Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-1_04-cv-00481/USCOURTS-almd-1_04-cv-00481-0/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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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.

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

SOUTHERN DIVISION

BERTHA D. RIVERS, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 1:04cv481-CSC

) (WO)

MICHAEL J. ASTRUE, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff applied for disability insurance benefits pursuant to Title II of the Social

Security Act, 42 U.S.C. §§ 401 et seq, and supplemental security income benefits under Title

XVI of the Social Security Act, 42 U.S.C. § 1381 et seq., alleging that she was unable to

work because of a disability. 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 on October 7, 2002. 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 1

Chester v. Bowen, 792 F.2d 129, 131 (11 Cir. 1986). The plaintiff appealed the th

Commissioner’s denial of this application to this Court. 

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 1 of 14
 In his favorable decision issued on October 28, 2004, the ALJ determined that Rivers was disabled 2

from August 2, 2002 through October 7, 2002, and that she has been disabled since October 8, 2002. (R. 33).

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

3

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

2

While the plaintiff’s first application was in the appellate process, the plaintiff filed

a second application. Following a hearing on the second application, the ALJ issued a

favorable decision on October 28, 2004 in which the ALJ determined that the plaintiff was

disabled. (R. 29). Thus, the period of disability at issue in this case is from the date of onset

on September 1, 1999 until August 1, 2002.2

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

1631(c)(3). Pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1, the parties have

consented to the United States Magistrate Judge conducting all proceedings in this case and

ordering the entry of final judgment. 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 3

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 2 of 14
diagnostic techniques.

 McDaniel v. Bowen, 800 F.2d 1026 (11 Cir. 1986), is a supplemental security income case (SSI). 4 th

The same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately

cited as authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5 Cir. 1981) (Unit A). th

3

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 (11 Cir. 1986). th 4

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); Graham v. Apfel, 129 F.3d 1420, 1422 (11 Cir. 1997). “Substantial th

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.” Richardson v.

Perales, 402 U.S. 389, 401 (1971). A reviewing court may not look only to those parts of

the record which support the decision of the ALJ but instead must view the record in its

entirety and take account of evidence which detracts from the evidence relied on by the ALJ.

Hillsman v. Bowen, 804 F.2d 1179 (11 Cir. 1986). th

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 3 of 14
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[The court must] . . . scrutinize the record in its entirety to determine the

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

presumption of validity attaches 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 (11 Cir. 1987). th

III. Procedural History

A. Introduction 

Rivers was 46 years old at the time of the last hearing before the ALJ. (R. 1157). She

has a high school equivalency diploma. (R. 1146, 1160). Rivers’s prior experience includes

work as a “child care worker, a presser in a dry cleaner, a laundry worker and a seamstress.”

(R. 32). 

Following a hearing, the ALJ concluded that Rivers has severe impairments of

“history of chronic lumbar strain, asymptomatic Human Immunodeficiency Virus (HIV)

infection and history of overactive bladder and mixed urinary incontinence.” (R. 31). The

ALJ concluded that Rivers was unable to perform her past relevant work. (R. 32). Relying

on the testimony of a vocational expert, the ALJ concluded that there were jobs existing in

significant numbers in the national economy that Rivers could perform, and thus, she was not

disabled. (R. 33).

B. Plaintiff’s Claims 

As stated by Rivers, she presents two issues for the Court’s review:

1. Whether the ALJ erred as a matter of law when he failed to

show good cause for discounting the opinion of a treating

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5

physician?

2. Whether the ALJ erred as matter of law when he failed to pose

a complete hypothetical to the vocational expert? 

(Pl’s Br., doc. # 16, pp. 1, 6 & 9).

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 (11 Cir. 1990). In determining whether th

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 (11 Cir. 1983). The court must scrutinize the record in its entirety to determine th

the reasonableness of the ALJ’s decision. See Walker, 826 F.2d at 999. 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 (11 Cir.

th

1981). The ALJ must also state, with sufficient specificity, the reasons for his decision

referencing the plaintiff’s impairments. Within this analytical framework, the court

addresses the plaintiff’s specific claims. 

A. Weight assigned to the opinion of a treating physician. The plaintiff complains

that the ALJ’s reasons for discounting the opinion of her treating physician, Dr. Jay

Beiswanger, are not supported by substantial evidence. (Pl’s Br. at 7). The ALJ did not

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 5 of 14
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accord much weight to the opinion of Dr. Beiswanger.

Little weight is given to the opinion of Jay C. Beiswanger, M.D., that the

claimant’s overactive bladder and mixed urinary incontinence would

necessitate frequent use of the bathroom and the need to stay in the bathroom

for extended periods of time. Dr. Beiswanger’s opinion was not supported by

his progress notes, which indicate that this condition had improved and that the

claimant was doing really well.

(R. 32).

Of course, the law in this circuit is well-settled that the ALJ must 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 (11 Cir. 1986); Broughton v. Heckler, 776 F.2d 960, 961 (11 Cir. 1985). th th

The Commissioner, as reflected in his 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 (11 Cir. 1997) (citing 20 CFR § 404.1527 (d)(2)). th

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

error. Broughton, 776 F.2d at 961-2; Wiggins v. Schweiker, 679 F.2d 1387 (11 Cir. 1982). th

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

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

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 6 of 14
 Although the ALJ did not recite all of Dr. Beiswanger’s medical records in his final opinion, he 5

adopted all the evidence he discussed in his earlier decision.

The medical evidence and testimony received at the claimant’s prior hearing were

completely and adequately summarized in the hearing decision dated October 7, 2002. Such

summarization of the medical and other evidence of record in that proceeding are adopted

and incorporated by reference as though fully set forth herein.”

(R. 31). 

7

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

supports a contrary finding. See Schnorr v. Bowen, 816 F.2d 578, 582 (11 Cir. 1987). Good th

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. Dept.

of Health & Human Servs., 941 F.2d 1529, 1532-33 (11 Cir. 1991); Edwards v. Sullivan,

th

937 F.2d 580, 584-85 (11 Cir. 1991); Johns v. Bowen, 821 F.2d 551, 555 (11 Cir. 1987). th th

The weight afforded to a physician’s conclusory 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 (11 Cir. 1986). th

The ALJ “may reject the opinion of any physician when the evidence supports a contrary

conclusion.” Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11 Cir. 1983). The ALJ must th

articulate the weight given to a treating physician’s opinion and must articulate any reasons

for discounting the opinion. Schnorr, 816 F.2d at 581. 

The plaintiff argues that the ALJ took a single comment by Dr. Beiswanger that

Rivers was “doing really well” “out of context,” and the statement is insufficient to discount

his opinion. (Pl’s Br. at 7-8). After reviewing all the medical records , the ALJ rejected Dr. 5

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 7 of 14
 Because Wilkins is a Physician’s Assistant, he is not considered a “treating physician,” or an 6

“acceptable medical source.” He would be considered an “other source.” See 20 C.F.R. § 416.913 (“In

addition to evidence from the acceptable medical sources listed in paragraph (a) of this section, we may also

use evidence from other sources . . . Other sources include, but are not limited to – (1) Medical sources not

listed in paragraph (a) of this section (for example, nurse-practitioners, physicians’ assistants, naturopaths,

chiropractors, audiologists, and therapists); . . .”

 Hematuria denotes the presence of blood in the urine.

7

 Pyuria denotes the presence of pus in the urine. 8

 Bacteriuria denotes the presence of bacteria in the urine. 9

 Nocturia denotes the need to frequent get up during the night to urinate. 10

8

Beiswanger’s opinion because “his opinion was not supported by his progress notes, which

indicate that this condition had improved and that the claimant was doing really well.” (R.

32). Dr. Beiswanger bases his opinion on treatment notes by Jay Wilkins, a certified

Physician’s Assistant, under his supervision and the supervision of other doctors in the

office. See 20 C.F.R. § 416.913(1). See also Social Security Ruling 06-03p. 6

Wilkins treated Rivers, under the supervision of Dr. Beiswanger and other doctors,

from June 9, 2000 until August 22, 2002. (R. 637-666, 954). Rivers first presented on June

9, 2000. (R. 648-49). At that time, she complained of “some intermittent gross hematuria7

over the past one month.” (Id.) (footnote added). She also complained of “urge

incontinence.” (Id.) Rivers was diagnosed with Hematuria, Pyuria, Bacteriuria, Mixed 8 9

Urinary Incontinence with stress and urge incontinence, and Nocturia. After a cystoscopic 10

examination on July 10, 2000, Rivers was prescribed antibiotics. (R. 648). Wilkins also

noted that Rivers “does have some incontinence, but at this time [she] is not interested in

therapy. . . .She may benefit from Prosed or some other type of antispasmodic.” (Id.) 

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 8 of 14
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Rivers returned to Dr. Beiswanger’s office on August 14, 2000. At that time, Wilkins

noted that she was

doing really well. She states the Prosed helped her symptoms quite a bit. She

does admit to going to the bathroom every hour during the day, has quite a

significant amount of urgency. It seems that her urge incontinence is worse

with better stress incontinence, but both are minimal at this point. She is

getting up four or five times a night as well. Since she did benefit from

Prosed, I think Detrol is in order. . . .

(R. 646) (emphasis added). Rivers was prescribed Detrol. (Id.) Rivers did not keep her

follow-up appointment on November 14, 2000. (Id.)

On December 28, 2000, Rivers complained that she continued to have “some mixed

urinary incontinence,” but she did not have “any interval problems.” (R. 646). She also

admitted that she had not taken the medication Destrol as prescribed. (Id.) 

She next saw Wilkins on April 23, 2001. At that time, she reported that she had been

taking Ditropan with “excellent results.” (R. 643-44). She was continued on Ditropan, three

times a day. (Id.). On August 9, 2001, Rivers was diagnosed with minor bacteriuria and

prescribed antibiotics. (R. 643). On August 20, 2001, Rivers complained of increased

urgency. It was suggested to Rivers that she practice timed voiding but she declined to

follow that suggestion. Her prescription for Ditropan was refilled. (R. 642).

On October 23, 2001, treatment notes indicate that Rivers had “frequent urination,

[but] was doing well on Ditropan.” (R. 641). A CT urogram on October 30, 2001 was

normal. (R. 638-39). On November 2, 2001, Rivers was diagnosed with Bacteriuria and

Urgency. (R. 638). Wilkins opined that Rivers’ back pain was musculoskeletal and

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 9 of 14
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unrelated to her bladder condition. (Id.) Because Rivers was also complaining of urgency,

her medication was changed from Ditropan to Ditropan XL and the dosage was increased.

(Id.) She was also prescribed antibiotics for the bacterial infection. (Id.) 

Rivers returned to Dr. Beiswanger’s office on December 23, 2001. At that time, she

was “doing well. The Ditropan XL is working great.” (R. 637). Wilkins did not anticipate

seeing Rivers again for a year. (Id.) 

Wilkins next saw Rivers on June 3, 2002. At that time, she complained of dysuria and

frequent urination during the night. However, she “has urgency and sensation of incomplete

emptying only with the onset of these symptoms.” (R. 955) (emphasis added). She was

diagnosed with Bacteriuria and Yeast Vaginitis and prescribed antibiotics for the infections

as well as Prosed DS for inflammation of the urinary tract. (Id.). On June 12, 2002, her

prescription for Ditropan XL was refilled. (Id.). 

Also on June 12, 2002, Dr. Beiswanger wrote a letter describing Rivers’ medical

condition.

Ms. Rivers suffers with overactive bladder and mixed urinary incontinence.

This does necessitate frequent use of the bathroom and medical therapy to

decrease the frequency of her symptoms. Urgency is a large component of

this, and she may feel the need to stay in the bathroom until the bladder spasms

subside.

(R. 666).

Dr. Beiswanger knew that the letter was to support Rivers’s claim for disability

benefits. (Id.) He did not opine that Rivers was disabled or even that she was unable to

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 10 of 14
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work. (Id.). After increasing Rivers’ medication in November 2001, Rivers did not present

to Dr. Beiswanger’s office again until she complained of an infection. When Wilkins saw

Rivers on June 3, 2002, she was treated for an urinary tract infection and it was noted that

her urgency symptoms began with the onset of the infection. (R.955). Thus, Rivers’ own

treatment records are inconsistent with and do not support Dr. Beiswanger’s opinion that her

condition causes“frequent use of the bathroom and the need to stay in the bathroom for

extended periods of time.” (R. 32).

Moreover, other medical records as a whole are inconsistent with and do not support

Beiswanger’s opinion that Rivers’s overactive bladder and incontinence cause functional

limitations. During the time period that Wilkins was treating Rivers, she was also treated by

Dr. William Bone. On September 7, 2000, Rivers denied any “dysuria, frequency, or

urgency.” (R. 597). On September 25, 2001, Rivers “[d]enies any urinary tract problems.”

(R. 608). On October 30, 2001, Dr. Bone reported that Rivers “denies any genito-urinary

complaints such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence,

etc.” (R. 570, 904). She denied such problems on December 24, 2001, January 31, 2002,

and February 28, 2002. (R. 609-10, 611, 613, 615).

On April 29, 2002, Rivers complained to Dr. Bone of urinary incontinence “for the

past several weeks.” (R. 655, 889). On June 4, 2002, Rivers informed Dr. Bone that Dr.

Beiswanger had treated her for a urinary tract infection. (R. 887). On August 5, 2002,

Rivers again denied “any genito-urinary complaints such as hematuria, dysuria, frequency,

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 11 of 14
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urgency, hesitancy, nocturia, incontinence, etc.” (R. 884).

During the first administrative hearing on January 26, 2005, Rivers was asked why

she could not work. While she initially responded “[m]y back, my feet, and my bladder,” she

later indicated she could not work due to the pain in her back and legs. (R. 1135). During

the second hearing on June 10, 2005, Rivers stated that she could not work due to her back.

(R. 1146, 1149). Finally, during the third administrative hearing, the ALJ and Rivers

engaged in the following colloquy. 

Q: . . . Okay, well tell us about your disability, ma’am. What are the

problems that you have that keep you from being able to work?

A: Pain.

Q: Okay, pain.

A: Severe pain.

Q: And where is it located?

A: My back, down my legs, feet, hands.

Q: Okay.

A: The back and the legs are the worst.

Q: Okay, so pain is a key part of the whole picture?

A: Yes.

Q: Okay.

A: And having to go to the bathroom. I have to go to the bathroom quite

frequently.

(R. 1163).

Based upon its review of the ALJ’s decision and the objective medical evidence of

record, the court concludes that the ALJ’s rejection of Dr. Beiswanger’s opinion that

plaintiff’s condition causes “frequent use of the bathroom and the need to stay in the

bathroom for extended periods of time” is supported by good cause and substantial evidence.

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 12 of 14
13

B. Hypothetical questions posed to the vocational expert. The plaintiff also

argues that the ALJ should have included functional restrictions related to her overactive

bladder and incontinence in the hypothetical questions posed to the vocational expert, and

his failure to do so constitutes error. (Pl’s Be. at 9-10). Specifically, Rivers argues that the

ALJ should have accepted Dr. Beiswanger’s opinion that Rivers would require frequent

bathroom breaks and extended periods of time in the bathroom, and thus, should have

incorporated these restrictions in his hypothetical questions to the vocational expert. The

court disagrees. For the reasons already stated, the ALJ had good cause to and properly

discounted Dr. Beiswanger’s opinion in this regard. 

Next, the plaintiff argues that “when asked to consider functional limitations related

to Ms. Rivers’s urinary problems, the VE testified that such functional limitations would

preclude employment (R. 1155).” (Pl’s Br. at 10). Rivers relies on the following question

posed to the vocational expert at the second administrative hearing to support her position.

Q: Sir, if you add to his hypothetical number one and number two the

necessity for unscheduled breaks every hour. She was having physical

problems causing urination that, and that was never resolved, and it was

requiring breaks, would require breaks every hour. Would that

preclude the jobs that you had listed?

A: Yes, I would expert that it would prevent the individual from sustaining

those jobs.

(R. 1154) (emphasis added). The problem with the plaintiff’s argument is the hypothetical

assumes a critical fact not supported by the medical evidence. Rivers suggests in the

hypothetical that her overactive bladder and incontinence conditions were never resolved;

Case 1:04-cv-00481-CSC Document 23 Filed 03/04/10 Page 13 of 14
14

however, the medical record does notsupport this suggestion. Treatment notes from Wilkins

and Dr. Bone demonstrate that Rivers’s urinary conditions were successfully treated with

medication. When she experienced frequency and urgency, these symptoms were caused by

urinary tract infections that were subsequently successfully treated with antibiotics. Thus,

the ALJ did not err by failing to include in his hypothetical questions limitations which have

not been established by the record. Thus, the court finds that the ALJ did not commit error

in his questioning of the vocational expert. This court must accept the factual findings of the

Commissioner if they are supported by substantial evidence and based upon the proper legal

standards. Bridges v. Bowen, 815 F.2d 622 (11 Cir. 1987). th

V. Conclusion

The court has carefully and independently reviewed the record and concludes that

substantial evidence supports the ALJ’s conclusion that plaintiff is not disabled. Thus, the

court concludes that the decision of the Commissioner is supported by substantial evidence

and is due to be affirmed.

A separate order will be entered.

Done this 4 day of March, 2010. th

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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