Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-6_14-cv-01403/USCOURTS-alnd-6_14-cv-01403-0/pdf.json

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

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

JASPER DIVISION

TERESA GRIER,

Plaintiff,

v.

CAROLYN W. COLVIN, ACTING

COMMISSIONER, SOCIAL

SECURITY ADMINISTRATION,

Defendant.

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Case No.: 6:14-CV-1403-VEH

 

MEMORANDUM OPINION

Plaintiff Teresa A. Grier (“Ms. Grier”) bringsthis action pursuant to 42 U.S.C.

§ 405(g) of the Social Security Act. She seeks review of a final adverse decision of

the Commissioner of the Social Security Administration, which denied her

application for Supplemental Security Income (“SSI”) benefits.

1 Ms. Grier timely

pursued and exhausted her administrative remedies available before the

Commissioner. The case is ripe for review pursuant to 42 U.S.C. § 405(g), § 205(g)

of the Social Security Act.

1

42 U.S.C. § 1383(c)(3) renders the judicial review provisions of 42 U.S.C. § 405(g) fully

applicable to claims for SSI.

FILED

 2015 Jul-31 PM 02:45

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 1 of 39
FACTUAL AND PROCEDURAL HISTORY

Ms. Grier was 45 years old at the time of her hearing before the Administrative

Law Judge (“ALJ”). (Tr. 161). Ms. Grier testified that she had a ninth (9th) grade

special education. (Tr. 32). Her past relevant work experience includes employment

as a painter. (Tr. 21). Ms. Grier stated she stopped working on December 31, 2002,

and claims she became disabled on that date.2(Tr. 140, 166).

On May 24, 2011, Ms. Grier protectively filed a Title XVI application for SSI.3

(Tr. 55). On October 5, 2011, the Commissioner initially denied this claim. (Tr. 74).

Ms. Grier timely filed a written request for a hearing on October 24, 2011. (Tr. 80).

On February 1, 2012, a fully favorable decision of Ms. Grier’s application was

reached by an attorney advisor.4

 (Tr. 56). On March 29, 2012, the Appeals Council

2On Ms. Grier’s disability report she listed several conditions that affected her ability to work

including:fibromyalgia, bipolar, diabetes, fattyliver disease, asthma, arthritis, tendonitis, ADD, high

blood pressure, anxiety, depression, acid reflux, restless leg syndrome, muscle deterioriation, muscle

spasms, learning disability. (Tr. 166). The court notes that DisabilityDetermination Service (“DDS”) 

identified organic mental disorders as Ms. Grier’s primary diagnosis, and disorders of back

(discogenic and degenerative) as her secondary diagnosis. (Tr. 55).

3The court notes that nearly every document states the application date as being May 24,

2011; however, the exhibit labeled “Application for Supplemental Security Income Benefits” states

that Ms. Grier applied on June 1, 2011. (Tr. 140).

4The prehearing proceeding was conducted pursuant to 20 C.F.R. § 416.1442(a):

After a hearing is requested but before it is held, an attorney advisor

may conduct prehearing proceedings as set out in paragraph (c) of this

section. If after the completion of these proceedings [the

commissioner] can make a decision that is fully favorable to [the

claimant] and all other parties based on the preponderance of the

2

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 2 of 39
sent notice to Ms. Grier of itsintention to review the decision reached by the attorney

advisor based on its own motion pursuant to 20 C.F.R. § 416.1469. (Tr. 96). On

October 17, 2012, the Appeals Council informed Ms. Grier that the previously

favorable decision had been vacated and her case had been remanded to an ALJ for

further proceedings. (Tr. 67). The ALJ conducted a hearing on the matter on July 7,

2013. (Tr. 30). On October 21, 2013, the ALJ issued his opinion concluding Ms.

Grier was not disabled and denied benefits. (Tr. 22). On May 20, 2014, the Appeals

Council issued a denial of review on her claim. (Tr. 1).

Ms. Grier filed a complaint with this court on July 22, 2014, seeking review of

the Commissioner’s determination. (Doc. 1). The Commissioner answered on

November 13, 2014. (Doc. 8). Ms. Grier filed a supporting brief (Doc. 12) on January

26, 2015, and the Commissioner responded with its own (Doc. 13) on February 27,

2015. With the parties having fully briefed the matter, the court has carefully

considered the record and, for the reasons stated below, reverses and remands the

decision of the ALJ.

5

evidence, an attorney advisor, instead of an administrative law judge,

may issue the decision.

5

In general, the legal standards applied are the same regardless of whether a claimant seeks

SSI or Disability Insurance Benefits (“DIB”). However, separate, parallel statutes and regulations

exist for SSI and DIB claims. Therefore, citations in this opinion should be considered to refer to the

appropriate parallel provision as context dictates. The same applies to citations of statutes or

regulations found in quoted court decisions.

3

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 3 of 39
STANDARD OF REVIEW

The court’sreview of the Commissioner’s decision is narrowly circumscribed.

The function of this court is to determine whether the decision of the Commissioner

issupported by substantial evidence and whether proper legalstandards were applied.

Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219,

1221 (11th Cir. 2002). This court must “scrutinize the record as a whole to determine

if the decision reached is reasonable and supported by substantial evidence.” 

Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). This court will

determine that the ALJ’s opinion issupported by substantial evidence if it finds “such

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

conclusion.” Id. Substantial evidence is “more than a scintilla, but less than a

preponderance.” Id. Factual findings that are supported by substantial evidence must

be upheld by the court. The ALJ’s legal conclusions, however, are reviewed de novo,

because no presumption of validity attaches to the ALJ’s determination of the proper

legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993).

If the court finds an error in the ALJ’s application of the law, or if the ALJ fails to

provide the court with sufficient reasoning for determining that the proper legal

analysis has been conducted, the ALJ’s decision must be reversed. Cornelius v.

Sullivan, 936 F. 2d 1143, 1145-46 (11th Cir. 1991).

4

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 4 of 39
STATUTORY AND REGULATORY FRAMEWORK

To qualify for disability benefits and establish his or her entitlement for a

period of disability, a claimant must be disabled as defined by the Social Security Act

and the Regulations promulgated thereunder.6 The Regulations define “disabled” as

“the inability to do 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

twelve (12) months.” 20 C.F.R. § 404.1505(a). To establish an entitlement to

disability benefits, a claimant must provide evidence about a “physical or mental

impairment” that “must result from anatomical, physiological, or psychological

abnormalities which can be shown by medically acceptable clinical and laboratory

diagnostic techniques.” 20 C.F.R. § 404.1508. 

TheRegulations provide a five-step processfor determining whether a claimant

is disabled. 20 C.F.R. § 404.1520(a)(4)(i-v). The Commissioner must determine in

sequence:

(1) whether the claimant is currently employed;

(2) whether the claimant has a severe impairment;

(3) whether the claimant’simpairment meets or equals an impairment listed

by the [Commissioner];

6The “Regulations” promulgated under the Social Security Act are listed in 20 C.F.R. Parts

400 to 499, revised as of June 26, 2014. 

5

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 5 of 39
(4) whether the claimant can perform his or her past work; and

(5) whether the claimant is capable of performing any work in the national

economy.

Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to formerly applicable

C.F.R. section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 562-

63 (7thCir. 1999); accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11thCir. 1986).

The sequential analysis goes as follows:

Once the claimant has satisfied steps One and Two, she will automatically be

found disabled if she suffers from a listed impairment. If the claimant does not

have a listed impairment but cannot perform her work, the burden shifts to the

[Commissioner] to show that the claimant can perform some other job. 

Pope, 998 F.2d at 477; accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995).

The Commissioner must further show that such work exists in the national economy

in significant numbers. Id. 

FINDINGS OF THE ADMINISTRATIVE LAW JUDGE

After consideration of the entire record, the ALJ made the following findings:

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

24, 2011, the application date. (20 C.F.R. § 416.971 et seq). (Tr. 12).

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

fibromyalgia, diabetes (non-insulin dependent Type II), nicotine

dependent with episodes of bronchitis, mild degenerative disk disease

of the spine, sleep apnea, and depression. The claimant’s rectal polyp

was successfully removed without any complications and is, therefore,

considered by the undersigned to be a non-severe impairment. (20

C.F.R. § 416.920(c)). (Tr. 12).

6

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 6 of 39
3. The claimant does not have an impairment or combination of

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

listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (20

C.F.R. §§ 416.920(d), 416.925, 416.926). (Tr. 13).

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

that the claimant has the residual functional capacity to perform less

than the full range of light work defined in 20 C.F.R. § 416.967(b). The

claimant can occasionally lift and/or carry 20 pounds and frequently lift

and/or carry 10 pounds. Claimant can stand and/or walk, with normal

breaks, for a total of 6 hours in an 8-hour workday and sit, with normal

breaks, for a total of 6 hours in an 8-hour workday. Pushing and/or

pulling of foot controls with the left lower extremity is limited to

occasionally, with the total restriction of climbing ladders, ropes, or

scaffolds and also crawling. Balancing, stooping, kneeling, and

crouching would be occasional. She should avoid concentrated exposure

to cold, heat, humidity, vibration, fumes, odors, dust, gases, and poor

ventilation. The claimant should not work at unprotected heights or

around dangerousmoving unguarded machinery.The claimant islimited

to performing unskilled work with no more than occasional interaction

with supervisors, coworkers, and the general public. Otherwise, she

would appear to be able to perform such work for periods up to 2

consecutive hours without a standard work break. (Tr. 14).

5. The claimant is unable to perform her past relevant work. (20 C.F.R. §

416.965). (Tr. 21).

6. The claimant was 43 years old, which is defined as a younger individual

age 18-49, on the date the application was filed. (20 C.F.R. § 416.963).

(Tr. 21).

7. The claimant has a limited education and is able to communicate in

English. (20 C.F.R. § 416.964). (Tr. 21).

8. Transferability of job skills is not material to the determination of

disability because using the Medical-Vocational Rules as a framework

supports a finding that the claimant is “not disabled,” whether or not the

7

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 7 of 39
claimant has transferable job skills. (See SSR 82-41 and 20 C.F.R. Part

404, Subpart P, Appendix 2). (Tr. 21).

9. Considering the claimant’s age, education, work experience, and

residual functional capacity, there are jobs that exist in significant

numbers in the national economy that the claimant can perform. (20

C.F.R. §§ 416.969 and 416.969(a)). (Tr. 21).

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

Security Act, since May 24, 2011, the date the application wasfiled. (20

C.F.R. § 416.920(g)). (Tr. 22).

ANALYSIS

The court may only reverse a finding of the Commissioner if it is notsupported

by substantial evidence. 42 U.S.C. § 405(g). “This does not relieve the court of its

responsibility to scrutinize the record in its entirety to ascertain whether substantial

evidence supports each essential administrative finding.” Walden v. Schweiker, 672

F.2d 835, 838 (11th Cir. 1982) (citing Strickland v. Harris, 615 F.2d 1103, 1106 (5th

Cir. 1980)).7 However, the court “abstains from reweighing the evidence or

substituting its own judgment for that of the [Commissioner].” Id. (citation omitted).

Ms. Grier assertsthat “the ALJimproperly discounted Grier’s testimony of disabling

limitations and failed to fully and fairly develop the record.” (Doc. 12 at 11).

The court has carefully reviewed the record and finds that this case should be

7

Strickland is binding precedent in this Circuit. See Bonner v. City of Prichard, 661 F.2d

1206, 1209 (11th Cir. 1981) (en banc) (adopting as binding precedent all decisions of the former

Fifth Circuit handed down prior to October 1, 1981).

8

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 8 of 39
remanded for further development. Under the instant circumstances, substantial

evidence does not exist in the record to support the ALJ’s conclusion that Ms. Grier

is not disabled and can perform reduced light work because: (1) the ALJ’s negative

credibility finding was not based on substantial evidence; and (2) independent of the

ALJ’s erroneous negative credibility finding, the ALJ’s RFC determination is not

supported by substantial evidence. While the court has endeavored to separate the

issues into their respective subparts, it recognizes the overlap and interrelated nature

of these findings.

I. The ALJ’s Credibility Finding Is Not Based On Substantial Evidence.

Ms. Grier arguesthat “the ALJ did not properly assess[Ms. Grier]’s credibility

consistent with the Regulations.” (Doc. 12 at 4). The court agrees. More specifically,

the ALJ’s decision that Ms. Grier does not meet the pain standard is based on an

inadequate negative credibility finding as to Ms. Grier’s subjective pain testimony.

The pain standard “applies when a disability claimant attempts to establish a

disability through his own testimony of pain or other subjective symptoms.” Dyer v.

Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). This standard requires “evidence of

an underlying medical condition and (1) objective medical evidence that confirmsthe

severity of the alleged pain arising from that condition or (2) that the objectively

determined medical condition is of such severity that it can be reasonably expected

9

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 9 of 39
to give rise to the alleged pain.” Landry v. Heckler, 782 F.2d 1551, 1553 (11th Cir.

1986). A claimant’s statements about pain or other symptoms do not alone establish

disability. See 20 C.F.R. § 404.1529(a) (“However, statements about [the claimant’s]

pain or other symptoms will not alone establish that you are disabled.”); accord 20

C.F.R. § 416.929(a) (same). Rather, “there must be medical signs and laboratory

findings which show that [claimants] have a medical impairment(s) which could

reasonably be expected to produce the pain or other symptoms alleged . . . .” Id. Even

if a claimant is able to show medical impairments that could reasonably be expected

to produce the alleged symptoms, the Commissioner “must then evaluate the

intensity, persistence of [the claimant’s] symptoms so that [the Commissioner] can

determine how [the claimant’s] symptoms limit [the claimant’s] capacity for work.”

20 C.F.R. § 404.1529(c)(1).

The ALJ may reject a claimant’s complaints of pain if he finds them not

credible. See Marbury v. Sullivan, 957 F.2d 837, 839 (11th Cir. 1992) (“After

considering a claimant’s complaints of pain, the ALJ may reject them as not

creditable [sic], and that determination will be reviewed for substantial evidence.”).

However, if the ALJ discredits a claimant’s testimony regarding the severity of her

symptoms, that determinationmust be supported by substantial evidence. Id.;see also

Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001) (explaining that the

10

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Commissioner’s factual findings must be supported by substantial evidence).

Furthermore, the ALJ may not reject the claimant’s statements as to the

intensity and persistence “solely because the available objective medical evidence

does not substantiate [claimant’s] statements.” 20 C.F.R. § 404.1529(c)(2); see also

SSR 96-7p ([T]he effect the symptoms have on [the claimant’s] ability to work may

not be disregarded solely because they are not substantiated by objective medical

evidence.”).8Instead, the ALJ is bound to consider other evidence, in addition to the

objective medical evidence, because “symptoms sometimessuggest a greater severity

of impairment than can be shown by objective medical evidence alone.” 20 C.F.R. §

404.1529(c)(3).

This other evidence includes “any symptom-related functional limitations and

restrictions which [the claimant], [the claimant’s] treating or non-treating source, or

other persons report, which can be reasonably be accepted as consistent with the

objective medical evidence and other evidence[.]” Id.Relevant factorsthat may show

the effect of claimant’s symptoms on her functional abilities include: the claimant’s

daily activities; the location, duration, frequency and intensity of the claimant’s pain;

8Although they lack the force of regulations, Social Security Rulings are “binding on all

components of the Social Security Administration.” 20 C.F.R. § 402.35(b)(1); see also McCloud v.

Barnhart, 166 F. App’x 410, 416 (11th Cir. 2006), 2006 WL 177576 (citing SSR 96-6p as

authoritative, for example).

11

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 11 of 39
any precipitating and aggravating factors; the type, dosage, effectiveness, and side

effects of medication taken to alleviate the pain; and other treatments or measures

taken by the claimant, not including medication. Id. Using these other factors, the

ALJmust showsubstantial evidence supporting his attempt to discredit the claimant’s

pain testimony. Id.

In applying this standard to the present case, the ALJfound that “the claimant’s

medically determinable impairments could reasonably be expected to cause the

alleged symptoms.” (Tr. 15). However, the ALJ determined “the claimant’s

statements concerning the intensity, persistence and limiting effects of these

symptoms are not entirely credible for the reasons explained in this decision.” Id. As

explained infra, the court finds that the ALJ’s reasons for discrediting the claimant’s

statement, while explicit, are not adequate as a matter of law. 

The ALJ attempted to articulate several adequate reasons for his credibility

finding adverse to Ms. Grier, including: her failure to seek additional treatment for

her mental impairments; her noncompliance with treatment recommendations; silence

from her treating physicians concerning whether she is disabled; his determination

that Ms. Grier’s treatment for her impairments has generally been routine and

conservative; and her testimony regarding her daily activities cannot be objectively

verified. As addressed in detail below, the court finds that the ALJ’s proffered

12

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reasons for discrediting the claimant’s pain testimony are flawed and, therefore, do

not satisfy the substantial evidence standard.

A. The ALJ improperly considered Ms.Grier’s lackof treatment

by a mental health professional as evidence weighing against

her credibility.

The ALJ inferred from Ms. Grier’s lack of treatment by a mental health

professional that her statements about the negative effect of her mental impairments

on her ability to work were not entirely credible.9 After discussing evidence in the

record concerning Ms. Grier’s history of mental illness, the ALJ states, “the

undersigned notes that the claimant has continued to fail to seek any treatment by a

mental health professional and she has received her medication from her treating

physicians.” (Tr. 20). The court finds that the ALJ did not inquire whether Ms. Grier

had any reasonable explanations for her decision not to seek treatment from a mental

health professional, and ignored a significant amount of evidence which support her

stated limitations attributable to her mental conditions.

SSR 96-7p provides a detailed explanation for how lack of medical treatment

should be handled by an ALJ when determining a claimant’s credibility, stating:

the adjudicator must not draw any inferences about an individual's

9While the ALJ’s disability determination does not explicitly contain this conclusion, the

hypothetical presented to the vocational expert that the ALJrelies upon in his decision indicates that

he did not credit all of Ms. Grier’s stated limitations stemming from her mental impairments. 

13

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 13 of 39
symptoms and their functional effects from a failure to seek or pursue

regularmedical treatment without first considering any explanations that

the individual may provide, or other information in the case record, that

may explain infrequent or irregular medical visits or failure to seek

medical treatment. The adjudicator may need to recontact the individual

or question the individual at the administrative proceeding in order to

determine whether there are good reasons the individual does not seek

medical treatment or does not pursue treatment in a consistent manner.

The explanations provided by the individual may provide insight into

the individual’s credibility.

Id. In the case at hand, the ALJ’s questioning of Ms. Grier to see if she had a

justifiable reason for not seeking treatment for her mental impairments was

inadequate.

At the hearing, the ALJ’s inquiry into the status of Ms. Grier’s treatment for

her mental health issues consisted of the following questions:

ALJ: And you’ve been diagnosed with some bipolar and depression; is

that correct?

Ms. Grier: Yes, sir.

ALJ: Are you seeking any kind of treatment for that, though?

Ms. Grier: Not right now.

ALJ: In what ways does your bipolar and depression affect you?

Ms. Grier: I stay in bed 90% of the time. I don’t have -- I don’t go

anywhere unless I have to. I just mainly stay in my room and stay in bed

ALJ: And why do you stay in your room?

Ms. Grier: Because I hurt too much to get up and move around. I just

14

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 14 of 39
rather just lay in the bed and just -- 

(Tr. 40-41). Absent in the ALJ’sinquiry is any question asking Ms. Grier why hasshe

not sought out treatment. 

Additionally, the ALJ either overlooked, or simply ignored, other credibilityrelated evidence in the record that supports Ms. Grier’s stated limitations caused by

her mental conditions. For example, according to the report produced by Dr. Bentley,

Ms. Grier has a long history of psychiatric symptoms. (Tr. 294). In 1992, Ms. Grier

was treated for two years at a Mental Health Center in Georgia. Id. Her mental

condition degraded to the point thatshe attempted suicide on three occasions. Id. Ms.

Grier has taken various antidepressants and benzodiazepines over the last fifteen

years which she claims improves her mood on some days. Id. Dr. Bentley concluded

that Ms. Grier’s prognosis is guarded. (Tr. 296). 

Moreover, Ms. Grier’ssister described in a third-party function report that Ms.

Grier has problems getting along with others, does not handle stress well, does not

handle changes well, and that she has effectively shut everybody out. (Tr. 194-96).

The ALJ did not acknowledge, much less give any reasons for rejecting the report

made by Ms. Grier’s sister. On remand, the ALJ should review this report and state

the weight accorded and the reasons for accepting or rejecting this piece of evidence

corroborating Ms. Grier’s subjective limitations. See Lucas v. Sullivan, 918 F.2d

15

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1567, 1574 (11th Cir. 1990) (reversed and remanded for further proceedings partially

because the ALJ failed to review the testimony of the claimant’s daughter and

neighbor and did not give reasons for rejecting such testimony); id. (“On remand the

ALJ should state the weight he accords to each item of impairment evidence and the

reasons for his decision to accept or reject that evidence, including all testimony

presented at the previous hearing or any subsequent hearings.” (citing Gibson v.

Heckler, 779 F.2d 619 (11th Cir. 1986))). 

In sum, the ALJ’s conclusion that Ms. Grier’s stated limitations caused by her

mental illnesses are incredible based upon hislimited questioning during the hearing

constitutes reversible error. As explained above, an ALJ may not draw any negative

inferences without first considering any reasonable explanations behind a claimant’s

lack of treatment. See SSR 96-7p. Despite this legal principle, as shown through the

hearing transcript, the ALJ made no attempt to ask Ms. Grier if she had a reason for

notseeking treatmentfroma mental health professional.(Tr. 28-52). Furthermore, the

ALJ did not consider and/or adequately address other evidence in the record that

supports Ms. Grier’s credibility regarding the limitations associated with her mental

health. Therefore, the ALJ’s decision to discount Ms. Grier’s subjective testimony

regarding her vocational limitations caused by her mental health conditions is not

backed by substantial evidence. 

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B. The ALJ mischaracterized Ms. Grier’s inability to quit

smoking as evidence of noncompliance with treatment

recommendations.

The ALJ states in his opinion that Ms. Grier “has consistently been

noncompliant with treatment recommendations” regarding her nicotine dependence,

despite its negative impact on her conditions of bronchitis and her sleep apnea. (Tr.

17). Although the ALJ never explicitly states that her noncompliance is a factor he

relied upon when discounting her credibility, it is implicitly apparent that the ALJ

considered this to be one of the reasons for his adverse credibility determination.

10

(Tr. 15). The court findsthat the ALJimproperly concluded that Ms. Grier’sinability

to quit smoking constituted noncompliance with treatment recommendations. Thus,

this reason does not serve as substantial evidence supporting the ALJ’s credibility

determination.

The Commissioner may deny benefits for the failure to follow treatment when

the claimant, without good reason, fails to follow a prescribed course of treatment

that could restore the ability to work. See Lucas v. Sullivan, 918 F.2d 1567, 1571

(11th Cir. 1990) (“The Secretary may deny SSI disability benefits if the Secretary

10The ALJ included this piece of evidence after stating his broad credibility assessment that

Ms. Grier’s “symptoms are not entirely credible for the reasons explained in this decision.” (Tr. 15).

At no point does the ALJ explicitly delineate which “reasons” did, or did not, affect his view of Ms.

Grier’s credibility, thus the undersigned can only presume that every reason stated was considered

by the ALJ.

17

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determines that 1) the claimant failed to follow a prescribed course of treatment, and

2) her ability to work would be restored if she had followed the treatment.”); McCall

v. Bowen, 846 F.2d 1317, 1319 (11th Cir. 1988) (“Secretary may deny SSI disability

benefits only when a claimant, without good reason, fails to follow a prescribed

course of treatment that could restore her ability to work.”). While the court is

unaware of any Eleventh Circuit published decision that speaks directly to the issue

of noncompliance to quit smoking, there is an analogous case decided within the

district that this court adopts as persuasive authority. 

In Seals v. Barnhart, 308 F. Supp. 2d 1241, 1247 (N.D. Ala. 2004), the ALJ

refused to credit the claimant’ssubjective complaints because the claimant continued

smoking despite numerous warnings from doctors to stop. Because the claimant had

failed to follow prescribed treatment to quit smoking, the ALJ found that 20 C.F.R.

§ 404.1530

11

 precluded the claimant from being found disabled. Id.

In addressing the claimant’s appeal in Seals,Judge Guin began his analysis by

correcting one of his previous holdings, stating “[t]his court has previously held that

‘continuing to smoke despite a physician’s warning asto consequencesindicatesthat

a claimant has made a conscious lifestyle choice which is inconsistent with a finding

11

“In order to get benefits, you must follow treatment prescribed by your physician if this

treatment can restore your ability to work.” 20 C.F.R. § 404.1530(a)

18

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of disability.’” Id. at 1248 (quoting Wilda Elliot v. Apfel, No. 5:98-CV-00820-JFG,

(Doc. 8 at 2) (N.D. Ala. Nov. 18, 1998). Judge Guin determined that his prior holding

“is not correct as a general statement of the law.” Id. The court then discussed and

adopted the approach utilized by the Seventh Circuit in Shramek v. Apfel, 226 F.3d

809 (7th Cir. 2000). See id.

In Shramek, the court found that “the ALJ erred in relying on [claimant’s]

inability to quit smoking as evidence of noncompliance and as a basis to find her

incredible.” 226 F.3d at 813. The Seventh Circuit reached this decision after noting

that “the ALJ here made no finding that the prescribed treatment would restore

[claimant’s] ability to work, and the record would not in factsupportsuch a finding.”

Id. Furthermore, no connection had been made between the claimant’ssymptoms and

her smoking. Id.

Finally, the court commented that failure to quit smoking is not synonymous

with treatment in the typical sense, stating: 

[w]e note that even if medical evidence had established a link between

smoking and her symptoms, it is extremely tenuous to infer from the

failure to give up smoking that the claimant is incredible when she

testifies that the condition is serious or painful. Given the addictive

nature of smoking, the failure to quit is as likely attributable to factors

unrelated to the effect of smoking on a person's health. One does not

need to look far to see persons with emphysema or lung cancer—directly

caused by smoking—who continue to smoke, not because they do not

suffer gravely from the disease, but because other factors such as the

19

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 19 of 39
addictive nature of the product impacts their ability to stop. This is an

unreliable basis on which to rest a credibility determination.

Shramek, 226 F.3d at 813. 

In applying these rules set forth in Shramek, the court in Seals stated that even

assuming the doctor’sstatements did constitute a prescribed course of treatment, “the

[claimant]’sfailure to stop smoking does not necessarily constitute a refusal to follow

that prescribed treatment. A willful refusal to follow treatment may not be assumed

from a mere failure to accomplish the recommended change.” Seals, 308 F. Supp. 2d

at 1250 (citing McCall, 846 F.2d at 1319) (holding that a claimant’s failure to lose

weight does not constitute a refusal to follow the treatment). The court found

evidence in the record that the claimant had been trying to quit, and determined that

“the record does not contain substantial evidence to support a finding that the plaintiff

did not try to stop smoking in the present case.” Id. at 1251. 

Judge Guin also commented about how the claimant’s addiction necessitates

a slightly different analysis than the typical noncompliance situation, stating:

[b]reaking an addiction is not a simple matter of rationally deciding to

cease the addictive behavior, whether it be smoking, drinking or drug

abuse. The world would obviously be a better place if that were so. In

the case of nicotine addiction, a mere failure to successfully stop

smoking will not support a finding of willful refusal to try. If the

plaintiff was unable to stop smoking because she was addicted to

nicotine, her noncompliance would not be unjustified. The burden is on

the Commissioner to produce evidence of unjustified noncompliance.

20

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Dawkins v. Bowen, 848 F.2d 1211, 1214, n.8 (11th Cir. 1988). In the

present case, the ALJ made no finding that the plaintiff was actually

able, mentally and physically, to stop smoking. Nor did the

Commissioner cite to any evidence, other than the plaintiff’s failure to

stop smoking, to show that her noncompliance was unjustified.

Seals, 308 F. Supp. 2d at 1251.

Further,theALJ also failed tomake another essentialfinding when discrediting

because of noncompliance with treatment. More specifically, the ALJ omitted any

determination that, had the claimantfollowed the prescribed treatment, the claimant’s

ability to work would be restored. Id. Although the ALJ found that the claimant’s

condition would improve if she stopped smoking, “[i]mprovement does not equal an

ability to work.” Id. at 1251-52. 

Assuming that the statements made to Ms. Grier by her treating physicians do

constitute prescribed treatment, the ALJ did not inquire whether her failure was

unjustified. Similar to the claimant in Seals, Ms. Grier is nicotine dependent and,

thus, because of her addiction, her inability to quit smoking does not constitute an

unjustified reason for noncompliance without any further inquiry by the ALJ. (Tr.

13); see Seals, 308 F. Supp. 2d at 1251(“If the plaintiff was unable to stop smoking

because she was addicted to nicotine, her noncompliance would not be unjustified.

The burden is on the Commissioner to produce evidence of unjustified

noncompliance.”);see also SSR 96-7p (“individual’sstatements may be less credible

21

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. . . , if the medical reports or records show that the individual is not following the

treatment as prescribed and there are no good reasons for this failure”) (emphasis

added).

In the present case, the ALJ did not state whether Ms. Grier was mentally and

physically capable of quitting smoking, nor did the ALJ cite to any evidence, other

than her failure to stop, to show that her noncompliance was unjustified.

12

Furthermore, the ALJ did not cite to any evidence that showed that, if Ms. Grier quit

smoking, her condition would improve to the point in which she could be capable of

performing work. While the record does show instances of Ms. Grier being warned

that her condition will not improve unless she quits smoking, the court is unable to

find any report that establishesthat if Ms. Grier did quit, her condition would improve

to the point that she could work. Therefore, the court finds that the ALJ’s reliance on

Ms. Grier’s failure to quitsmoking as evidence weighing against her credibility does

not serve as substantial evidence supporting the ALJ’s credibility determination.

C. The ALJ improperly concluded that Ms. Grier’s testimony is

not credible because of the absence in the record of a treating

physician’s opinion stating Ms. Grier was disabled.

The ALJ made the following observation about the medical record:

12When asked about her smoking at her hearing, Ms. Grier testified that she quit smoking

about a month and a half before the hearing took place. (Tr. 33). The ALJ did not inquire why she

had not quit earlier.

22

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[t]he undersigned notes that as for opinion evidence, given the

claimant’s allegations of disabling pain symptoms, one might expect to

see some indication in the treatment record of restrictions placed on the

claimant by a treating physician. Yet, a review of the record does not

contain any opinionsfromtreating or examining physiciansthat indicate

that the claimant was disabled or even had limitations greater than those

determined in this decision.

(Tr. 20). This finding by the ALJ not only runs afoul of Eleventh Circuit precedent,

but also misstates the evidence in the record.

The Eleventh Circuit has held that a physician’s silence regarding a claimant’s

functional capacity does not translate into an opinion that a claimant can work. See

Lamb v. Bowen, 847 F.2d 698, 703 (11th Cir. 1988). In Lamb, the Commissioner

attempted to argue that because claimant’s treating physicians only noted that the

claimant could not return to his past work, the Commissioner’s finding that the

claimant could perform light work was uncontradicted. Id. The court rejected this

argument, stating:

[claimant’s physician] opined in June of 1984 that appellant's condition

and the restriction of activity necessitated by the condition was not

compatible with his former employment. It is true that [claimant’s

physician] did not restrict appellant from light work. It is equally true

that he did not recommend light work. In fact, Dr. Kane did not address

the issue of any type of work but appellant's former work. Such silence

is equally susceptible to either inference, therefore, no inference should

be taken.

Id. (emphasis added). The ALJ in the instant case committed an error comparable to

23

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 23 of 39
the one described in Lamb.

It is plain from the ALJ’s statement that he treated silence by her treating

physicians regarding Ms. Grier’s limitations as evidence showing that the degree of

her stated limitations is not credible. This is inconsistent with the principle espoused

in Lamb. 

Furthermore, the ALJ’s description of the record, specifically that “a review of

the record does not contain any opinions from treating or examining physicians that

indicate that the claimant was disabled or even had limitations greater than those

determined in this decision,” misstates the evidence. (Tr. 20). Ramesh Reddy, MD,

performed a complete physical examination of Ms. Grier on August 2, 2011, and

concluded that, in his opinion, Ms. Grier is unable to work.

13

(Tr. 286). For the

reasons described above, the court findsthat the ALJ’sreliance on the lack of opinion

evidence in an effort to discredit Ms. Grier’ssubjective limitations wasimproper and

does not serve as substantial evidence supporting the ALJ’s adverse credibility

determination.

13The ALJ did state in his opinion that he afforded little weight to Dr. Reddy’s opinion, but,

for reasons which will be developed in Part II, the court finds that the ALJ’s reasoning for placing

little weight with Dr. Reddy’s opinion is not supported by substantial evidence.

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D. The ALJ incorrectly characterized the treatment received by

Ms. Grier for her fibromyalgia and back pain as generally

conservative and effective.

The ALJ notes that the treatment Ms. Grier has received for her diagnosed

impairments of fibromyalgia, mild degenerative disk disease of the spine, and

diabetes (non-insulin dependant Type II) has been “essentially routine and

conservative in nature and has been successful in controlling her symptoms.” (Tr. 15-

16, 19). Ms. Grier argues that the ALJ mischaracterized her treatment and that the

ALJfailed to properly credit the longitudinal treatment history for her pain. (Doc. 12

at 5). The court agrees with Ms. Grier that the ALJ did not accurately described the

treatment received by Ms. Grier for fibromyalgia and the ALJ also failed to credit Ms.

Grier’s longitudinal history of back pain.

14

The Regulations state that relevant factors for an ALJ to consider when

evaluating a claimant’s pain symptoms include, “the type, dosage, effectiveness, and

side effects of any medication” taken by the claimant, as well as any “[t]reatment,

other than medication, [claimant] receives or ha[s] received for relief of [claimant’s]

pain or other symptoms[.]” 20 C.F.R. § 404.1529(c)(3)(iv)-(v). A claimant’s

14The court finds that the ALJ did not necessarily mischaracterize the treatment received by

Ms. Grier for her diabetes; however, as explained fully in section E, the ALJ’s reliance upon this

evidence to discredit Ms. Grier’s subjective complaints of pain was improper under the

circumstances of this case.

25

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 25 of 39
statements “may be less credible if the level or frequency of treatment is inconsistent

with the level of complaints[.]” SSR 96-7p; see also Farley v. Astrue, No. 2:08-CV2219-VEH, (Doc. 11 at 9-12) (N.D. Ala. Dec. 2, 2009) (holding that exaggeration of

pain versus treatment sought was substantial evidence for the ALJ’s credibility

determination). However, the ALJ

must not draw any inferences about an individual’s symptoms and their

functional effects from a failure to seek or pursue regular medical

treatment without first considering any explanations that the individual

may provide, or other information in the case record, that may explain

infrequent or irregular medical visits or failure to seek medical

treatment.

96-7p (emphasis added). In the instant case, the ALJ did not consider the obvious

explanations for Ms. Grier’s perceived conservative treatment for her fibromyalgia.

On February 28, 2013, Ms. Grier was examined by one of her treating

physicians,WilliamJ. Shergy, MD. (Tr. 441). Dr. Shergy noted in hisreport that “Ms.

Grier has underlying fibromyalgia, most likely secondary to severe sleep apnea. She

clearly will not improve from her fibromyalgia symptoms unless her sleep apnea is

addressed and she begins to exercise.” Id. (emphasis added). The ALJ failed to

recognize this link between her fibromyalgia and her severe sleep apnea condition. 

Consequently, the treatment prescribed for Ms. Grier’s sleep apnea condition

also relates to managing her symptoms associated with fibromyalgia. Further, after

26

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reviewing Ms. Grier’streatment for sleep apnea, the record lackssubstantial evidence

to support the ALJ’s conclusion that such treatment was conservative or effective.

Ms. Grier was evaluated at the Shoals Sleep Center on September 6, 2012. (Tr. 358).

The study found that Ms. Grier suffered from obstructive sleep apnea syndrome. (Tr.

379). It was recommended that Ms. Grier use a continuous positive airway pressure

machine (CPAP) to treat her sleep apnea; however, Ms. Grier did not have the ability

pay for a CPAP initially.

15

(Tr. 349, 382). Ms. Grier did eventually obtain a CPAP

machine; however, she continued to report to her physicians that the CPAP machine

was not successful in controlling her symptoms.

16 Therefore, as shown above, the

court finds that this evidence does not constitute substantial evidence supporting the

ALJ’s credibility determination because the ALJ failed to address the dependent

relationship her fibromyalgia shares with her sleep apnea; and such error is not

harmless because the undersigned is unable to conclude that her sleep apnea treatment

is conservative, or successful in controlling her symptoms. 

15While a remediable or controllable medical condition is generally not disabling, when a

claimant cannot afford the prescribed treatment and can find no way to obtain it, she is excused from

noncompliance. SeeDawkins v. Bowen, 848 F.2d 1211, 1213 (11th Cir. 1988) (“We agree with every

circuit that has considered the issue that poverty excuses noncompliance.”).

16On January31, 2013, Ms. Grier visited Dr. Ridgewaybecause of symptoms associated with

her sleep apnea condition. (Tr. 478). Dr. Ridgeway noted that Ms. Grier’s sleep apnea condition has

been present for several months, that she is treating the condition with a CPAP machine, and that

she is completely compliant to therapy. Id.

27

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Lastly, regarding Ms. Grier’s mild degenerative disk disease of the spine, the

ALJ again erroneously labeled her treatment received as “routine and conservative

in nature and has generally been successful in controlling her symptoms.” (Tr. 16).

Ms. Grier arguesthat the ALJfailed to credit Ms. Grier’s “longitudinal history for her

pain and continued treatment for the same.” (Doc. 12 at 5). The court agrees with Ms.

Grier. SSR 96-7p, defines longitudinal history of pain as the following:

In general, a longitudinal medical record demonstrating an individual's

attempts to seek medical treatment for pain or other symptoms and to

follow that treatment once it is prescribed lends support to an

individual's allegations of intense and persistent pain or other symptoms

for the purposes of judging the credibility of the individual'sstatements.

Persistent attempts by the individual to obtain relief of pain or other

symptoms, such as by increasing medications, trials of a variety of

treatment modalitiesin an attempt to find one that works or that does not

have side effects, referrals to specialists, or changing treatment sources

may be a strong indication that the symptoms are a source of distress to

the individual and generally lend support to an individual's allegations

of intense and persistent symptoms. 

Id. Ms. Grier’s medical record shows that she has continuously sought medical

treatment for her back pain, and the ALJ was incorrect in classifying her treatment as

conservative and effective.

The record reveals that Ms. Grier has consistently been complaining of back

since March of 2009. (Tr. 254). Ms. Grier returned twice that year with complaints

of back pain. (Tr. 252-53). On August 5, 2010, Ms. Grier reported that her back pain

28

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 28 of 39
seemed to be getting worse. (Tr. 249). On April 18, 2012, Ms. Grier was examined

at the Shoals Pain Center where she was diagnosed with lumbar radiculopathy and

lumbar disc displacement. (Tr. 344-45). Following this diagnoses, Ms. Grier

underwent an interlaminar lumbar steroid injection at the L5-S1 level; however,

instead of getting relief, Ms. Grier reported that the injections made her feel worse.

(Tr. 346, 412). She further stated that she had increased her pain medication without

much relief. (Tr. 412). Because of Ms. Grier’s history of continuously complaining

about her back pain, while also getting little to no relief from medication, the court

finds that the ALJ erred in classifying her treatment as conservative and effective.

Therefore, the ALJ’s observation about Ms. Grier’s treatment received for her

fibromyalgia and mild degenerative disc disease does not constitute substantial

evidence supporting the ALJ’s credibility determination.

E. The ALJ improperly relied upon Ms. Grier’s diabetes

treatment to discredit unrelated debilitating limitations.

The ALJ addressed Ms. Grier’s diabetic condition by noting the following,

“[r]egarding the claimant’s alleged diabetes (non-insulin dependent Type II), again

the undersigned notes while the claimant has undergone treatment for her alleged

impairment, the treatment she has received has again been essentially routine and

conservative in nature and has been successful in controlling her symptoms.” (Tr. 19).

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The ALJ is generally correct that the treatment received for Ms. Grier’s diabetes has

been conservative and effective; however, the court finds that the ALJ’s inclusion of

Ms. Grier’s conservative treatment for diabetes as a factor weighing against her

credibility is inappropriate under the circumstances of this case.17

While Ms. Grier did state in her initial disability report that her diabetic

condition affected her ability to work (Tr. 166), this impairment is not the crux of her

SSI claim. In fact, the court is only able to find one statement made by Ms. Grier

where she alleges that her diabetic condition has had some effect on her functional

abilities.

18 The insignificance of her diabetic condition to her SSI claim is

underscored by (1) the disability determination document completed by the SSA

which identifies organic mental disorders as Ms. Grier’s primary diagnoses, and

disorders of the back as her secondary diagnoses (Tr. 55); and (2) the ALJ never

questioned Ms. Grier about her diabetic condition during the hearing. (Tr. 28-52).

17The ALJ included this piece of evidence after stating his broad credibility assessment that

Ms. Grier’s “symptoms are not entirely credible for the reasons explained in this decision.” (Tr. 15).

At no point does the ALJ explicitly delineate which “reasons” did, or did not, affect his view of Ms.

Grier’s credibility, thus the undersigned can only presume that every reason stated was considered

by the ALJ.

18

In a handwritten note by Ms. Grier, she stated that she has an appointment with an

optometrist because of complications to her vision caused byher diabetic condition. (Tr. 215). While

there is no document in the record from an optometrist, Dr. Reddy noted in his report that Ms. Grier

did have an eye exam two months prior to his examination, and that she was prescribed glasses. (Tr.

284).

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The ALJ also made no attempt to explain how evidence of routine treatment

for her diabetic condition somehow makes Ms. Grier’s subjective complaints caused

by her other independent impairments not credible, including, in particular her mental

limitations. Nonetheless, the ALJ partially and inadequately based his decision to

discredit Ms. Grier’s entire subjective disabling symptoms because of routine

treatment she received to deal with her diabetic condition. Therefore, to the extent

that Ms. Grier’s diabetestreatment is appropriately characterized as conservative and

successful in controlling her symptoms, such evidence does not serve as substantial

evidence supporting the ALJ’s entire credibility determination.

19

F. The ALJ improperly discounted Ms. Grier’s testimony

pertaining to her daily activities.

During Ms. Grier’s hearing in front of the ALJ, she testified that her

impairments have a profound effect on her daily activities. She stated that she is

unable to sit or stand for longer than about fifteen minutes. (Tr. 38). She testified that

she is unable to walk to her mailbox without stopping. (Tr. 39). Ms. Grier testified

that because of her depression and bipolar disorder and her physical pain she stays

in bed 90% of the day. (Tr. 40). Ms. Grier also indicated thatshe doesthe laundry and

19Alternatively, assuming the conservative nature of Ms. Grier’s diabetes treatment doesserve

as substantial evidence to discredit her alleged physical limitations, the case should still be remanded

because, as described in section A, the ALJ inadequately discredited Ms. Grier’s alleged limitations

caused by her mental impairments.

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Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 31 of 39
dishes with the aid of her nephew or daughter. (Tr. 41). She stated that she only goes

to the grocery store about once a month and is only able to stay in the store ten to

fifteen minutes at a time. (Tr. 43). Ms. Grier indicated that she usually drives herself

to the grocery store or to doctor appointments; however, she testified that when she

makesthe thirty-minute commute to her doctor’s office she sometimes hasto stop and

walk around her car because of the pain. (Tr. 43-44).

The ALJ attempted to explain his reasoning for not crediting her statements

about her limited daily activities, stating:

Although the claimant has described daily activities which are fairly

limited, two factors weigh against considering these allegations to be

strong evidence in favor offinding the claimant disabled. First, allegedly

limited daily activities cannot be objectively verified with any

reasonable degree of certainty. Secondly, even if the claimant’s daily

activities are truly as limited as alleged, it is difficult to attribute that

degree of limitation to the claimant’s medical condition, as opposed to

other reasons, in view of the relatively weak medical evidence and other

factors discussed in this decision. 

Id. The court finds that both factors listed by the ALJ are inadequate.

As to the first factor mentioned by the ALJ, the court is unable to find any

binding authority that states testimony regarding daily activities must be objectively

verified. Furthermore, if a claimant is not required to provide objective proof of pain,

it follows that the claimant’s testimony regarding daily activities does not need to be

objectively verified either. Seemingly, the ALJ would never credit a claimant’s

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Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 32 of 39
testimony about limited daily activities, unless the claimant allows some third-party

to observe her daily activities for some period of time. 

The ALJ’s second reason for discrediting Ms. Grier’s testimony about her

limited daily activities is also inadequate. Regarding the “other factors” mentioned

by the ALJ, the court has determined that none of the other factors mentioned by the

ALJ constitute substantial evidence supporting the ALJ’s credibility determination.

See supra sections (A)-(E). The “weak medical evidence” the ALJ mentions was an

erroneous finding as described in section (C) above. Lastly, the ALJ’s statement that

“it is difficult to attribute that degree of limitation to the claimant’s medical condition,

as opposed to other reasons” seemingly implies that the ALJ believes Ms. Grier has

chosen to live her limited lifestyle. While the ALJ’s theory may be correct, he did not

point to adequate evidence to back up this conclusion.

For all the reasons described above, the ALJ failed to adequately support his

credibility assessment of Ms. Grier. On remand, the ALJ should re-assess the effect

of the claimant’stestimony on her ability to work after either accepting her testimony,

including her sister’s corroborating statements, or by articulating adequate reasons

to reject Ms. Grier’s subjective pain and mental limitations. 

33

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 33 of 39
II. Alternatively And Independent Of The ALJ’s Erroneous Negative

Credibility Finding, The ALJ’s RFC Determination Is Not Supported By

Substantial Evidence.

In determining Ms. Grier’s RFC, the ALJ placed “great weight” on the mental

and physical assessments prepared by state agent medical consultants who never saw

Ms. Grier and only reviewed her record. (Tr. 20). The ALJ gave “little weight” to the

opinions prepared by Dr. Reddy and Dr. Bentley because they “only saw the claimant

on one occasion and they did not treat her, and their assessments appear to be based

primarily on the claimant’s subjective complaints and they are not consistent with the

medical record.” Ms. Grier contends that the non-examining opinions produced by

the state agency consultants are “flawed and incomplete at best.” (Doc. 12 at 8). The

court agrees with Ms. Grier. More specifically, the court finds that the ALJ’s reasons

for placing more weight to the non-examining reports over the examining reports is

not backed by substantial evidence.

The opinion of a non-examining physician “is entitled to little weight and taken

alone does not constitute substantial evidence to support an administrative decision.”

Swindle v. Sullivan, 914 F.2d 222, 226 n.3 (11th Cir. 1990) (citing Broughton v.

Heckler, 776 F.2d 960, 962 (11th Cir. 1985)). When the opinion of an examining

physician is compared with an opinion of a non-examining physician, “[t]he opinion

of an examining physician is generally entitled to more weight than the opinion of a

34

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 34 of 39
non-examining physician.” Broughton, 776 F.2d at 962 (internal quotation omitted).

An ALJ may accord substantial weight to the opinion of a non-examining physician

if certain conditions are present.

An ALJ may accord substantial weight to the opinion of a non-examining

physician if the opinion is consistent with examining physician reports. See Edwards

v. Sullivan, 937 F.2d 580, 584-85 (11th Cir. 1991) (finding that the ALJ did not err

in relying on the opinion of the non-examining physician since this opinion did not

contradict the opinions of the examining physicians). Reports from non-examining

sources must also be supported by other evidence in the record. See 20 C.F.R. §

404.1527(d)(3) (“[B]ecause nonexamining sources have no examining or treating

relationship with [the claimant], the weight will depend on the degree to which [the

physicians] provide supporting explanations for their opinions[.]”). These opinions

will be evaluated by “the degree to which these opinions consider all of the pertinent

evidence in [the claimant’s] claim, including opinions oftreating and other examining

sources.” Id. (emphasis added).

The ALJ stated in his opinion that

[b]oth State Agency medical consultants have provided extensive

evaluationsfromboth a physical andmentalstandpoint, and considering

the totality of the medical record in this case, as well as the consistency

of the findings of the State Agency medical consultants with the

objective record, the undersigned has adopted those opinions as

35

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 35 of 39
indicative of the claimant’s [RFC]. 

(Tr. 20). The first of many flaws associated with the ALJ’s analysis is his assessment

that the non-examining physicians provided “extensive evaluations.” Dr. Callins’s

physical RFC assessment of Ms. Grier was based on, at most, three treatment notes,

not including Dr. Reddy’s examination. (Tr. 324). Kirstin J. Bailey, Ph.D., produced

the mental evaluation which the ALJ relies upon. (Tr. 299). As Ms. Grier points out

in her brief, it is unclear if Dr. Bailey examined any of Ms. Grier’s actual treatment

records. (Doc. 12 at 8). The only report that Dr. Bailey cites in her notessection isthe

report produced by consultative examiner Dr. Bentley.

The second critical flaw about the ALJ’s analysis is the lack of support

provided by the ALJ for his determination that the non-examining physician reports

were deserving of greater weight than the examining physician reports of Dr. Reddy

and Dr. Bentley. The ALJ’s first reason for not placing greater weight with the

examining physicians’ reports was because they “only saw the claimant on one

occasion and they did not treat her[.]” (Tr. 20). The undersigned might have been

persuaded by this observation had the ALJ not placed greater weight to reports

produced by physicians who have never seen nor treated Ms. Grier.

The second justification the ALJ proffers is that “their assessments appear to

be based primarily on the claimant’ssubjective complaints and they are not consistent

36

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 36 of 39
with the medical record.” Id. Assuming this is correct, the ALJ’s reliance on Dr.

Bailey’s non-examining report should be discounted for the same reasoning,

considering her report is based solely from Dr. Bentley’s report. Further, the ALJ’s

contention that Dr. Reddy’s report is based primarily on subjective complaints is not

backed by substantial evidence. Dr. Reddy reviewed the medical record provided to

him by DDS and he conducted various physical tests on Ms. Grier, including a

straight-leg raising test which resulted in a positive result for lumbosacral pain at

thirty degrees.

20

 (Tr. 284-86).

Lastly, and possibly most critically, the ALJ’s RFC analysis is unsupported by

substantial evidence because it is based solely on the reports of the non-examining

physicians. See Swindle, 914 F.2d at 226 n.3 (explaining that the opinion of a nonexamining physician “is entitled to little weight and taken alone does not constitute

substantial evidence to support an administrative decision.”). Therefore, for the

reasons discussed above, the ALJ’sRFC determination is notsupported by substantial

evidence. This alone requires that the ALJ’s decision be reversed.

21

20A straight-leg raise is recognized by the regulations as a clinically appropriate test for the

presence of pain and limitation of motion of the spine. See 20 C.F.R. Pt. 404, Subpt. P, App. 1(D).

21The undersigned has rendered several other comparable decisions which address the

inadequacies of the respective ALJ’s RFC determinations from which the disposition of this case

persuasively flow. See, e.g., Mahaley v. Astrue, No. 5:09-CV-0347-VEH, (Docs. 12, 13) (N.D. Ala.

Feb. 18, 2010) (reversing and remanding under similar circumstances in which the court found that

the ALJ’s RCF finding was not supported by substantial evidence); Glover v. Astrue, No. 3:09-CV37

Case 6:14-cv-01403-VEH Document 14 Filed 07/31/15 Page 37 of 39
Furthermore, because Dr. Reddy’s finding is ambiguous as to whether he was

referring to all work at any exertional level or only her past work,

22

the case should

be remanded to allow the ALJ to seek clarification from Dr. Reddy to resolve this

uncertainty. See Rivers v. Colvin, No. 2:12-CV-00792-VEH, (Doc. 10 at 10-13) (N.D.

Ala. Aug. 2, 2013) (holding that the case should be remanded so that the ALJ could

resolve an ambiguous statement in the consultative examiner’s report). 

CONCLUSION

Based upon the court’s evaluation of the evidence in the record and the

submissions of the parties, the court findsthat the Commissioner’sfinal decision was

not supported by substantial evidence. More specifically, the ALJ inadequately

discredited Ms. Grier’s subjective testimony, and failed to provide a proper,

medically-supported RFC. Accordingly, the decision of the Commissioner is due to

be reversed and remanded. A separate order in accordance with this memorandum

opinion will be entered.

0033-VEH, (Docs. 15, 16) (N.D. Ala. Mar. 4, 2010) (same); Johnson v. Astrue, No. 3:08-CV-1761-

VEH, (Docs. 15, 16) (N.D. Ala. Mar. 12, 2010) (same); Martin v. Astrue, No. 5:09-CV-1029-VEH,

(Docs. 11, 12) (N.D. Ala. Mar. 25, 2010) (same).

22Dr. Reddy concluded his examination report of Ms. Grier by stating, “I feel that the

claimant is unable to work given her history and physical exam.” (Tr. 286).

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DONE and ORDERED this the 31st day of July, 2015.

 

 VIRGINIA EMERSON HOPKINS

United States District Judge

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