Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_15-cv-02224/USCOURTS-alnd-2_15-cv-02224-0/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)

---

1

IN THE UNITED STATES DISTRICT COURT 

FOR THE NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

BENNETT EVANS, )

)

CLAIMANT, )

)

v. ) CIVIL ACTION NO.

) 2:15-CV-02224-KOB

)

NANCY BERRYHILL )

ACTING COMMISSIONER OF )

SOCIAL SECURITY )

)

RESPONDENT. )

)

MEMORANDUM OPINION

I. INTRODUCTION

On September 21, 2012, the claimant, Bennett Evans, protectively applied for 

disability and disability insurance benefits under Title II and part A of Title XVIII of the 

Social Security Act. (R. 145). The claimant initially alleged disability commencing on 

June 16, 2012 because of coronary artery disease, cervical spine disease, depression, acid 

reflux, insomnia, glaucoma, and cataracts. (R. 145, 184). The Commissioner denied the 

claim on December 26, 2012. (R. 87). The claimant filed a timely request for a hearing 

before an Administrative Law Judge, and the ALJ held a hearing on January 22, 2013.

(R. 95).

In a decision dated May 1, 2014, the ALJ found that the claimant was not disabled 

as defined by the Social Security Act and was, therefore, ineligible for social security 

benefits. (R. 7-28). On October 6, 2015 the Appeals Council denied the claimant’s 

FILED

 2017 Mar-21 PM 03:42

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 1 of 27
2

requests for review. (R. 1-4). Consequently, the ALJ’s decision became the final decision 

of the Commissioner of the Social Security Administration. The claimant has exhausted 

his administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. 

§§405(g) and 1383(c) (3). For the reasons stated below, this court AFFIRMS the decision 

of the Commissioner.

II. ISSUE PRESENTED

The issue before the court is whether, under the Eleventh Circuit’s pain standard,

the ALJ properly assessed the claimant’s subjective complaints of disabling pain.

III. STANDARD OF REVIEW

The standard for reviewing the Commissioner’s decision is limited. This court 

must affirm the ALJ’s decision if the ALJ applied the correct legal standards and if 

substantial evidence supports the ALJ’s factual conclusions. See 42 U.S.C. § 405(g); 

Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 

999 (11th Cir. 1987).

“No...presumption of validity attaches to the [Commissioner’s] legal conclusions, 

including determination of the proper standards to be applied in evaluating claims.” 

Walker, 826 F.2d at 999. This court does not review the Commissioner’s factual 

determinations de novo. The court will affirm those factual determinations that are 

supported by substantial evidence. “Substantial evidence” is “more than a mere scintilla. 

It means such relevant evidence as a reasonable mind might accept as adequate to support 

a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971).

The court must keep in mind that opinions, such as whether a claimant is disabled, 

the nature and extent of a claimant’s residual functional capacity, and the application of 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 2 of 27
3

vocational factors, “are not medical opinions,...but are, instead, opinions on issues 

reserved to the Commissioner because they are administrative findings that are 

dispositive of a case; i.e., that would direct the determination or decision of disability.” 

20 C.F.R. §§ 404.1527(d), 416.927(d). Whether the claimant meets the listing and is 

qualified for Social Security disability benefits is a question reserved for the ALJ, and the 

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

that of the Commissioner.” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). 

Thus, even if the court were to disagree with the ALJ about the significance of certain 

facts, the court has no power to reverse that finding as long as substantial evidence in the 

record supports it.

The court must “scrutinize the record in its entirety to determine the 

reasonableness of the [Commissioner]’s factual findings.” Walker, 826 F.2d at 999. A 

reviewing court must not only look to those parts of the record that support the decision 

of the ALJ, but also must view the record in its entirety and take account of evidence that 

detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 

(11th Cir. 1986).

IV. LEGAL STANDARD

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....” 42 U.S.C. § 423(d) (1) (A). To make this determination the 

Commissioner employs a five-step, sequential evaluation process:

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 3 of 27
4

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

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

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

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

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

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

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

negative answer to any question, other than step three, leads to a 

determination of “not disabled.”

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986)1

; 20 C.F.R. §§ 404.1520, 

416.920.

V. FACTS

The claimant was fifty-four years old at the time of the ALJ’s final decision. (R. 

34). The claimant has a twelfth grade education and past relevant work as a shredder, 

delivery driver, produce clerk, and material handler. (R. 62, 185). The claimant alleges 

disability based on coronary artery disease, cervical spine disease, depression, acid 

reflux, insomnia, glaucoma, and cataracts. (R. 184). 

Physical and Mental Impairments

On September 6, 2005, the claimant visited the University of Alabama at 

Birmingham emergency room because a heavy tire fell while the claimant was working, 

hitting him in the chest. On the same day, Dr. Tom McElderry, a cardiologist, diagnosed

the claimant with a chest wall contusion and hypertension. Dr. McElderry referred the 

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

(SSI). The same sequence applies to disability insurance benefits. See, e.g., Ware v. Schweiker, 

651 F.2d 408 (5th Cir. 1981) (Unit A).

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 4 of 27
5

claimant to the Kirklin Clinic for further hypertension evaluation after discharge.2 (R 

269-74, 279). 

At the recommendation of his emergency room doctors, the claimant visited the 

Birmingham Veteran’s Association Medical Clinic to establish primary care on 

November 30, 2005. During this initial visit, nurse practitioner Jennifer Dardy-Bonner 

determined that the claimant still suffered from hypertension and diagnosed the claimant 

with gastroesophageal reflux disease (gerd). She prescribed a blood pressure regimen 

consisting of Ramipril, Felodipine, and HCTZ to stabilize his hypertension, and 

Omeprazole for his gerd. (R. 1108-1112).

During his yearly follow-up at the VA on August 24, 2006 with Dr. Felicia R. 

Noerager, the claimant’s hypertension and gerd were both controlled. Similarly, on 

January 4, 2007, the claimant’s hypertension and gerd were stable; however, Dr. 

Noerager sent the claimant to the emergency room because of an abnormal EKG. 

Ultimately, all emergency room tests and evaluations were normal. (R. 1095-97, 1102).

The claimant continued to see Dr. Noerager for two yearly follow-up 

appointments, and the claimant’s hypertension and gerd remained controlled until 2009. 

On February 27, 2009, Dr. Noerager reported that the claimant’s hypertension was poorly 

controlled because of his failure to consistently take prescribed medications. Dr. 

Noerager also prescribed Ibprofin for claimant’s new hip and back pain complaints. 

Similarly, during a September 15, 2009 follow-up, the claimant stated that he no longer 

took hypertension and gerd medication, but continued to experience chest pain. (R. 1025, 

1029).

 2 The court can find no record from the Kirklin Clinic immediately after this visit; 

however, the claimant did visit the Kirklin Clinic in August 2012. (R. 280).

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 5 of 27
6

On April 27, 2010, the claimant received a Kenalog shot and a Lortab perscription

for back pain, and Dr. Noerager ordered an MRI of the claimant’s back. Dr. Noerager 

also reported that the claimant’s hypertension and gerd were again stabilized with 

medication. An MRI of the claimant’s back taken on May 18, 2010 showed narrowing of 

the claimant’s spinal column. (R. 1003-05, 1011). 

The claimant called the VA on October 13, 2011 to renew his hypertension, gerd, 

and pain medications; however, the medical clinic, not having seen the claimant in over a 

year, did not have authorization to renew. Subsequently, on December 8, 2011, the 

claimant visited Dr. Noerager for his yearly follow-up. During this appointment, Dr. 

Noerager ordered x-rays and a stress test, and prescribed tramadol for the claimant’s 

chest pain. The claimant’s hypertension and gerd both continued to remain stable. (R.

989-90, 1102).

In a letter dated December 13, 2011, Dr. Noerager notified the claimant that the xrays showed no abnormalities. Similarly, after a nuclear cardiac stress test conducted on 

January 20, 2012, Dr. Noerager sent another letter notifying the claimant that the stress 

test was also normal. (R. 981-86).

On April 18, 2012, the claimant called the VA hospital complaining of chronic 

pain. Dr. Noerager scheduled a follow-up appointment to address this pain on April 24, 

2012. During the appointment, Dr. Noerager diagnosed the claimant with hematuria and 

lipoma, ordered an MRI, and prescribed Roboxin, Tramadol, and Gabapentin for lower 

back pain. (R. 976-980)

The claimant underwent the MRI on June 1, 2012. During the MRI follow-up on 

June 5, 2012, Dr. Noerager diagnosed the claimant with spinal stenosis and lipomatosis

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 6 of 27
7

caused by mild central canal narrowing and cord compression at C6-C7, and referred the

claimant to the VA neurosurgeon. Before the neurology consultation, however, the 

claimant was admitted to the intensive care unit and diagnosed with angina on June 17, 

2012. (R. 943, 972-73).

The claimant remained in the hospital for three days. On June 18, 2012, the 

claimant underwent an angiography and cardiac catheterization surgery to place a heart 

catheter and stent in the claimant’s coronary artery. Although the angina was ultimately 

unresolved, the treating physician prescribed Plaviz and Lisinopril and discharged the 

claimant on June 19, 2012. During the claimant’s June 28, 2012 emergency room followup, Dr. Noerager reported no substantial changes regarding his hypertension, gerd, chest 

pain, lower back pain, hematuria, or lipoma. (R. 877-78, 906, 925).

Upon Dr. Noerager’s referral, the claimant also visited Dr. Carin Eubanks at the 

VA the mental health department on June 28, 2012. Dr. Eubanks diagnosed the claimant 

with moderate psychological distress and recommended future treatment, but the 

claimant refused further treatment. (R. 876-77). 

On July 17, 2012, the claimant visited Dr. Gilbert J. Perry at the VA Cardiology 

Clinic to follow-up on his cardiac surgery. Dr. Perry reported that the claimant’s 

hypertension was controlled, and referred the claimant to cardiac rehab. (R. 862-64). 

During his yearly follow-up on August 7, 2012, Dr. Noerager stated that the 

claimant’s hypertension was controlled; however, his gerd was not improving because he 

no longer took his medication. She noted that the claimant needed to stop any activity 

causing chest pain, and that he should not return to work until early September 2012 after 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 7 of 27
8

cardiac rehab. On the same day, the claimant underwent a GXT echocardiogram to 

evaluate chest pain that showed no abnormalities. (R. 848, 855).

The claimant visited the Kirklin Clinic at UAB Health Center – Hueytown on 

August 14, 2012. During this initial visit, Dr. Jonathan D. Mize suggested the claimant 

continue his current blood pressure medication, and gave the claimant a detailed meal 

plan. (R. 280).

On August 23, 2012, the claimant enrolled in cardiac rehab at Spain Rehab 

Center. He attended two cardiac rehab sessions before his first visit with the VA 

neurosurgeon Dr. Kimberly P. Kicielinski. After a general consultation on August 28, 

2012, Dr. Kicielinski recommended the claimant continue cardiac rehab and discuss 

occupational therapy with his primary physician before any potential spinal surgeries are 

discussed further. (R.303-04, 841-42).

The claimant attended five more cardiac rehab sessions before a cardiac follow-up 

with Dr. Perry on September 11, 2012. The claimant asserted that he felt his physical 

endurance was improving; however, Dr. Perry did not report any significant health 

changes and recommended the claimant continue cardiac rehab. (R. 306-14, 840).

On September 17, 2012, the claimant called Dr. Noerager’s office requesting to 

stay off work until he completed cardiac rehab. After reviewing the phone call, Dr. 

Noerager concluded that she needed more information before agreeing to the note. Before 

Dr. Noerager could gather that information, though, the claimant visited Dr. Perry on 

September 19, 2012 for a formal clearance to return to work as a truck driver. Dr. Perry 

wrote a letter to the claimant’s company clearing the claimant to drive from a 

cardiovascular standpoint, but restricting lifting until cleared by a neurosurgeon, and 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 8 of 27
9

restricting lifting to twenty-five pounds after a neurosurgical clearance. Dr. Perry also 

opined that cervical or lumbar spine surgery would have to wait approximately twelve 

months until the stent in the claimant’s heart could be removed. (R. 833-35). 

The claimant attended his yearly check-up at the VA on October 15, 2012. Dr. 

Therese Mays noted no changes to the claimant’s medical report. Similarly, at a 

neurology follow-up on November 6, 2012, the claimant told Dr. Joshua York Menendez 

that he had not fully engaged in cardiac rehab, and that he continued to experience chest 

pain and shortness of breath while walking. Dr. Menendez noted no medical changes and 

recommended that the claimant continue cardiac rehab before following up for additional 

neurological remedies. (R. 806, 818-19).

The claimant submitted a function report and cardiovascular questionnaire to the 

Social Security Administration on October 22, 2012. He explained that he walks around 

his block two to three times a week, and walks on a treadmill and rides a bike at 

cardiovascular therapy. He also stated that he does laundry on occasion, and sometimes 

drove himself to therapy or to church. (R. R. 211-225). 

On November 30, 2012, the claimant went to the VA emergency room with the 

chief complaint that he hurt all over. He remained hospitalized for three additional days, 

and underwent another cardiac catheterization operation. He was diagnosed with 

hemorrhoids, but doctors noted no echocardiogram or other cardiac changes, and the 

claimant was ultimately discharged on December 3, 2012. (R. 707, 724, 790-92).

The claimant returned to his primary doctor at the VA for a follow-up on 

December 11, 2012, where Dr. Noerager noted his controlled hypertension. Dr. Noerager 

also noted the claimant’s back pain and deteriorating arm strength, and expressed the 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 9 of 27
10

claimant’s need for back surgery. Dr. Noerager also ordered an abdominal and pelvis CT 

scan because of an enlarged prostate. (R. 1145-47).

The claimant attended his first psychotherapy session at the VA on December 14, 

2012 with Dr. Lindsey Moore. Dr. Moore noted that the claimant experienced a 

significant level of psychological distress, and requested the claimant return at the end of 

the month. (R. 1138-40). 

On December 21, 2012, the claimant called Dr. Noerager’s office to request an 

Oxycodone and Clonzepam refill. Dr. Noerager declined to prescribe Oxycodone and 

Clonzepam, but instead perscribed Percocet for pain. Again, on January 18, 2013, the 

claimant called to renew his pain medication.3 (R. 1494, 1506-07).

The claimant attended another psychotherapy treatment session with Dr. Moore 

on December 31, 2012. During this meeting, Dr. Moore recommended the claimant 

continue seeing Dr. Noerager, and suggested he continue psychotherapy treatment to 

discuss coping mechanisms. Subsequently, the claimant attended two additional 

psychotherapy sessions in January 2013. 

Because of abnormal CT results, the claimant underwent flexible 

cystourethroscopy surgery on January 28, 2013 at the VA to evaluate at the claimant’s 

bladder for disease, which yielded no abnormalities. On February 5, 2013, the 

psychotherapy treatment department at the VA noted the claimant’s stable mental state. 

Then, on February 11, 2013, the claimant again called Dr. Noerager to refill his pain 

medication. (R. 1476, 1486).

 3 The medical record states that Dr. Noerager’s office received the request, but does not 

specify whether Dr. Noerager granted the request.

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 10 of 27
11

During his yearly check-up at the VA on February 15, 2013, Dr. Noerager noted 

that the claimant’s gerd was getting worse, so she referred him to a gastroenterologist to 

further analyze the claimant’s non-improving gerd. Lastly, Dr. Noerager and the claimant 

discussed increasing the claimant’s Percocet dosage or switching to Morphine for pain 

treatment. The claimant did not want to switch to Morphine, so Dr. Noerager agreed to 

prescribe more Percocet for the claimant’s chronic back pain. (R. 1471).

On March 3, 2013, the claimant visited Dr. Michael Passarella in the VA’s 

gastroenterology department at Dr. Noerager’s request. Dr. Passarella conducted a 

barium swallow test and ordered an esophagogastroduodenoscopy procedure to test for 

dysphagia. During his follow-up on March 4, 2013, Dr. Passarella notified the claimant 

that the barium swallow yielded a mild gerd diagnosis. The claimant again requested 

more pain medication from Dr. Noerager on April 3, 2013.4 (R. 1452, 1459, 1465).

In April 2013, the claimant attended two additional psychotherapy sessions at the 

VA, when he discussed mental health issues arising from his health problems; however, 

Dr. Moore did not note any significant changes in mental health, and planned to continue 

discussing coping mechanisms. 

The claimant underwent an esophagogastroduodenoscopy with possible 

interventions procedure on April 28, 2013 to examine and treat esophagus, stomach, and 

upper intestinal issues. On May 6, 2013, the claimant re-requested pain medication from 

Dr. Noerager.5 Subsequently, during the procedure follow-up appointment on May 13, 

 4 The medical record states that Dr. Noerager’s office received the request, but does not 

specify whether Dr. Noerager granted the request.

5 The medical record states that Dr. Noerager’s office received the request, but does not 

specify whether Dr. Noerager granted the request.

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 11 of 27
12

2013, Dr. Passarella noted that the bowel biopsies were normal; however, he diagnosed 

the claimant with dysphagia, and ordered a CT scan and pre-creatinine. (R. 1571, 1582).

On August 30, 2013, Dr. Barton Guthrie at the VA performed a C6-C7 anterior 

cervical discectomy with fusion on the claimant’s back. The claimant noted improvement 

in his left upper extremity after surgery, and was discharged that same day. (R. 1539). 

Dr. Noerager ordered physical therapy to treat the claimant’s continued back pain

on October 25, 2013. The order specified that the therapy should be conducted two times 

per week for six weeks, and gave no medical precautions. The claimant scheduled four 

appointments between October 30, 2013 and December 9, 2013; however, the therapy 

department discontinued because the claimant failed to show up to two of the four 

appointments. (R. 1544-46).

A post-surgery MRI of the claimant’s back on December 3, 2013 revealed 

degenerative changes involving the facet joints, lateral recess stenosis at L2-3 and L3-4 

without definite nerve root compression, left forminal stenosis at L4-5, and nerve root 

compression in the roof of the neural foramen. (R. 1516-17).

The claimant again visited the VA emergency room on December 10, 2013 with 

complaints of chest pain. The attending physician, Dr. Thomas Stewart Huddle 

determined that, because three sets of cardiac markers were negative and his

echocardiogram was normal, the claimant’s chest pain was likely musculoskeletal. The 

emergency room discharged the claimant without a new diagnosis on December 11, 

2013. (R. 1536-1538). 

On December 17, 2013, Dr. Noerager submitted another order for physical 

therapy. The order specified that physical therapy should take place two times per week 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 12 of 27
13

for six weeks with no medical precautions. She noted that physical therapy was 

previously discontinued because the claimant was hospitalized, and explained that he 

needed physical therapy before his neurosurgeon would schedule a follow-up. The 

claimant scheduled nine appointments between December 19, 2013 and February 12, 

2014. The physical therapy department cancelled two of the nine appointments for 

administrative purposes; however, the claimant cancelled one appointment and did not 

show up to three of the nine appointments. The physical therapy department again

discontinued treatment per hospital policy. (R. 1542-44). 

Finally, during a cardiology follow-up on February 18, 2014, the claimant 

underwent a GXT echocardiogram and x-rays, and all results were normal. Then, after 

the claimant asserted that he could walk one and a half miles in twenty minutes without 

significant difficulty, the cardiologist also concluded that the claimant’s chest pain was 

unlikely heart related. The cardiologist also noted that the claimant’s musculoskeletal 

exam yielded full range of motion, no joint effusion or crepitus, and no CCE. (R. 1547).

The ALJ Hearing

At the hearing on October 23, 2013, the claimant testified that he lives at home 

with his wife, eighteen-year-old daughter, and thirteen-year-old son. He testified that if 

he is not laying around at home, he tries to walk around his neighborhood and do 

streatching exercises. He stated that he tries to walk two miles; however, he often has to 

stop and finish later. (R. 35-36). 

The claimant further testified that he could no longer drive after his neck surgery 

on December 30, 2013. He stated that the last road trip he took was to New York for his 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 13 of 27
14

brother’s funeral November 2013. He explained that the trip took twelve to thirteen 

hours; however, he did not drive at all during the trip. (R. 38-39).

The claimant testified that his son used to play basketball, and his daughter used 

to play track. He stated that he would attend every game and track meet they were 

involved in. He also testified that he would often drive them to practice prior to his neck 

surgery. (R. 39-40). 

When questioned about unemployment, food stamps, and health insurance, the 

claimant explained that he did not qualify for them. He could not afford to add himself to 

his wife’s health insurance; however, he does receive health coverage at the VA hospital. 

He testified that from June to October 2012 he received Aflac short term disability, but 

no longer receives any type of worker’s compensation. (R. 40-42). 

The claimant testified that he stopped working because of his heart condition, and 

he cannot work any longer because of his inability to lift more than eight pounds and 

shortness of breath. He also stated that he has mental impairments that keep him from 

working and that he does not take care of anyone while staying at home. (R. 42-46, 48).

When asked if he smoked or drank alcohol, the claimant explained that he did in 

the past, but he stopped after he underwent heart surgery in 2012. He also stated that he 

only took illegal drugs in high school, and no longer uses them. (R. 47-48).

The claimant testified that prior to his neck surgery he would have rated his pain 

as a ten on a scale from zero to ten. He also stated that prior to heart surgery he did not 

know he had an issue with his heart. He explained that he was experiencing pain 

everywhere but did not know why and would consistently complain to his supervisor. (R. 

51-52).

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 14 of 27
15

When asked about prior work, the claimant testified that he had been a truck 

driver for Tyson Shared Services in 1999. This job did not require the claimant to lift, as 

he was hauling livestock. In 2000, the claimant testified that he was a meat separator, 

which required him to lift and transfer approximately eighty pounds of groceries from a 

cooler to a truck. Then, in 2001, he pulled stock on pallets using a go-cart to transfer the 

stacks to the trucks or into the grocery store. From 2001-2003, he delivered wine from a 

delivery truck, which required him to lift approximately one-hundred pounds at every 

stop. Next, from 2004-2006, the claimant worked as a shredder for EnviroShred and 

Bruce Office Supply. Finally, in 2007, the claimant went back to driving trucks and 

delivering wine. (R. 57-61).

A vocational expert, Dr. Jewel Elizabeth Bishop Euto, testified concerning the 

type and availability of jobs that the claimant was able to perform. Dr. Euto testified that 

the claimant’s past relevant work was as a shredder, a delivery driver, a produce clerk, 

and a material handler. Dr. Euto classified the shredder position as medium and unskilled 

work; the delivery driver position as medium and semi-skilled work; the produce clerk 

position as medium and unskilled work; and the material handler position as heavy and 

semi-skilled work. (R. 62).

The ALJ asked Dr. Euto to assume that a hypothetical individual with the same 

age, education, and work experience as the claimant is limited to light work with 

occasional balancing, stooping, kneeling, crouching, crawling, and climbing ramps and 

stairs; no climbing ladders or scaffolds; occasional bilateral overhead reaching; no 

exposure to extreme cold, heat, fumes, dust, gases, poor ventilation, or vibration; and no 

hazardous machinery or unprotected heights. Dr. Euto stated the hypothetical individual 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 15 of 27
16

could not perform the claimant’s previous work. The ALJ asked Dr. Euto if other jobs 

existed in the region or nation that the individual could perform. Dr. Euto replied that the 

hypothetical individual could perform work as a counter clerk, classified as light exertion, 

and unskilled work, with 8,500 jobs in Alabama and 432,650 jobs in the nation; usher, 

classified as light exertion, unskilled work, with 1,750 jobs in Alabama and 106,650 jobs 

in the nation; and rental clerk, classified as light exertion, unskilled work, with 8,550 jobs 

in Alabama and 432,750 in the nation. (R. 62-63).

The ALJ then added an additional limitation requiring the hypothetical person to 

alternate between standing and sitting every thirty minutes to an hour while being on 

task, and asked if the same jobs would remain available. Dr. Euto testified that the same 

jobs would remain available, with a reduction in numbers by fifty percent. (R. 64).

The ALJ then changed the hypothetical to include an individual who can perform 

simple tasks for two hours at a time with normal breaks, and can only tolerate infrequent

changes in the workplace introduced gradually when necessary. The ALJ asked if the 

individual would be able to perform any jobs. Dr. Euto replied that the hypothetical 

individual could perform work as a bench assembler, classified as light exertion, and 

unskilled work, with 1,800 jobs in Alabama and 218,700 jobs in the nation; a sorter, 

classified as light exertion, unskilled work, with 375 jobs in Alabama and 39,050 jobs in 

the nation; and an inspector, classified as light exertion, unskilled work, with 7,100 jobs 

in Alabama and 454,010 in the nation. (R. 64-65).

Again, the ALJ added an additional limitation of sedentary work, and asked if the 

claimant in this case had acquired any skills in his past relevant work that would transfer 

to jobs at a sedentary exertion level. Dr. Euto testified that the claimant has not acquired 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 16 of 27
17

the required skills. (R. 65).

Then, the ALJ went back to the first three proposed hypotheticals, and asked 

whether the jobs would remain if the individual would be off task for ten percent of the 

day. Dr. Euto stated that the jobs would remain the same. The ALJ then increased the 

percentage to fifteen percent, and asked if the jobs would remain the same. Dr. Euto 

testified that fifteen percent of the day would be excessively off task and would preclude 

all work activity. (R. 65-66).

Finally, the claimant’s counsel proposed a final adjustment to the hypothetical 

when he asked if any jobs would be available to the described individual if the individual 

was required to recline two to three hours in a workday. Dr. Euto stated that this 

adjustment would preclude all work activity; however, she described this hypothetical as

abnormal because of potential future surgeries. Dr. Euto expressed concern that frequent 

surgery would affect reliability and excessive absenteeism. (R. 66-68).

The ALJ’s Decision

On May 1, 2014, the ALJ issued a decision finding that the claimant was not 

disabled under the Social Security Act. First, the ALJ found that the claimant met the 

insured status requirements of the Social Security Act through December 31, 2016, and 

had not engaged in substantial gainful activity since his June 16, 2012 alleged onset date.

(R. 12).

Next, the ALJ found that the claimant had the severe impairments of coronary 

artery disease status post stent; hypertension; degenerative disc disease of the lumbar 

spine; degenerative disc disease of the cervical spine; and adjustment disorder with both 

depressed and anxious mood. The ALJ found the claimant’s gerd to be non-severe after 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 17 of 27
18

reviewing two EGDs that revealed a normal esophagus and only mild chronic gastritis 

results, and two barium swallows that yielded only mild results. The ALJ explained that 

doctors increased the claimant’s medication, and that the subsequent treatment records do 

not support ongoing symptoms that would cause more than a minimal limitation to the 

claimant’s working ability. (R. 12-13). 

Similarly, the ALJ stated the claimant’s hematuria was confirmed by lab work, 

however a CT scan did not render a cause, and the claimant was not treated for his 

impairment, so the record does not support symptoms that would cause more than 

minimal limitations. Additionally, the ALJ did not find any record to show treatment for 

a cataract or ongoing symptoms of a visual impairment, and the claimant’s hemorrhoids 

were managed with warm soaks, rendering them nonsevere. (R. 13). 

The ALJ next found that the claimant did not have an impairment or combination 

of impairments that met or medically equaled the severity of one of the listed 

impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ considered whether 

the claimant met the criteria for listing 1.04 concerning a disorder of the spine. To meet 

this listing, the claimant would have to demonstrate evidence of nerve rood compression 

in a neuro-anatomic distribution with motor, sensory, or reflex loss, or spinal 

arachnoiditis confirmed by operative note or pathology report or lumbar spinal stenosis 

resulting in pseudoclaudication with an inability to ambulate effectively. The ALJ noted 

that the claimant did not tender such evidence. (R. 14).

Additionally, the ALJ considered whether the claimant met the requirements of 

listing 4.00 and 4.06, requiring evidence of the required levels of cardiac enlargement, 

congestive heart failure or of a vision, kidney, or neurological impairment. The ALJ 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 18 of 27
19

explained that the evidence does not support the level of occlusion of arteries resulting in 

a serious limitation in the ability to initiate, sustain, or complete activities or daily living 

required by these listings. (R. 14).

The ALJ also considered whether the claimant met the criteria for listing 12.04 

and 12.06 “paragraph B” concerning mental impairments. To meet this listing, the 

claimant would have to demonstrate that the mental impairments result in at least two of 

the following: marked restriction of activities of daily living; marked difficulties in 

maintaining social functioning; marked difficulties in maintaining concentration, 

persistence, or pace; or repeated episodes of decompensation, each of extended duration. 

The ALJ noted that based on the claimant’s reported daily activities and social 

functioning, such as doing laundry, driving, attending church, and ability to pay attention 

and follow instructions, his mental impairments did not cause at least two “marked” 

limitations or one “marked” limitation. (R. 14-15).

Additionally, the ALJ considered whether the claimant met the requirements of 

“paragraph C,” requiring evidence of episodes of decompensation, potential episodes of 

decompensation, or the inability to function outside a highly supportive living 

arrangement. The ALJ determined that the claimant has experienced no episodes of 

decompensation, and no evidence showed a residual disease process that has resulted in 

such marginal adjustment that even a minimal increase in mental demands or change in 

environment would be predicted to cause the claimant to decompensate. (R. 15).

Next, the ALJ determined that the claimant had the residual functional capacity to 

perform light work as defined in 20 CFR 404.1567(b) except for the following 

limitations: occasional balancing, stooping, kneeling, crouching, crawling, and climbing 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 19 of 27
20

ramps and stairs; no climbing ladders, ropes, or scaffolds; occasional bilateral reaching 

overhead; no concentrated exposure to extreme cold, heat, fumes, dust, gases, poor 

ventilation, or vibration; and no hazardous machinery or unprotected heights. The 

claimant must be able to alternate between standing and sitting every thirty minutes to 

one hour while remaining on task. Mentally, the claimant is able to understand, 

remember, and carry out unskilled, simple tasks for two hours at a time with normal 

breaks; and have casual contact with coworkers, supervisors, and the public. The 

claimant is limited to an environment where changes are infrequent but, when necessary, 

are introduced gradually. (R. 16).

In making this finding, the ALJ considered the claimant’s symptoms and the 

corresponding medical record. The ALJ concluded that, although the claimant’s 

medically determinable impairments could reasonably be expected to cause his

symptoms, the claimant’s allegations regarding the intensity, persistence, and limiting 

effects of those symptoms were not fully credible when compared with the evidence. (R. 

17). 

First, the ALJ considered the claimant’s coronary artery disease allegations in 

light of the medical record. She discussed the angiography the claimant underwent on 

June 18, 2012, which showed severe proximal left anterior descending artery disease, but 

no obstructive coronary artery disease. The ALJ noted that post procedure stenosis was 

improved, and a follow-up stress test on August 7, 2012 was normal. (R. 17).

The ALJ then looked to the cardiac rehabilitation notes to show that the 

claimant’s cardiac issues were improving. The ALJ stated that on August 2012, tests 

showed no cardiac issues or symptoms, and the claimant expressed that his endurance 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 20 of 27
21

was improving. Then, on November 6, 2012, the claimant told his neurologist that he had 

not fully engaged in cardiac rehab, and that he continued to have chest pain while 

walking and to be short of breath. The ALJ noted that on that same day, the claimant’s 

cardiologist noted that his coronary artery disease and hypertension were stable. (R. 17).

The ALJ explained that the claimant’s chest plain was frequently dismissed as 

non-cardiac related. For example, the ALJ looked to the November 30, 2012 emergency 

room visit, during which cardiac catheterization showed a stable stent and no obstructive 

disease. The ALJ noted that after four days of being monitored, the hospital discharged 

the claimant with his previously prescribed cardiac medication, and doctors noted that the 

chest pain was likely musculoskeletal in nature. (R. 17).

Similarly, the ALJ looked at the claimant’s emergency room visit on December 

10, 2013. The ALJ noted that the cardiac markers were all negative and that the treating 

physician again thought the chest pain was a musculoskeletal problem. Then, the ALJ 

looked at the follow- up appointment on February 18, 2014, when the claimant’s 

cardiologist opined that the claimant’s chest pain was unlikely heart related. (R. 18). 

Second, the ALJ considered the claimant’s degenerative disc disease allegations 

in light of the medical record. The ALJ began by referencing the claimant’s June 1, 2012 

MRI, which revealed mild central canal narrowing and cord compression at C6-C7. She 

then compared the June MRI with an MRI taken on December 3, 2013 and an x-ray taken 

on February 18, 2013 to show only minimal degenerative progression. (R. 18).

The ALJ pinpointed December 2012 as the month the claimant began 

experiencing slightly reduced grip in his hands. The ALJ stated that the claimant 

ultimately underwent a C6-C7 anterior cervical discectomy with fusion on August 30, 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 21 of 27
22

2013; however, the claimant maintained full range of motion during his cardiology 

follow-up on February 18, 2014. (R. 18).

While the objective evidence does reveal abnormalities, the medical findings do 

not support the degree of debilitation alleged. For example, the ALJ noted that the MRI’s 

taken do show significant changes in the cervical spine; however, the claimant’s strength 

over time has only decreased slightly. Similarly, although the MRI’s revealed some nerve 

root compression, the claimant ambulated normally. (R. 19). 

The ALJ then considered the claimant’s daily activities and determined that, 

because the claimant reported that he mowed his lawn two weeks after heart surgery, 

walks approximately 2 miles several times per week, attended his children’s sporting 

events, and recently took a thirteen-hour road trip from Alabama to New York, his daily 

activities support light work capabilities. Furthermore, the ALJ noted that the claimant’s 

cardiologist released him back to work, as long as he only performed the equivalent of 

light work. Similarly, the ALJ stated that the neurosurgeon who performed the claimant’s 

spinal surgery opined that the claimant could engage in activity as tolerated, but should 

not participate in strenuous activity. The ALJ determined that these factors undermine 

allegations of the severity and frequency of the claimant’s symptoms. (R. 21-22). 

Finally, the ALJ, relying on the vocational expert’s testimony, found that the 

claimant is unable to perform any of his past relevant work. The ALJ determined that 

based on the claimant’s age, education, work experience, residual functional capacity, 

and the vocational expert’s testimony, jobs existed in significant numbers in the national 

economy that the claimant could perform. (R. 23).

VI. DISCUSSION

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 22 of 27
23

The claimant argues that the ALJ improperly discredited the claimant’s subjective 

complaints of pain and characterizations of his physical limitations. To the contrary, this 

court finds that substantial evidence supports the ALJ’s findings and that she applied the 

appropriate legal standards to her evaluation of the claimant’s subjective complaints and 

allegations of pain.

A Commissioner evaluating a claimant’s pain and other subjective complaints 

must first consider whether the claimant demonstrated an underlying medical condition. 

Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991); see also Wilson v. Barnhart, 284 

F.3d 1219, 1221 (11th Cir. 2002); 20 C.F.R. § 404.1529. If the claimant demonstrates an 

underlying medical condition, the Commissioner must then determine if any objective 

medical evidence confirms the severity of the alleged pain, or if the underlying medical 

condition has been objectively confirmed and is so severe that one could reasonably 

expect it to give rise to the alleged pain. Holt, 921 F.2d at 1223. Subjective testimony can 

satisfy the pain standard if the testimony is supported by objective medical evidence.

Foote v. Chater, 67 F.3d 1553, 1561(11th Cir. 1995).

The ALJ must articulate reasons for discrediting the claimant’s subjective 

testimony. Foote, 67 F.3d at 1561-62; Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 

1991). The reasons articulated for discrediting the claimant’s testimony may include the 

claimant’s daily activities. Harwell v. Heckler, 735 F.2d 1292, 1293 (11th Cir. 1984). 

However, if the ALJ does not articulate reasons, the court must accept the claimant’s 

testimony as true. Holt, 921 F.2d at 1236.

On March 16, 2016, the Social Security Administration issued a Notice of Social 

Security Ruling, which provides guidance and clarification on how to evaluate claimant 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 23 of 27
24

statements about “the intensity, persistence, and limiting effects of symptoms in disability 

claims under Titles II and XVI . . . and blindness claims under Title XVI of the Act.” 

SSR 16-3p, 81 Fed. Reg. 14166-01 (Mar. 16, 2016). Concerned that subjective evidence 

was being viewed in light of the claimant’s personal character, the Social Security 

Administration clarified the two step pain standard, eliminating the term “credibility,” 

and delineating that evaluation of subjective evidence is not an analysis of the claimant’s 

character: 

Step 1: We Determine Whether the Individual Has a Medically 

Determinable Impairment (MDI) That Could Reasonably be Expected to 

Produce the Individual’s Alleged Symptoms . . . Step 2: We Evaluate the 

Intensity and Persistence of an Individual’s Symptoms Such as Pain and 

Determine the Extent to Which an Individual’s Symptoms Limit His or 

Her Ability To Perform Work-Related Activities for an Adult or To 

Function Independently, Appropriately, and Effectively in an AgeAppropriate Manner for a Child With a Title XVI Disability Claim.

Id. (emphasis omitted).

The Social Security Administration did not explicitly deem this ruling retroactive, 

and neither the Eleventh Circuit nor any district court within it has addressed the ruling’s 

retroactivity. See Hargress v. Berryhill, No. 4:16-cv-1079-CLS, 2017 WL 588608, at *2 

(N.D. Ala. Feb. 14, 2017) (stating that “[t]he retroactivity of the Rule has not been 

directly addressed by any Circuit Court of Appeals, or by any district court within this 

Circuit.”). However, even if the court applied SSR 16-3p retroactively, the ALJ did not 

violate it in this case. See id. (explaining that “[e]ven though the ALJ used the word 

‘credible,’ he did not assess claimant’s general, or ‘overall’ character or truthfulness.”). 

Although the ALJ in this case used the term “credible” throughout the opinion, she did 

not use the term to assess the claimant’s character. The ALJ properly analyzed the 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 24 of 27
25

claimant’s subjective evidence in light of the objective medical evidence to determine 

that the subjective evidence was not medically supported.

Furthermore, the ALJ properly articulated her reasons for finding that the 

claimant’s testimony about his pain and characterization of his physical capabilities do 

not warrant a disability. The ALJ concluded that, although the claimant’s medically 

determinable impairments could reasonably be expected to cause symptoms, the 

claimant’s allegations regarding the intensity, persistence, and limiting effects of these 

symptoms were not fully consistent with the evidence. (R. 17). 

The ALJ set forth several reasons for finding the claimant’s allegations 

inconsistent with the evidence. She found that the objective medical evidence conflicted 

with the claimant’s allegations. When evaluating the alleged pain caused by coronary 

artery disease in light of the medical record, the ALJ explained that not only were the 

claimant’s cardiac issues improving over time, the chest pain the claimant complained of 

was not cardiac related. The ALJ pointed to two emergency room visits, during which 

treating physicians noted that the chest pain was likely musculoskeletal in nature.

Furthermore, the claimant admitted that he could walk one and a half miles in less than 

twenty minutes without significant difficulty. (R. 17-18). 

The ALJ then considered pain allegations caused by degenerative disc disease in 

light of the medical record to determine that the claimant’s allegations do not withstand 

objective medical evidence. (R. 19). The ALJ compared the first MRI taken on June 1, 

2012 to the MRI taken on December 3, 2013 after the claimant’s spinal fusion to 

determine that there was only minimal degenerative progression. Then, the ALJ outlined 

the multiple occasions the claimant complained of back pain, and pointed to the record to 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 25 of 27
26

indicate that the claimant maintained full strength, sensation, reflexes, and range of 

motion throughout the entire timeline. Most notably, the ALJ references the August 30, 

2013 spinal fusion, and although the ALJ points out that the post-surgery medical record 

is sparse, the record shows that the claimant maintained full range of motion during his 

cardiology follow-up on February 18, 2014. (R. 18).6

The ALJ also considered the claimant’s daily activity characterizations. The ALJ 

pointed out that the claimant reported to have mowed his lawn only two weeks after heart 

surgery, and that that he consistently walks around his neighborhood without significant 

difficulty. She also noted that the claimant attended every one of his children’s sporting 

events, often transporting them to practice, and recently took a thirteen-hour road trip 

from Alabama to New York. (R. 21)

Lastly, the ALJ referenced two significant medical records implying that the 

claimant is capable of performing light work. First, the ALJ noted that the claimant’s 

cardiologist released him back to work, restricting him to the equivalent of light work. 

Second, his neurosurgeon allowed him to engage in activity as tolerated immediately 

after spinal fusion surgery. While the ALJ did point out that the objective evidence does 

reveal abnormalities, the ALJ concluded that the objective medical evidence does not 

support allegations that the claimant is not capable of performing light work. (R. 22). 

The court finds that these reasons constitute substantial evidence to support the 

ALJ’s determination that the claimant’s subjective complaints do not warrant a disability. 

 6 The record indicates two discontinued physical therapy orders because of the claimant’s 

failure to attend physical therapy. Furthermore, the order form gives the referring 

physician the option to inform the physical therapist of limitations on lifting and/or a 

cardiac pulse cap; however, Dr. Noerager marked “none,” implying that the claimant had 

no weight limitation or cardiac restrictions. (R. 1542-46). 

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 26 of 27
27

Consequently, the ALJ properly characterized the claimant’s subjective complaints in 

light of the objective evidence presented.

VII. CONCLUSION

For the reasons stated above, this court concludes that substantial evidence 

supports the Commissioner’s decision. Accordingly, this court AFFIRMS the decision of 

the Commissioner. 

The court will enter a separate Order in accordance with the Memorandum 

Opinion.

DONE and ORDERED this 21st day of March, 2017.

____________________________________

KARON OWEN BOWDRE

CHIEF UNITED STATES DISTRICT JUDGE

Case 2:15-cv-02224-KOB Document 13 Filed 03/21/17 Page 27 of 27