Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_13-cv-00600/USCOURTS-almd-3_13-cv-00600-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

EASTERN DIVISION

PAULA DALLAS PRESLEY, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 3:13cv600-CSC

) (WO)

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff applied for applied for disability insurance benefits pursuant to Title II

of the Social Security Act, 42 U.S.C. §§ 401, et seq., alleging that she was unable to work

because of a disability. She is seeking disability benefits for a closed period from the date

of onset on May 18, 2007 until the date she was last insured on March 31, 2008. Her

application was denied at the initial administrative level. The plaintiff then requested and

received a hearing before an Administrative Law Judge (“ALJ”). Following the hearing, the

ALJ also denied the claim. The Appeals Council rejected a subsequent request for review. 

The ALJ’s decision consequently became the final decision of the Commissioner of Social

Security (Commissioner). See Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The 1

case is now before the court for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). The

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

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

Security matters were transferred to the Commissioner of Social Security.

Case 3:13-cv-00600-CSC Document 18 Filed 10/02/14 Page 1 of 13
parties have consented to the United States Magistrate Judge conducting all proceedings in

this case and ordering the entry of final judgment, pursuant to 28 U.S.C. § 636(c)(1) and

M.D. Ala. LR 73.1. Based on the court’s review of the record in this case and the briefs of

the parties, the court concludes that the decision of the Commissioner should be affirmed.

 II. Standard of Review

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

person is unable to

engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result

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

of not less than 12 months . . . 

To make this determination, the Commissioner employs a five-step, sequential 2

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

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

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

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

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

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

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

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

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

disabled.”

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

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

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.

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

must find the Commissioner’s decision conclusive if it is supported by substantial evidence. 

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

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

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

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

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

. [its] judgment for that of the [Commissioner].” Phillips v. Barnhart, 357 F.3d 1232, 1240

n. 8 (11th Cir. 2004) (alteration in original) (quotation marks omitted).

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

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

presumption of validityattaches to the [Commissioner’s] . . . legal conclusions,

including determination of the proper standards to be applied in evaluating

claims.

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

III. The Issues

A. Introduction. Plaintiff Paula Dallas Presley (“Presley”) was completely

incapacitated on the date of administrative hearing due to suffering an aneurysm in January

2010. (R. 35). Her husband testified on her behalf. Following the hearing, the ALJ

concluded that Presley has medically determinable impairments of “hypertension; thyroid

problems; and obesity.” (R. 24). The ALJ also determined that her heart problems were not

severe. (Id.) The ALJ concluded that Presley was not disabled because “[t]hrough the date

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last insured, the claimant did not have an impairment or combination of impairments that

significantly limited the ability to perform basic work-related activities for 12 consecutive

months.” (Id.)

 B. Plaintiff’s Claims. As stated by the plaintiff, she presents two issues for the

Court’s review.

I. Whether the Administrative Law Judge failed to properly

consider plaintiff’s alleged heart problems as a medical

impairment. 

II. Whether the Administrative Law Judge failed to provide

sufficient good cause for according little weight to the medical

opinions of two treating physicians. 

(Doc. # 12, Pl’s Br. at 1-2, 6-7). 

IV. Discussion

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

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

the claimant has satisfied this burden, the Commissioner is guided by four factors: (1)

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

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

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

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

all relevant facts to elicit both favorable and unfavorable facts for review. Cowart v.

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

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

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

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

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

setting forth a discussion of the evidence, and stating the Commissioner’s

determination and the reason or reasons upon which it is based.

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

address the plaintiff’s claims. 

A. Heart Problems - Medical Impairment. The court quickly dispenses with

the plaintiff’s first issue. Presley argues that because the ALJ failed to delineate her heart

problems as a medically determinable impairment, the ALJ failed to properly “consider and

explain the findings relating to [her] heart problems and the severity of those problems.” 

(Doc. # 12 at 7). The ALJ denied Presley disability benefits because the ALJ concluded that

her impairments did not significantly interfere with her ability to perform work during the

closed period from May 18, 2007 until the last insured date of March 31, 2008. The ALJ

considered Presley’s heart problems but found that “the medical evidence of record, . . . 

indicates that these were mild and controlled by medication.” (R. 24). In reaching that

finding, the ALJ reviewed the plaintiff’s medical records for the closed period in question. 

It is clear that the ALJ considered Presley’s heart problems. Moreover, after carefully

reviewing the medical records, the court concludes that substantial evidence supports the

ALJ’s conclusion that Presley’s heart problems did not render her disabled during the closed

period. 

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Presleyapplied for disabilityincome benefits on February17, 2010, alleging disability

due to an aneurysm, heart problems, high blood pressure and thyroid problems. (R. 156). 

She alleged an onset date of May 18, 2007. (R. 175). On May 18, 2007, Presley presented

to her family doctor, Dr. Vester, complaining of being lightheaded and dizzy. (R. 192). 

According to Presley, these symptoms began three weeks earlier, and were getting worse. 

(Id.) Dr. Vester referred Presley to Dr. Reddy, a cardiologist. 

Dr. Reddy saw Presley on June 14, 2007. (R. 259-60). At that time, she complained

of palpitations, chest discomfort, frank syncope and issues with her blood pressure. (R. 259).

Over the past six months increasing rapid heart rate episodes according to her

causing some tightness in the chest and dyspnea on exertion. . . . She has been

having dizzy spells, heart racing lasting approximately 5 minutes with

tightness in the chest. No radiation. No nausea. Does admit to shortness of

breath with this.

(Id.)

Dr. Reddysuspected uncontrolled hypertension, prescribed medication and scheduled

cardiac studies. A nuclear perfusion study was within normal limits. (R. 191, 200, 258). A

carotid study was normal. (Id.) On August 9, 2007, Dr. Reddy noted that Presley’s

palpitations had improved with medication, and there was no evidence of ischemia. (R. 258).

On September 20, 2007, Presley returned to Dr. Reddy. At that time, she complained

of “occasional chest pain, heart rate beating fast and feeling lightheaded.” (R. 257). She had

no further episodes of fainting. (Id.) A stress test was equivocal; the “GXT portion was

abnormal, but the perfusion portion was normal.” (Id.)

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Presley underwent a heart catheterization which revealed “only mild coronary artery

disease, mild peripheral vascular disease, and no renovascular hypertension.” (R. 256, 186). 

Her thyroid function was also normal. (Id.) On October 23, 2007, Dr. Reddy opined that 

from a cardiac standpoint, she would be at low-risk for going back to work. 

She needs to lose weight. Low salt diet and she can return to work.

(Id.)

Presley did not see Dr. Reddy again until July 15, 2008, over three months after her

insured status expired. At that time, she “denies any of the symptoms, specifically denies

chest pain, shortness of breath, orthopnea, PND, palpitations, or syncope.” (R. 185, 254). 

Her EKG revealed a normal sinus rhythm and she had normal thyroid function. (Id.) 

In September 2008, Presley again reported to Dr. Reddy that she was not experiencing “any

significant chest pain, shortness of breath, palpitations or syncope.” (R. 182, 151). She was

“feeling better overall.” (Id.) 

To be eligible for disability insurance benefits, Presley must demonstrate that “she is

unable to engage in substantial gainful activity by reason of a medically determinable

impairment that can be expected to result in death or which has lasted or can be expected

to last for a continuous period of at least 12 months.” 42 U.S.C. § 423(d)(1)(A) (emphasis

added). See also Denomme v. Comm’r, Soc. Sec. Admin., 518 Fed. Appx. 875, 877 (11th Cir.

2013); Beegle v. Soc. Sec. Admin., Comm’r., 482 Fed. Appx. 483, 485 (11th Cir. 2012). The

medical records support the ALJ’s determination that Presley’s heart problems did not rise

to the level of an impairment because they did not last for a continuous period of at least

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twelve months, and they did not interfere with her ability to perform work. See Sanchez v.

Comm’r of Soc. Sec., 507 Fed. Appx. 855, 857 (11th Cir. 2013) (“An impairment or

combination of impairments is not severe if it does not significantly limit the claimant’s

physical or mental ability to do basic work activities.”). Dr. Reddy, Presley’s treating

cardiologist, specifically opined in October 2007, during the closed period at issue, that

Presley’s heart condition did not prevent her from working. See R. 256. 

Even if the ALJ erred, at this juncture, the error was harmless. See Diorio v. Heckler,

721 F.2d 726, 728 (11th Cir. 1983) (applying harmless error analysis in the Social Security

case context). See also Gray v. Comm’r of Soc. Sec., 550 Fed. Appx. 850, 853 (11th Cir.

2013) (same); Denomme, 518 Fed. Appx. at 877-878 (“When, however, an incorrect

application of the regulations results in harmless error because the correct application would

not contradict the ALJ’s ultimate findings, the ALJ’s decision will stand.”). In this case, the

ALJ considered that Presley had been treated for heart problems but concluded that her heart

problems did not significantly impede her ability to work. “While the ALJ could have been

more specific and explicit in his findings, he did consider all of the evidence and found that

it did not support the level of disability [Presley] claimed.” Freeman v. Barnhart, 220 Fed.

Appx. 957, 960 (11th Cir. 2007). Thus, to the extent that the ALJ erred by failing to

specifically identify Presley’s heart problems as an impairment that error was harmless. 

B. Treating Physicians. Presley argues that the ALJ failed to provide sufficient

reasons for failing to give great weight to the opinions of her treating physicians, Dr. Vester

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and Dr. Reddy. (Doc. # 12, Pl’s Br. at 7-8). The law in this circuit is well-settled that the

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

medical evidence of the claimant’s treating physician unless good cause exists for not doing

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

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

demonstrates a similar preference for the opinion of treating physicians.

Generally, we give more weight to opinions from your treating sources, since

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

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

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

objective medical findings alone or from reports of individual examinations,

such as consultive examinations or brief hospitalizations.

Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (citing 20 CFR § 404.1527 (d)(2)). 

The ALJ’s failure to give considerable weight to the treating physician’s opinion is reversible

error. Broughton, 776 F.2d at 961-62.

There are, however, limited circumstances when the ALJ can disregard a treating

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

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

supports a contrary finding. Good cause may also exist where a doctor’s opinions are merely

conclusory, inconsistent with the doctor’s medical records, or unsupported by objective

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

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

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

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

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

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

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

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

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

Bowen, 816 F.2d 578, 581 (11th Cir. 1987). 

In October 2011, over three years after the expiration of her insured status, Dr. Vester

and Dr. Reddy submitted letters in support of Presley’s claim for disability benefits. The 3

letters from the doctors are identical.

It is my opinion that from at least as early as 03/31/2008 and continuing

to the present, that Paula Presley would be expected to be unable to work at all

at least 3 or more days per month on average, at any level of exertion,

including work at a sedentary level of exertion, due to her multiple health

impairments, including, but not limited to, claudication fromverydiffuse small

vessel disease, fatigue, chest pain, tachychardia, palpitations, shortness of

breath, syncopal episodes, hypertension, headaches and dizziness. 

(R. 354, 357). 

After reviewing the medical evidence, the ALJ afforded the opinions of Dr. Vester

Dr. Reddy submitted two other statements in which he opined that “from at least as early as 3

03/31/2008 and continuing to present,” Presley would be unable to sustain regular work activity and she

would have to “lie down and/or elevate her feet and legs for a total of at least two hours” each day. (R. 356,

358). These restrictions are due to her “medical impairments including, but not limited to, claudication from

very diffuse small vessel disease,fatigue, chest pain, tachychardia, palpitations, shortness of breath, syncopal

episodes, hypertension, headaches and dizziness.” (Id.) 

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and Dr. Reddy “little weight” because

these opinions do not apply to the period from the alleged disability onset date

of May 18, 2007 to the date last insured of March 31, 2008. Both of these

opinions state that the claimant was unable to work “from at least as early as

03/31/2008 and continuing to present.” This does not provide information

concerning the claimant’s condition during the relevant period.

(R. 28). The ALJ, however, gave great weight to Dr. Reddy’s October 23, 2007 opinion that

“the claimant could return to work.” (R. 21). 

The ALJ acknowledged that Dr. Reddy and Dr. Vester treated Presley, but after a

thorough review of her treatment records, discounted the doctors’ assessments. (R. 26-28). 

The ALJ’s decision to discount these assessments is supported by substantial evidence. 

Neither Dr. Vester nor Dr. Reddy’s treatment records support their assessments of the

severity of Presley’s impairments during the insured period. 

First, because the doctors’ assessment of Presley are identical, it is clear that theywere

not written personally by each doctor. It is also clear that these opinions were not based on

a review of their treatment notes. For example, when Presley presented to Dr. Vester on May

18, 2007, complaining oflightheadedness and dizziness, Dr. Vester referred her to Dr. Reddy

for consultation and treatment. Thereafter, Dr. Vester’s records simply reflect Dr. Reddy’s

cardiac testing and treatment of Presley. After her initial consultation with Dr. Vester in May

2007, Presley did not complain to him of any problems until April 9, 2008, after the

expiration of her insured status. (R. 191, 200). There is nothing in Dr. Vester’s treatment

notes to indicate the level of disability he attributed to Presley.

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Furthermore, Dr. Reddy’s treatment notes do not support the level of disability he

attributes to Presley. Her cardiac tests were normal or within normal limits. (R. 241, 258,

186). On October 23, 2007, Dr. Reddy specifically opined that Presley could return to work. 

(R. 256). In July 2008, almost four months after the expiration of her insured status, Presley

denied that she was experiencing “chest pain, shortness of breath, orthopnea, PND,

palpitations, or syncope.” (R. 185, 254). On September 23, 2008, she reported “feeling

better overall,” and again denied “anysignificant chest pain, shortness of breath, palpitations,

or syncope.” (R. 182, 251).

The medical evidence in the record contradicts Dr. Reddy’s assessment of the severity

of Presley’s impairments. The ALJ may disregard the opinion of a physician, provided that

he states with particularity reasons therefor. Sharfarz v. Bowen, 825 F.2d 278, 280 (11th Cir.

1987). The ALJ examined and evaluated the treatment records for evidence supporting Dr.

Reddy and Dr. Vester’s assessments of Presley’s ability to work. Only then did the ALJ

discount the doctors’ assessments of Presley’s abilities. “Even though Social Security courts

are inquisitorial, not adversarial, in nature, claimants must establish that they are eligible for

benefits.” Ingram v. Comm’r of Soc. Sec., 496 F.3d 1253, 1269 (11th Cir. 2007) (citing

Doughty v. Apfel, 245 F.3d 1274, 1281 (11th Cir. 2001)). See also Holladay v. Bowen, 848

F.2d 1206, 1209 (11th Cir. 1988). This the plaintiff has failed to do. Based upon its review

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

the ALJ properly rejected Dr. Reddy and Dr. Vester’s opinions regarding Presley’s

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limitations during the closed period from the date of onset on May 18, 2007 until the date she

was last insured on March 31, 2008.

Pursuant to the substantial evidence standard, this court’s review is a limited one; the

entire record must be scrutinized to determine the reasonableness of the ALJ’s factual

findings. Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992). Given this standard of

review, the court finds that the ALJ’s decision was supported by substantial evidence. 

V. Conclusion

The court has carefullyand independently reviewed the record, and concludes that the

decision of the Commissioner is supported by substantial evidence. 

A separate order will be entered affirming the Commissioner’s decision.

Done this 2nd day of October, 2014. 

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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