Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_15-cv-00349/USCOURTS-almd-3_15-cv-00349-0/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

RHONDA RENFROE )

)

Plaintiff, )

)

v. ) CASE NO. 3:15-cv-349-TFM

) [wo]

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

Following administrative denial of her application for disability insurance benefits under 

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, Rhonda Renfroe (“Renfroe” or “Plaintiff”) 

received a requested hearing before an administrative law judge (“ALJ”) who rendered an 

unfavorable decision. When the Appeals Council rejected review, the ALJ’s decision became 

the final decision of the Commissioner of Social Security (“Commissioner”). See Chester v. 

Bowen, 792 F.2d 129, 131 (11th Cir. 1986). Judicial review proceeds pursuant to 42 U.S.C. § 

405(g), 42 U.S.C. § 1383(c)(3), and 28 U.S.C. § 636(c), and for reasons herein explained, the 

Court AFFIRMS the Commissioner’s decision denying disability insurance benefits and 

supplemental security income benefits.

I. NATURE OF THE CASE

Renfroe seeks judicial review of the Commissioner of Social Security Administration 

decision to deny her application for disability insurance benefits. United States District Courts 

may conduct limited review of such decisions to determine whether they comply with applicable 

law and are supported by substantial evidence. 42 U.S.C. § 405 (2006). The court may affirm, 

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reverse and remand with instructions, or reverse and render a judgment. Id.

II. STANDARD OF REVIEW

Judicial review of the Commissioner’s decision to deny benefits is narrowly 

circumscribed. The court reviews a social security case solely to determine whether the 

Commissioner’s decision is supported by substantial evidence and based upon proper legal 

standards. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011). The court 

“may not decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of the 

Commissioner,” but rather “must defer to the Commissioner’s decision if it is supported by 

substantial evidence.” Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1997) (quoting 

Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)); see also Winschel, 631 F.3d at 

1178 (stating the court should not re-weigh the evidence). This court must find the 

Commissioner’s decision conclusive “if it is supported by substantial evidence and the correct 

legal standards were applied.” Kelley v. Apfel, 185 F.3d 1211, 1213 (11th Cir. 1999); see also 

Kosloff v. Comm’r of Soc. Sec., 581 Fed. Appx. 811, 811 (11th Cir. 2015) (citing Kelley).

Substantial evidence is more than a scintilla — i.e., the evidence must do more than 

merely create a suspicion of the existence of a fact, and must include such relevant evidence as a 

reasonable person would accept as adequate to support the conclusion. Winschel, 631 F.3d at 

1178 (quoting Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004)); Lewis v. 

Callahan, 125 F.3d 1436, 1440 (citing Richardson v. Perales, 402 U.S. 389, 401, 91 S. Ct. 1420, 

1427, 28 L.Ed.2d 842 (1971)). If the Commissioner’s decision is supported by substantial 

evidence, the district court will affirm, even if the court would have reached a contrary result as 

finder of fact, and even if the court finds that the evidence preponderates against the 

Commissioner’s decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); see also 

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Henry v. Comm’r of Soc. Sec., 802 F.3d 1264, 1267 (11th Cir. 2015) (“even if the evidence 

preponderates against the Commissioner’s findings, we must affirm if the decision reached is 

supported by substantial evidence.”) (citation omitted). The district court must view the record 

as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote 

v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Chester v. Bowen, 792 F.2d 129, 131 

(11th Cir. 1986)). 

The district court will reverse a Commissioner’s decision on plenary review if the 

decision applies incorrect law, or if the decision fails to provide the district court with sufficient 

reasoning to determine that the Commissioner properly applied the law. Keeton v. Department 

of Health and Human Services, 21 F.3d 1064, 1066 (11th Cir. 1994) (internal citations omitted). 

There is no presumption that the Secretary’s conclusions of law are valid. Id.; Brown v. Sullivan, 

921 F.2d 1233, 1236 (11th Cir. 1991).

III. STATUTORY AND REGULATORY FRAMEWORK

The Social Security Act’s general disability insurance benefits program (“DIB”) provides 

income to individuals who are forced into involuntary, premature retirement, provided they are 

both insured and disabled, regardless of indigence.1 See 42 U.S.C. § 423(a). The Social Security 

Act’s Supplemental Security Income (“SSI”) is a separate and distinct program. SSI is a general 

public assistance measure providing an additional resource to the aged, blind, and disabled to 

assure that their income does not fall below the poverty line.2 Eligibility for SSI is based upon 

proof of indigence and disability. See 42 U.S.C. §§ 1382(a), 1382c(a)(3). However, despite the 

 1 DIB is authorized by Title II of the Social Security Act, and is funded by Social Security taxes. 

See Social Security Administration, Social Security Handbook, § 136.1, available at

http://www.ssa.gov/OP_Home/handbook/handbook.html

2 SSI benefits are authorized by Title XVI of the Social Security Act and are funded by general tax 

revenues. See Social Security Administration, Social Security Handbook, §§ 136.2, 2100, available at

http://www.ssa.gov/OP_Home/handbook/handbook.html

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fact they are separate programs, the law and regulations governing a claim for DIB and a claim 

for SSI are identical; therefore, claims for DIB and SSI are treated identically for the purpose of 

determining whether a claimant is disabled. Patterson v. Bowen, 799 F.2d 1455, 1456 n. 1 (11th 

Cir. 1986). Applicants under DIB and SSI must provide “disability” within the meaning of the 

Social Security Act which defines disability in virtually identical language for both programs. 

See 42 U.S.C. §§ 423(d), 1382c(a)(3), 1382c(a)(3)(G); 20 C.F.R. §§ 404.1505(a), 416.905(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.

42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). A “physical or mental impairment” is one resulting 

from anatomical, physiological, or psychological abnormalities which are demonstrable by 

medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C. §§ 423(d)(3), 

1382c(a)(3)(D).

The Commissioner utilizes a five-step, burden-shifting analysis to determine when 

claimants are disabled. 20 C.F.R. §§ 404.1520; Phillips v. Barnhart, 357 F.3d 1232, 1237 (11th 

Cir. 2004); O’Neal v. Comm’r of Soc. Sec., 614 Fed. Appx. 456, 2015 U.S. App. LEXIS 9640, 

2015 WL 3605682 (11th Cir. June 10, 2015). The ALJ determines:

(1) Whether the claimant is currently engaged in substantial gainful activity;

(2) Whether the claimant has a severe impairment or combination of impairments;

(3) Whether the impairment meets or exceeds one of the impairments in the listings;3

(4) Whether the claimant can perform past relevant work; and

(5) Whether the claimant can perform other work in the national economy.

 3 See 20 C.F.R. Pt. 404, Subpt. P, App. 1

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Winschel, 631 F.3d at 1178; Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). When a 

claimant is found disabled – or not – at an early step, the remaining steps are not considered. 

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). This procedure is a fair and just way 

for determining disability applications in conformity with the Social Security Act. See Bowen v. 

Yuckert, 482 U.S. 137, 153, 107 S. Ct. 2287, 2297, 96 L.Ed.2d 119 (1987) (citing Heckler v. 

Campbell, 461 U.S. 458, 461, 103 S. Ct. 1952, 1954, 76 L.Ed.2d 66 (1983)) (The use of the 

sequential evaluation process “contribute[s] to the uniformity and efficiency of disability 

determinations”). 

The burden of proof rests on the claimant through Step 4. See Ostborg v. Comm’r of Soc. 

Sec., 610 Fed. Appx. 907, 915 (11th Cir. 2015); Phillips, 357 F.3d at 1237-39. A prima facie

case of qualifying disability exists when a claimant carries the Step 1 through Step 4 burden. 

Only at the fifth step does the burden shift to the Commissioner, who must then show there are a 

significant number of jobs in the national economy the claimant can perform. Id. 

To perform the fourth and fifth steps, the ALJ must determine the claimant’s Residual 

Functioning Capacity (“RFC”). 20 C.F.R. § 404.1520(a)(4). RFC is what the claimant is still 

able to do despite the impairments, is based on all relevant medical and other evidence, and can 

contain both exertional and nonexertional limitations. Phillips, 357 F.3d at 1242-43. At the fifth 

step, the ALJ considers the claimant’s RFC, age, education, and work experience to determine if 

there are jobs available in the national economy the claimant can perform. Id. at 1239. In order 

to do this, the ALJ can either use the Medical Vocational Guidelines4 (“grids”) or call a 

vocational expert. Id. at 1239-40.

The grids allow the ALJ to consider factors such as age, confinement to sedentary or light 

work, inability to speak English, educational deficiencies, and lack of job experience. Each of 

 4 See 20 C.F.R. pt. 404 subpt. P, app. 2

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these factors can independently limit the number of jobs realistically available to an individual. 

Id. at 1240. Combinations of these factors yield a statutorily-required finding of “Disabled” or 

“Not Disabled.” Id. Otherwise, the ALJ may use a vocational expert. Id. A vocational expert is 

an expert on the kinds of jobs an individual can perform based on her capacity and impairments. 

Id. In order for a vocational expert’s testimony to constitute substantial evidence, the ALJ must 

pose a hypothetical question which comprises all of the claimant’s impairments. Jones v. Apfel, 

190 F.3d 1224, 1229 (11th Cir. 1999) (citing McSwain v. Bowen, 814 F.2d 617, 619-20 (11th 

Cir. 1987)).

IV. BACKGROUND AND PROCEEDINGS

Renfroe claims disability as a result of ischemic heart disease and Affective/Mood 

disorders (R. 58,116,117). Following initial administrative denial of her claim, Renfroe sought a 

hearing before an administrative law judge (“ALJ”) (R. 58, 119-129, 133-136). On January 9, 

2014, ALJ Elizabeth De Gruy (“the ALJ”) convened an evidentiary hearing by video 

teleconference between the ALJ in Jackson, Mississippi and Renfroe and her non-attorney 

representative in Montgomery, Alabama (R. 73-91). The ALJ received direct testimony from 

Renfroe, and a vocational expert. The remaining evidentiary record consisted of medical reports 

from treating and consultative sources and residual functional capacity assessments completed 

by a single decision maker (“SDM”) and medical consultant who reviewed Renfroe’s medical 

records upon request of Alabama Disability Determination Services.

5 The ALJ rendered an 

 5 R 92-115. Robert Estock, M.D. “A medical consultant is a person who is a member of a team that 

makes disability determinations in a State agency, as explained in § 404.1615, or who is a member of a 

team that makes disability determinations for us when we make disability determinations ourselves.” 20 

C.F.R. § 404.1616(a). 

Anitra Hudson, SDM “In the single decisionmaker model, the decisionmaker will make the disability 

determination and may also determine whether the other conditions for entitlement to benefits based on 

disability are met. The decisionmaker will make the disability determination after any appropriate 

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unfavorable decision on February 18, 2014. (R. 55-66). On March 27, 2015, the Appeals 

Council denied Renfroe’s request for review (R. 47-51). Renfroe filed her Social Security 

Appeal on May 21, 2015. See Doc. 1, Complaint.

V. ADMINISTRATIVE DECISION

Employing the five step process, the ALJ found that Renfroe has not engaged in 

substantial gainful activity since the alleged onset date (Step 1); has severe impairments (Step 

2)6; the impairments, considered individually and in combination, do not meet or equal in 

severity any impairment set forth in the listings (Step 3); and Renfroe can perform light work 

(Step 4). (R. 62-66). Renfroe thus had not met her prima facie case for disability and the burden 

rested upon Renfroe to prove she was unable to perform the suggested jobs.

At Step Four, the ALJ found Renfroe had the RFC to perform a reduced range of light 

work as light work would not require Renfroe to perform work related activities precluded by her 

residual functional capacity. (R. 62-66). Consequently, the ALJ found Renfroe has not been 

disabled since the alleged onset date. (R. 25).

VI. ISSUES

Renfroe raises two issues on appeal:

(1) The ALJ erred when relying on the opinion of a Single Decision Maker 

(SDM). Substantial evidence does not support the administrative law 

 

consultation with a medical or psychological consultant. The medical or psychological consultant will not 

be required to sign the disability determination forms we use to have the State agency certify the 

determination of disability to us (see § 404.1615). However, before an initial determination is made that a 

claimant is not disabled in any case where there is evidence which indicates the existence of a mental 

impairment, the decisionmaker will make every reasonable effort to ensure that a qualified psychiatrist or 

psychologist has completed the medical portion of the case review and any applicable residual functional 

capacity assessment pursuant to our existing procedures (see § 404.1617). In some instances, the 

decisionmaker may be the disability claim manager described in paragraph (b)(1) of this section. When 

the decisionmaker is a State agency employee, a team of individuals that includes a Federal employee will 

determine whether the other conditions for entitlement to benefits are met.” 20 C.F.R. § 404.906(b)(2) 

6 The ALJ found the following “severe” impairments: coronary artery disease, status post coronary 

bypass surgery; depression; diabetes mellitus, and diabetic neuropathy. (Tr. 60).

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judge’s (ALJ’s) decision because the ALJ gave significant weight to the 

SDM’s opinion when deciding Rhonda Renfroe’s (hereafter referred to as 

Ms. Renfroe), residual functional capacity (RFC) assessment.

(2) Substantial evidence does not support the ALJ’s residual functional 

capacity (RFC) assessment because it is inconsistent with the ALJ’s 

findings. At step two of the sequential evaluation the ALJ found a 

“severe” mental impairment, i.e., depression. But the ALJ did not express 

a single mental functional limitation in the RFC assessment, despite 

finding a “severe” mental impairment.

Pl. Br. at p. 1. 

The Commissioner re-words the issue as follows:

(1) Whether the Administrative Law Judge committed reversible error in 

relying on the statement of a Single Decision Maker where substantial 

evidence otherwise supports the Administrative Law Judge’s residual 

functional capacity finding.

(2) Whether the Administrative Law Judge committed reversible error by not 

including mental limitations in her residual functional capacity finding 

where the hypothetical question to the vocational expert included mental 

limitations.

Def. Br. at p. 1. Regardless of the wording, the Commissioner does address the issues raised by 

Plaintiff in her brief. 

VII. DISCUSSION AND ANALYSIS

A. Substantial evidence supports the RFC findings aside from the SDM opinion.

In a nutshell, Renfroe argues that the ALJ improperly relied upon the opinion of the SDM 

Anitra Hudson who is not a physician or one who may offer a medical opinion. Renfroe also

cites internal Social Security Policy that SDM opinions are not entitled to any evidentiary weight

as medical opinions. See POMS DI 24510.05; Letter from Frank Cristaudo, Chief 

Administrative Law Judge re: Evaluation of Single Decisonmaker Residual Functional Capacity 

Assessments Reminder May 19, 2010. While the parties and the Court agree that Hudson is not 

a physician or medical provider who could provide a medical opinion, much less a medical 

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opinion that could be relied upon, the parties apparently fail to notice that Robert Estock, M.D. 

did electronically sign the August 30, 2012 RFC assessment. (R. 97, 110). The signature of Dr. 

Estock appears after specific reference to a number of medical and mental health records 

generated by Renfroe’s treating physicians and healthcare providers. From the RFC assessment 

signed by Dr. Estock the Court concludes that Dr. Estock concurred with the opinion of Ms. 

Hudson as the SDM. Setting aside the fact that Dr. Estock concurred with the opinion of Ms. 

Hudson, the Court finds the remaining evidence before and considered by the ALJ was sufficient 

to support the ALJ’s RFC finding.

 A claimant’s RFC is an administrative finding as to the most the claimant can do despite 

their limitations. 20 C.F.R. §§ 404.1527(d), 404.1545(a), 416.927(d), 416.945(a) (2015); SSR 

96-8p, 1996 WL374184 (S.S.A.). The ALJ has the duty to determine the RFC of the claimant 20 

C.F.R. § § 404.1527A(d)(2), 404.1546(c), 416.927(d)(2), 416.946(c). The ALJ may find the RFC 

from all the relevant medical evidence and other evidence in the case record, not just medical 

opinions. 20 C.F.R §§ 404.1545(a)(3), 416.945(a)(3); Beegle v. Soc. Sec. Admin., Comm’r, 482 

Fed. App’x 483, 486 (11th Cir. 2012) 

Aside from the opinion of the SDM, the ALJ cites and considered substantial evidence to 

support her RFC finding. The ALJ had and considered the medical records related to Renfroe’s 

heart attack and medical records subsequent to the infarction plus mental health records. (R-60-

64). While Renfroe’s coronary health is not optimal, the medical records the ALJ considered 

indicate Renfroe had many normal health findings such as no pleural effusions, no heart 

enlargement, no palpitations, no tachycardia, and no syncope or presyncope. A medical 

examination by Mercy Medical Center, in the normal course of treatment post infarction revealed 

Renfroe is a well-developed and well-nourished person who ambulates normally with a normal 

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gait and station. Her lung and cardiovascular examination findings were within normal limits. 

Renfroe had normal motor strength and tone plus she had no cyanosis, edema, or varicosities. In 

addition, Renfroe is described as enjoying an active lifestyle. Medical records also indicate

Renfroe was noncompliant with her medical regimen to minimize the risk of heart problems. 

Renfroe is diabetic and hypertensive which her medical providers treat by medication. Renfroe 

claims she is unable to afford medication yet her records indicate Renfroe smokes two packs of 

cigarettes a day. 

The Court finds that while the ALJ gave significant weight to the state agency’s medical 

consultant, she did so only because the opinion was consistent with the other evidence in the 

record. (emphasis supplied.) (R. 64) The ALJ went to great lengths to discuss the other evidence 

in the record and clearly performed her role to determine the RFC. Nothing persuasive is before 

the Court which indicates that the ALJ relinquished her duty to the SDM or Dr. Estock to 

determine the RFC. In fact, the ALJ made one reference to the SDM/medical consultant which

was merely to state the opinion was consistent with the record which includes voluminous, 

longitudinal medical evidence from treating physicians and health care providers. The analysis 

which precedes the one-line reference to the opinion is more than adequate to demonstrate the 

ALJ made her own RFC finding from adequate evidence. 

Alternatively, to the extent any error was made, the error was harmless. Harmless error 

occurs when the correct application of appropriate regulation would not contradict the ALJ’s 

ultimate findings. Caldwell v. Barnhart, 261 Fed. Appx. 188, 190 (11th Cir. 2008) (citing 

Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983)). It is not the province of this court to 

reweigh the evidence especially as the record relied on by the ALJ is replete with sufficient 

information from sources other than the SDM for the ALJ to determine the RFC.

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B. The mental RFC was properly determined by the ALJ.

Plaintiff argues the RFC vis a vis mental impairment is defective because the ALJ did not 

include mental limitations in her RFC assessment. The Commissioner concedes, as well she 

should, that the RFC does not expressly state Renfroe would be limited to simple one to two step 

tasks. With respect to Renfroe’s mental health the ALJ noted

Psychiatrically, the claimant had good judgment. Mental status revealed a normal 

mood and affect. The claimant was active and alert. She was oriented to time, 

place and person. The claimant reported having no depression (Exhibit 9-F). The 

undersigned notes that the claimant has some depression; however, her depression 

appears to coincide with environmental circumstances in her life. In 2008 it was a 

divorce. She was not seen after 2008 until she returned to mental health in 2012. 

She is on medication and it has helped. The undersigned notes there was also 

some question of malingering (Exhibit 12-F). The claimant did not want to 

increase med dosage in October 2013 as she was doing okay. The claimant was 

smiling and alert. Everything was within normal limits except mood was 

depressed (Exhibit 14-F). It is noted that the undersigned has given moderate 

limitations in depression due to side effects from medications. The claimant 

testified that they make her drowsy so she cannot perform work activity that 

requires more than simple one to two step tasks. While the undersigned has 

limited the claimant due to drowsiness from medication, it is notable with regard 

that she has complained to her therapist that she has difficulty going to sleep 

rather than complaints of drowsiness. 

(R. 64). While the RFC does not expressly limit Renfroe to simple one to two step tasks, the 

ALJ asked the Vocational Examiner (VE) a hypothetical limiting Renfroe to jobs which entail 

simple one to two step tasks. (R. 89). In response to the hypothetical containing all of the 

limitations of Renfroe, the VE opined there were a number of jobs Renfroe could perform. (R. 

89). In circumstances such as this, it is unnecessary to remand as the administrative result would

not change and thus, the error harmless. 

Based on the above, the Court finds no reason to remand or reverse on this point as the 

ALJ already limited Renfroe to simple one or two step occupations. 

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VIII. CONCLUSION

Pursuant to the findings and conclusions detailed in this Memorandum Opinion, the Court 

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

DONE this 4th day of August, 2016.

/s/ Terry F. Moorer

TERRY F. MOORER

UNITED STATES MAGISTRATE JUDGE

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