magistrate judge stated, the burden in this case rests not 

on Ms. Fleck, as in the typical case involving an initial claim for benefits, but on 

the Commissioner. (Doc. 14, p. 4) (“‘Pursuant to 42 U.S.C. § 423(f) and the 

implementing regulations, in a termination case the burden is placed on the 

Commissioner to show the plaintiff has the ability to engage in substantial gainful 

activity.’ Cross v. Astrue, 659 F. Supp. 2d 1216, 1224 (N.D. Ala. 2009) (citing 

Glenn v. Shalala, 21 F.3d 983, 987 (10th Cir. 1994); Griego v. Sullivan, 940 F.2d 

942, 944 (5th Cir. 1991).”). As the Fifth Circuit explained in Griego, in a 

termination case: 

[t]he first part of the evaluation process [] focuses on medical 

improvement. . . . 

The second part of the evaluation process relates to ability to engage 

in substantial gainful activity. Here the implementing regulations 

incorporate many of the standards set forth in the regulations 

governing initial disability determinations. See 20 C.F.R. §§ 

404.1594(b)(5) and (f)(7). The difference, of course, is that the 

ultimate burden of proof lies with the Secretary in termination 

proceedings. In evaluating ability to engage in substantial gainful 

activity, the Secretary considers, first, whether the claimant can 

perform past relevant work and, if not, whether the claimant can 

perform other work. 20 C.F.R. §§ 404.1594(f)(7) and (f)(8). 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 4 of 12
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Griego, 940 F.2d at 944. 

 In 2006, the Social Security Administration found that Ms. Fleck was 

disabled because of breast cancer and related impairments. (Doc. 6-3, pp. 16, 18). 

In December 2010, the Administration concluded that Ms. Fleck’s medical 

condition had improved, and she was no longer disabled. (Doc. 6-3, p. 16). Ms. 

Fleck concedes that her breast cancer is not active; however, she contends that she 

remains disabled because of lupus and inflammatory arthritis. (Doc. 10, p. 1). Ms. 

Fleck argues that the ALJ erred by failing to find that she meets Listing 14.02 for 

lupus or Listing 14.09(D) for inflammatory arthritis. The Court considers only the 

lupus listing in this opinion. 

 The applicable regulations define systemic lupus erythematosus as “a 

chronic inflammatory disease that can affect any organ or body system. It is 

frequently, but not always, accompanied by constitutional symptoms or signs 

(severe fatigue, fever, malaise, involuntary weight loss).” 20 C.F.R. Pt. 404, 

Subpt. P, App. 1, § 14.00(D)(1)(a). Major organs or body systems include: 

[r]espiratory (pleuritis, pneumonitis), cardiovascular (endocarditis, 

myocarditis, pericarditis, vasculitis), renal (glomerulonephritis), 

hematologic (anemia, leukopenia, thrombocytopenia), skin 

(photosensitivity), neurologic (seizures), mental (anxiety, fluctuating 

cognition (“lupus fog”), mood disorders, organic brain syndrome, 

psychosis), or immune system disorders (inflammatory arthritis). 

Id. Listing 14.02 for systemic lupus erythematosus (SLE) requires a lupus 

diagnosis with: 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 5 of 12
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A. Involvement of two or more organs/body systems, with: 

1. One of the organs/body systems involved to at least a moderate 

level of severity; and 

2. At least two of the constitutional symptoms or signs (severe fatigue, 

fever, malaise, or involuntary weight loss). 

or 

B. Repeated manifestations of SLE, with at least two of the 

constitutional symptoms or signs (severe fatigue, fever, malaise, or 

involuntary weight loss) and one of the following at the marked level: 

1. Limitation of activities of daily living. 

2. Limitation in maintaining social functioning. 

3. Limitation in completing tasks in a timely manner due to 

deficiencies in concentration, persistence, or pace. 

20 C.F.R. § 404, Subpt. P, App. 1, § 14.02. 

 Although an ALJ may make implicit findings regarding the listings, see 

supra note 1, “[a] clear articulation of both fact and law is essential to [the Court’s] 

ability to conduct a review that is both limited and meaningful.” Owens v. 

Heckler, 748 F.2d 1511, 1514-15 (11th Cir. 1984). The Court cannot tell from the 

ALJ’s opinion whether the ALJ considered listing 14.02. In concluding that Ms. 

Fleck “did not have an impairment or a combination of impairments which met or 

medically equaled” a listing, the ALJ stated, “[s]pecifically, evidence has not 

shown limitations consistent with listing 14.01, regarding immune system 

disorders or listing 14.09, regarding inflammatory arthritis, with objective findings 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 6 of 12
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discussed in more detail below.” (Doc. 6-3, p. 18). The ALJ did not specifically 

mention listing 14.02. In assessing Ms. Fleck’s RFC, the ALJ focused on certain 

aspects of the treatment notes from Ms. Fleck’s physicians and intimated that Ms. 

Fleck might not even have lupus.2

 For example, the ALJ described a record from 

Ms. Fleck’s September 2011 visit to the Vanderbilt University Medical Center 

Rheumatology Clinic. The ALJ pointed out that the examining physician felt that 

Ms. Fleck, at worse, had a mild case of lupus. (Doc. 6-3, p. 23). 

 The ALJ then discussed select findings in records from Ms. Fleck’s local 

rheumatologist. Citing a January 2012 record, the ALJ stated that Ms. Fleck 

reported neck and back pain and “significant depression” but no other significant 

symptoms. (Doc. 6-3, p. 24). The record to which the ALJ referred states that Ms. 

Fleck “feels miserable and feels like taking her life off [sic]. She’s taking her 

depression pill regularly.” (Doc. 6-13, p. 32). The “Assessment and Plan” section 

of the record states “has active lupus.” (Doc. 6-13, p. 32). With respect to an 

April 2012 record, the ALJ noted that Ms. Fleck “had stopped her medication for 

lupus” and “she felt much better.” (Doc. 6-3, p. 24). The corresponding record 

states that Ms. Fleck had “active lupus,” and her doctor gave her new prescriptions. 

(Doc. 6-13, p. 31). Citing a record from August 2012, the ALJ stated that Ms. 

                                                            

2

 At stage four of her analysis, the ALJ stated that as of December 2010, Ms. Fleck had the 

“medically determinable impairment[]” of lupus, but the ALJ did not indicate whether she 

regarded lupus as a severe or a non-severe impairment. (Doc. 6-3, p. 18). 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 7 of 12
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Fleck “continued to do well” and was “‘stable.’” (Doc. 6-3, p. 24). That record 

confirms few lupus symptoms other than abdominal problems (Doc. 6-13, p. 30), 

but a record from September 2012 reflects that Ms. Fleck returned to her 

rheumatologist two weeks later complaining of a “rash around her mouth” and 

“some increased pain.” Dr. Jampala found that Ms. Fleck was developing “some 

knots in her left index finger.” Dr. Jampala once again diagnosed “active lupus” 

and stated that Ms. Fleck was experiencing a “lupus flare up and possible rash 

from lupus.” (Doc. 6-13, p. 29). 

 Describing a record from November 2012, the ALJ wrote: “the claimant 

reported her depression was not too bad. While she reported dryness in her eyes, 

she had no loss of vision or double vision. There was no joint swelling.” (Doc. 6-

3, p. 24). The record that the ALJ cited also states: 

Patient continues to feel miserable. She has pain all over. Some of 

her medicines were changed her [sic] and her depression is not too 

bad. She has neck pain and has lot of headache. She continues to 

have significant dryness in the eye and pain. . . . Patient feels cold in 

her feet and always numb. She has pain in her abdomen. She has 

small cyst in her left third finger. It is not hurting. 

(Doc. 6-13, p. 28). Her other systems were negative. Dr. Jampala maintained a 

diagnosis of “active lupus,” stated that Ms. Fleck had “ongoing problem with her 

pain. She has lot of stress,” and added Trazadone to Ms. Fleck’s prescription 

medicine regime. (Doc. 6-13, p. 28). 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 8 of 12
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 Thus, the administrative record, viewed in its entirety, suggests that the ALJ 

may have overlooked the portions of Ms. Fleck’s records that may support a 

finding that Ms. Fleck meets the lupus listing. See McCruter v. Bowen, 791 F.2d 

1544, 1548 (11th Cir. 1986) (If the record viewed in its entirety indicates that the 

ALJ “focus[ed] upon one aspect of the evidence and ignor[ed] other parts of the 

record,” then the reviewing court “cannot properly find that the administrative 

decision is supported by substantial evidence. It is not enough to discover a piece 

of evidence which supports that decision, but to disregard other contrary evidence. 

The review must take into account and evaluate the record as a whole.”). The 

medical records in the administrative record demonstrate that several doctors have 

diagnosed Ms. Fleck with lupus. (See e.g., Doc. 6-11, p. 36; Doc. 6-13, pp. 26-33; 

Doc. 6-23, p. 13). 

 In his report, the magistrate judge found that substantial evidence in the 

administrative record indicates that Ms. Fleck does not meet Listing 14.02 for 

lupus because “the record does not support a finding [Ms. Fleck] has two of the 

constitutional symptoms or signs.” (Doc. 14, pp. 9-10). As stated above, those 

constitutional symptoms or signs are severe fatigue, fever, malaise, or involuntary 

weight loss. The magistrate judge found, and the undersigned agrees, that 

“considerable medical evidence support[s] a finding of chronic fatigue.” (Doc. 14, 

p. 9; see also Doc. 6-3, p. 46; Doc. 6-8, p. 56; Doc. 6-10, p. 53; Doc. 6-11, pp. 34, 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 9 of 12
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40, 61; Doc. 6-12, pp. 11, 33, 38; Doc. 6-13, pp. 26, 39; Doc. 6-14, p. 6; Doc. 6-15, 

p. 17; Doc. 6-21, p. 3; Doc. 6-30, p. 19). The magistrate judge also concluded that 

references in the medical evidence to “ICD-9-CM code 780.79 – Other malaise and 

fatigue,” were insufficient to support a finding that Ms. Fleck suffers from malaise, 

a symptom that would give Ms. Fleck the two constitutional signs or symptoms 

that listing 14.02 requires. (Doc. 14, pp. 9-10).3

 The ALJ’s analysis contains no discussion of the standard for malaise or the 

distinction between fatigue and malaise. According to the Social Security 

regulations, “[s]evere fatigue means a frequent sense of exhaustion that results in 

significantly reduced physical activity or mental function. Malaise means frequent 

feelings of illness, bodily discomfort, or lack of well-being that result in 

significantly reduced physical activity or mental function.” 20 C.F.R. Pt. 404, 

Subpt. P, App. 1 Listing 14.00(C)(2). In addition to the records discussed above, 

many of Ms. Fleck’s records contain evidence of “feelings of illness, bodily 

discomfort, or lack of well-being.” And there are records that indicate that Ms. 

Fleck suffers not only from severe depression but also from other reduced mental 

functions. (See, e.g. Doc. 6-10, p. 65) (July 2007 record noting diagnosis of 

decreased short-term memory and referral to Neurology “to have her memory 

                                                            

3

 The magistrate judge stated that the diagnoses of other malaise and fatigue “could potentially 

indicate a finding of malaise,” and they “could just as likely reference the physicians’ explicit 

findings of fatigue.” (Doc. 14, pp. 9-10). 

 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 10 of 12
11 

changes evaluated more closely, as I think that her pattern of memory loss is a little 

bit more unusual timing-wise from her chemotherapy and is persistent.”); (Doc. 6-

10, p. 63) (April 2008 record reflecting memory trouble with referral for 

neurocognitive retraining); (Doc. 6-10, pp. 53-54) (December 2008 record noting 

cognitive difficulties with “mental fog”; record contains instruction that Ms. Fleck 

should begin stretching exercises and a walking program); (Doc. 6-10, p. 55) 

(March 2009 record explaining that because of pain in her calf, Ms. Fleck had “to 

stop after she walks a few yards. Once she rests and she can feel better and she can 

walk back again. She does regular walking and she goes swimming . . . lupus has 

history of connective tissue disease”); (Doc. 6-14, p. 6) (May 2012 record from 

neurological clinic examining cognitive dysfunction and noting that Ms. Fleck 

reported “a significant amount of worsening of her cognition,” though her 

depression was under control); (Doc. 6-15, p. 17) (November 2012 record 

describing “very disruptive” headaches that “can occur more than 4 times a day”). 

 The Court expresses no opinion about the significance of these records; that 

is for the ALJ to decide. The Court merely identifies the records and notes that 

they may be pertinent to an examination of malaise. Also relevant is the fact that 

one of Ms. Fleck’s treating physicians wrote in four separate records “780.79 – 

other malaise and fatigue.” (Doc. 6-10, p. 19; Doc. 6-12, p. 15; Doc. 6-26, p. 32; 

Doc. 6-26, p. 36). As the magistrate judge observed, it is not clear from these 

Case 5:15-cv-01293-MHH Document 20 Filed 09/30/16 Page 11 of 12
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notations whether the physician, Dr. Haley, was diagnosing only malaise or fatigue 

or both malaise and fatigue. The record does not indicate that the ALJ contacted 

Dr. Haley to ask for clarification. “Social security disability proceedings are 

inquisitorial rather than adversarial.” Crawford & Co. v. Apfel, 235 F.3d 1298, 

1304 (11th Cir. 2000). “[A]n ALJ should recontact a claimant’s treating physician 

if the evidence in the record is otherwise inadequate to determine whether the 

claimant is disabled.” Robinson v. Astrue, 365 Fed. Appx. 993, 999 (11th Cir. 

2010).4

 Logically, the obligation to recontact a treating physician is more pressing 

in a termination setting like this one. 

CONCLUSION 

 For the reasons stated above, the Court will remand this action to the 

Commissioner for further administrative proceedings consistent with this 

memorandum opinion. 

DONE and ORDERED this September 30, 2016.

 _________________________________ 

 MADELINE HUGHES HAIKALA 

 UNITED STATES DISTRICT JUDGE 

                                                            

4 See also SSR 96-5p, 1996 WL 374183, at *6 (“[I]f the evidence does not support a treating 

source’s opinion on any issue reserved to the Commissioner and the adjudicator cannot ascertain 

the basis of the opinion from the case record, the adjudicator must make ‘every reasonable effort’ 

to recontact the source for clarification of the reasons for the opinion.” 

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