Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-4_18-cv-01131/USCOURTS-alnd-4_18-cv-01131-0/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

MIDDLE DIVISION

JOYCE INEZ MOORE,

Plaintiff,

v.

ANDREW SAUL, 

Commissioner of the Social 

Security Administration, 

Defendant.

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Case No. 4:18-CV-01131-CLM

MEMORANDUM OPINION

Joyce Inez Moore (“Moore”) seeks Disability Insurance Benefits (“DIB”) 

from the Social Security Administration (“SSA”) based on two impairments: anxiety 

and fibromyalgia. As the Commissioner essentially conceded at oral argument, the 

Administrative Law Judge’s (“ALJ”) conclusion that Moore did not have a 

medically determinable impairment of fibromyalgia is not supported by the record.

While this type of error can be harmless, it’s not harmless here. The Court thus 

vacates the decision below and remands for further consideration.

I. Statement of the Case

Moore received two ALJ opinions below. This appeal involves the second. 

But before the Court details those opinions, it summarizes Moore’s impairments, as 

she explained them to the ALJs.

FILED

 2020 Mar-19 AM 11:36

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 1 of 16
A. Moore’s Impairments, as told to the ALJs

Again, Moore claims two impairments: anxiety and fibromyalgia. Moore 

testified that she began dealing with anxiety issues during her childhood and felt 

panicked going places and being around people. R. at 73. Moore graduated from 

high school and attended college for one year, R. at 71-72, then worked for her 

mother’s property management business. R. at 44, 74. She then worked from home 

preparing disbursement sheets and had no interactions with renters or contractors. 

R. at 74-75. Moore experienced anxiety while dealing with money at her job. R. at 

76. Moore typically worked around ten hours per week. R. at 47.

Moore testified that her anxiety can make her black out and not remember 

things. R. at 46, 77-78. When she is driving, Moore sometimes has to pull over 

during panic attacks. R. at 79. Her episodes occur weekly. R. at 80. Moore has not 

gone grocery shopping for years due to anxiety. R. at 46, 90. Shopping also caused 

Moore back pain and she would need to lean on the grocery cart to get through the 

store. R. at 49-50.

Moore testified that she was diagnosed with fibromyalgia in 1988 when she 

was living in North Carolina. R. at 80. Due to her pain, Moore has trouble sleeping 

and some nights can only sleep for one hour. R. at 54, 77, 81. Moore has pain from 

head to toe and this distracts her from working. R. at 81-82. At times, the pain is so 

bad it makes it difficult for Moore to get out of bed. R. at 47. The pain makes it 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 2 of 16
difficult for Moore to cook, do laundry, or prepare her meals without taking breaks. 

R. at 48. She estimates she can sit for 20 minutes at a time and has trouble writing 

and holding objects due to her pain. R. at 82-83. If she stands for more than 10 

minutes, Moore experiences pain in her hips and back. R. at 86. 

B. The First ALJ Decision

The SSA reviews applications for disability benefits in three stages: (1) Initial 

determination, including reconsideration, (2) review by an ALJ, and (3) review by 

the SSA Appeals Council. See 20 C.F.R. § 404.900(a)(1-4) (2019). 

Moore applied for DIB, and the SSA initially denied her claim in February

2013. R. at 150. Moore requested an ALJ hearing. R. at 151-153. 

The first ALJ heard Moore’s claims in September 2014. R. at 64, 199. Two 

months later, the ALJ denied Moore’s request for benefits, R. at 128-140, finding 

that Moore did not have a severe impairment or combination of impairments and 

that her testimony was not entirely credible. R. at 130, 132. 

Moore then asked the Appeals Council to review the decision. It did, and in 

June 2016, the Council vacated the opinion because the ALJ wrongly listed Moore’s 

Date Last Insured. R. at 141-143. The Appeals Council gave two remand instructions 

relevant here. First, the Council instructed the ALJ to give more consideration to

Moore’s impairments at Step Two. R. at 143. Second, the Council instructed the ALJ 

to “give further consideration of Dr. Balcarek’s treating source opinion.” Id.

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 3 of 16
C. Determining Disability

Before detailing the second ALJ’s opinion—the one at issue here—it is 

important to lay out the SSA’s five-step process to determine whether an individual 

is disabled and thus entitled to benefits under the Social Security Act: 

The 5-Step Test

Step 1 Is the Claimant engaged in substantial 

gainful activity?

If yes, claim denied.

If no, proceed to Step 2.

Step 2 Does the Claimant suffer from a severe, 

medically-determinable impairment or 

combination of impairments?

If no, claim denied.

If yes, proceed to Step 3.

Step 3 Does the Step 2 impairment meet the 

criteria of an impairment listed in 20 

CFR Part 404, Subpart P, Appx. 1?

If yes, claim granted.

If no, proceed to Step 4.

Step 4 Does the Claimant possess the residual 

functional capacity to perform the 

requirements of his past relevant work?

If yes, claim denied.

If no, proceed to Step 5. 

Step 5 Is the Claimant able to do any other 

work considering his residual functional 

capacity, age, education, and work 

experience?

If yes, claim denied.

If no, claim granted.

See 20 C.F.R. §§ 404.1520(a), 404.1520(b) (2019) (Step 1); 20 C.F.R. § 404.1520(c) 

(2019) (Step 2); 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526 (2019) (Step 3); 20

C.F.R. § 404.1520(e-f) (2019) (Step 4); 20 C.F.R. § 404.1520(g) (2019) (Step 5).

Here, the ALJ’s findings at Steps 2 and 3 are the most relevant. Step 2 is 

important because that is where the error occurred—i.e., the ALJ failed to consider 

Moore’s fibromyalgia as a medically determinable impairment. Step 3 is important 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 4 of 16
because it is the first step (although not necessarily the only one) that shows why the 

Step 2 error was not harmless. 

D. The Second ALJ’s Decision

A second ALJ conducted a hearing on Moore’s DIB claims in October 2016. 

The second ALJ issued an unfavorable decision in June the next year.

The ALJ found at Step 1 that Moore did not engage in substantial gainful 

activity from her alleged onset date of December 31, 2011 through her date last 

insured of September 30, 2014. R. at 24. 

The ALJ found at Step 2 that Moore had a severe impairment of anxiety. R. 

at 24. Relevant here, the ALJ found that Moore’s allegations of fibromyalgia did not 

rise to the level of a medically determinable impairment. R. at 25. The ALJ also 

found that, while Moore has degenerative disc disease and degenerative joint 

disease, these conditions were “not ‘severe’ as defined by the Regulations.” R. at 25. 

At Step 3, the ALJ reviewed the medical evidence about Moore’s anxiety and 

found that Moore did not meet the listing criteria under Listing 12.06. R. at 26. The 

ALJ also found that none of Moore’s impairments, individually or combined, met or 

equaled the severity of the impairments listed in 20 CFR Part 404, Subpart P, 

Appendix 1. R. at 26. 

The ALJ next determined Moore’s residual functional capacity: “the full 

range of light work,” with certain limitations. R. at 27. 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 5 of 16
The ALJ went to Step 4 and 5, where she found that, while Moore was unable 

to perform any of her past relevant work (Step 4), there were light, unskilled jobs in 

the national economy that Moore could perform, including laundry classifier, router, 

or garment sorter (Step 5). R. at 30-31. The ALJ thus found that Moore was not 

disabled and not entitled to benefits. R. at 32.

Moore requested an Appeals Council review of the second ALJ’s decision. 

R. at 290. The SSA Appeals Council will review an ALJ’s decision only for very 

particular reasons, and the Council found that Moore had not established one of the 

reasons. As a result, the second ALJ’s decision became the final decision of the SSA 

Commissioner, and thus the decision subject to review by this Court. 

II. Standard of Review

This Court’s role in reviewing claims brought under the Social Security Act 

is a narrow one. The scope of the Court’s review is limited to (a) whether the record 

contains substantial evidence to sustain the ALJ’s decision, see 42 U.S.C. § 405(g); 

Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982), and (b) whether the ALJ 

applied the correct legal standards, see Stone v. Comm'r of Soc. Sec., 544 F. App'x 

839, 841 (11th Cir. 2013) (citing Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 

1158 (11th Cir. 2004)).

The Court’s decision hinges on the first of these roles—i.e., reviewing the 

ALJ’s fact findings. Again, 42 U.S.C. §§ 405(g) and 1383(c) mandate that the 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 6 of 16
Commissioner’s “factual findings are conclusive if supported by ‘substantial 

evidence.’” Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). So even if this 

Court finds that the proof preponderates against the Commissioner’s decision, it 

must affirm if the decision is supported by substantial evidence. Miles, 84 F.3d at 

1400 (citing Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).

That said, no decision is automatic, for “despite th[e] deferential standard, it 

is imperative that th[is] Court scrutinize the record in its entirety to determine the 

reasonableness of the decision reached.” Bridges v. Bowen, 815 F.2d 622, 624 (11th 

Cir. 1987) (citing Arnold v. Heckler, 732 F.2d 881, 883 (11th Cir. 1984)). 

As explained below, this is one of those rare cases in which the Commissioner/ 

ALJ’s factual findings are not supported by substantial evidence.

III. Legal Analysis

Moore raised five arguments in her original brief to the Court. Doc. 8 at 1-2. 

Because the Court is reversing and remanding on the third argument—i.e., the ALJ 

wrongly decided in Step 2 that Moore’s fibromyalgia was not a medically 

determinable impairment—the Court does not decide the remaining four issues.1

 1 Although the Court does not reach it here, the Court notes that Moore conceded at oral argument 

that her first argument regarding res judicata was meritless because the first ALJ’s decision was 

set aside. Trans. 14. 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 7 of 16
I. The ALJ’s finding that Moore’s Fibromyalgia is a not a “medically 

determinable impairment” is not supported by substantial evidence.

Moore argues that the following finding in Step 2 is not supported by 

substantial evidence: “Under the circumstances, the undersigned must conclude that 

the claimant’s allegations of fibromyalgia do not give rise to a medically 

determinable impairment (SSR 96-3).2

” R. at 25.

During oral argument, the Commissioner essentially conceded the issue: 

“Your honor, fairly, I think there is a very good argument that Plaintiff has that 

substantial evidence doesn’t support the finding that there was not a medically 

determinable impact—medically determinable impairment on Step Two.” Trans. 11. 

The Commissioner argued instead that the error was harmless; a contention the Court 

addresses in Part II. But the Court first explains the ALJ’s error because it matters 

to the harmless error analysis.

The ALJ made the following fact finding regarding fibromyalgia in Step 2:

There is no evidence the claimant has ever been diagnosed with 

fibromyalgia or that she has sought treatment for fibromyalgia. 

Although tender points were noted in the back, as noted below in the 

regulations, tender points must be shown above and below the waist, 

which was not shown in the record. Furthermore, even though the 

rheumatologist stated her symptoms were ‘classic fibromyalgia,’ all 

other diagnosis or causes for the symptoms were not ruled out and she 

did not return after one visit. 

 2 Social Security Ruling 96-3p, cited by the ALJ, has been rescinded. The SSA applies Ruling 16-

3p to determine whether an ailment is a “medically determinable impairment,” and if so, whether 

that impairment is severe. 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 8 of 16
R. at 24. In his initial brief (i.e., before he conceded the point), the Commissioner 

used this quote to argue that the ALJ’s conclusion was supported by four findings: 

“1) the lack of evidence of a diagnosis of fibromyalgia, 2) the lack of treatment for 

fibromyalgia, 3) the lack of evidence that there were tender point above and below 

the waist, and 4) the failure to rule out other causes for Plaintiff’s symptoms.” Doc. 

9 at 7-9. Each of these findings is refuted by the record.

1. No Diagnosis of Fibromyalgia: Contrary to the ALJ’s finding that “there is 

no evidence that the claimant has ever been diagnosed with fibromyalgia,” R. at 24, 

the record contains evidence of at least five diagnosis of fibromyalgia. Moore 

testified that she was first diagnosed as having fibromyalgia by two persons (a doctor 

and a chiropractor) in 1988. R. at 80-81. 

Next, on at least three trips to Primary Care Medical Center in 1997, Dr. Mary 

Toland specified a “diagnosis” of “fibromyalgia”:

R. at 471-73.

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 9 of 16
In March 2012, Dr. Ruth Yates referred Moore to Rheumatologist William 

Shergy to investigate “fibromyalgia.” R. 479. After meeting with Moore, Dr. Shergy 

stated that Moore displayed “the clinical picture of fibromyalgia,” R. 480, and 

diagnosed her with having “fibromyalgia syndrome.” R. 481.

Two months later, Dr. Edward Whit found that “Patient [Moore] is positive 

for myalgias.” R. at 493. When Moore returned one month later (June 2012), Dr. 

Whit diagnosed her with fibromyalgia:

 

R. at 504.3

Finally, in September 2014, Dr. John Balcarek opined that Moore could not 

work an 8-hour, 5-day-a-week job because “Ms. Moore has fibromyalgia[.]” R. at 

532. This is the “treating source opinion” that the SSA Appeals Counsel instructed 

the second ALJ to “give further consideration” when vacating the first ALJ opinion. 

 3 These two cites from Dr. Whit’s records contradict the ALJ’s statement that Dr. Whit made 

“no specific diagnosis of fibromyalgia” after Moore’s May and June 2012 visits. R. at 25.

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 10 of 16
R. at 143.

2. Never Sought Treatment: The ALJ’s finding that Moore never “sought 

treatment for fibromyalgia,” R. 24, is similarly refuted by the record. Dr. Yates 

referred Moore to a rheumatologist (Dr. Shergy) specifically to investigate 

“fibromyalgia.” R. at 479. Soon after, Moore’s chief complaint to Dr. Whit was 

“joint pain” and “fibromyalgia,” R. at 492, and Dr. Whitt prescribed Moore 

medication for fibromyalgia (Savella). R. at 491, 494. 

3. Tender points below the waist: The ALJ’s finding that Moore failed to 

provide evidence of tender points “above and below the waste,” R. at 24, is similarly 

refuted by the record, although not to the same extent.

4 When describing Moore’s 

joint pain/fibromyalgia complaint, Dr. Shergy (the rheumatologist) noted that 

Moore’s pain went from “head to toe” and that she suffered from “chronic” pain in 

her “full body.” R. at 492. 

4. Other possible sources: The ALJ’s fourth finding, that “other diagnoses or 

causes for the symptoms were not ruled out,” R. at 24, is also refuted by the record. 

The ALJ made this finding about Dr. Shergy’s statement that Moore’s case “is the 

clinical picture of fibromyalgia.” Id. (quoting R. at 480), but failed to mention the 

very next sentence: “She does not have other features to suggest an inflammatory 

 4 The ALJ acknowledged “tender points were noted in the back,” R. at 24, so the ALJ’s finding 

is that Moore failed to show tender points below the waist.

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 11 of 16
synovitis or a connective tissue disease.” R. at 480. 

* * *

After making these factual findings/statements, the ALJ laid out the proper 

Step 2 analysis for determining whether a claimant’s fibromyalgia (a) amounts to a 

medically determinable impairment, and if so, (b) whether the MDI is severe. R. at 

25, citing Social Security Ruling (“SSR”) 12-2p. But the ALJ made no findings 

after citing SSR 12-2p, see R. at 25, meaning that—if anything—the ALJ applied 

factually inaccurate statements to the correct legal standard. This leads to several 

concerns about the ALJ’s ultimate conclusion, not the least of which is the fact that 

the ALJ cites no medical opinion that refutes the diagnosis of fibromyalgia made by 

a rheumatologist and Moore’s treating source, among others. 

Under these circumstances, the Court finds that the ALJ’s Step 2 finding that 

Moore’s fibromyalgia is not a “medically determinable impairment” is not supported 

by substantial evidence. Even if Moore’s fibromyalgia is deemed “severe,” which is 

a distinct Step 2 question, see SSR 16-3P, 12-2P, a reasonable person reviewing the 

record would not conclude that Moore’s fibromyalgia is not an impairment, 

whatsoever—a finding, again, that the Commissioner essentially conceded at oral 

argument. Trans. at 11. (“I think there is a very good argument that plaintiff has that 

substantial evidence doesn’t support the finding that there was not a medically 

determinable impact—medically determinable impairment.”)

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 12 of 16
II. The ALJ’s error was not harmless.

The Court’s review does not end with finding error in Step 2 because the 

ALJ’s opinion need not be disturbed if the error was harmless. See Diorio v. Heckler, 

721 F.2d 726, 729 (“We find that the ALJ made erroneous statements of fact, but we 

conclude that this was harmless error in the context of this case and that the ALJ 

applied the proper legal standard.”).

According to the Commissioner, Step 2 merely “‘acts as a filter,’ and requires 

only that Plaintiff establish at least one severe impairment.” Mosley v. Colvin, No. 

2:17-cv-00169-RDP, 2018 WL 905369, at *6 (N.D. Ala. Feb 15, 2018) (quoting 

Jamison v. Bowen, 814 F.2d 585, 588 (11th Cir. 1987)). The Commissioner argues 

that, because Step 2 is merely a filter, “the failure to properly identify any one 

specific impairment as severe is harmless where a step two finding of even a single 

[severe] impairment has been made.” Doc. 15 at 2 (citing Heatly v. Comm’r of Soc. 

Sec., 382 F. App’x 823, 825 (11th Cir. 2010). That leads the Commissioner to 

conclude that the ALJ’s failure to find that fibromyalgia is a severe impairment is 

harmless because the ALJ found that anxiety was a severe impairment.

But there’s a problem with this argument: the ALJ did not find that Moore’s 

fibromyalgia was a “non-severe” impairment; she found that it wasn’t an impairment 

at all. R. at 25 (“the undersigned must conclude the claimant’s allegations of 

fibromyalgia do not give rise to a medically determinable impairment”). 

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 13 of 16
This distinction matters once reviews passes Step 2, as proved by the case 

relied on by the Commissioner, Heatly v. Commissioner, 382 Fed. Appx. 823 (June 

11, 2010, 11th Cir.). In Step 3, “the ALJ is required to demonstrate that it has 

considered all of the claimant’s impairments, whether severe or not, in combination” 

to determine whether the claimant meets a listing. Id. at 825. In other words, if an 

ALJ finds in Step 2 that an impairment exists, but is not severe, that “non-severe” 

impairment is still considered in Step 3 as part of the “combination” of impairments. 

That “combination” is why the error in Heatly was harmless. The Heatly ALJ 

found two impairments: a severe status-post cervical fusion and a non-severe chronic 

back pain. Id. at 824-25. Heatly argued that the ALJ erred by failing to find that his 

chronic back pain impairment was not severe in Step 2. The Eleventh Circuit held 

that, even if the ALJ should have found Heatly’s back pain to be severe, the error 

was harmless because that fact that the ALJ found it to be an impairment at all meant 

that the ALJ considered it combined with the cervical fusion in Step 3:

Nothing requires that the ALJ must identify, at step two, all of the 

impairments that should be considered severe. Instead, at step three, the 

ALJ is required to demonstrate that it has considered all of the 

claimant’s impairments, whether severe or not, in combination. Here, 

that the ALJ did consider all of Heatly’s impairments (whether severe 

or not) in combination is clear. The ALJ discussed in detail Heatly’s 

testimony and medical history, which included Heatly’s pain 

complaints, his limitations due to pain, and the diagnoses he received 

related to his pain. 

Id. at 825.

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 14 of 16
That’s not what happened here. Because the ALJ found that Moore’s 

fibromyalgia was not a medically determinable impairment, whatsoever, in Step 2, 

the ALJ did not consider a combination of anxiety and fibromyalgia in Step 3; she 

only considered Moore’s anxiety. R. at 26-27. Because Step 3 requires the ALJ to 

consider a “combination of impairments,” regardless of severity, see Heatly, supra,

if the ALJ erred by failing to find that fibromyalgia was an impairment in Step 2, 

then the ALJ necessarily erred by failing to consider fibromyalgia in Step 3, meaning 

that the Step 2 error cannot be deemed harmless. 

While unnecessary to the Court’s conclusion, the Court notes that the ALJ’s 

Step 2 error continues past Step 3, as residual functional capacity—which governs 

Steps 4 and 5—also focuses on Step 2 impairments, severe or not: “We will consider 

all of your medically determinable impairments of which we are aware, including 

your medically determinable impairments that are not ‘severe,’ as explained in §§ 

404.1520(c), 404.1521, and 404.1523, when we assess your residual functional 

capacity.” 20 CFR §404.1545(a)(2). That’s likely why the word “fibromyalgia” 

disappears from the ALJ’s opinion after Step 2; a result that could not happen if the 

ALJ found that fibromyalgia was a medically determinable impairment. 

In short, the Court cannot say the Step 2 error was harmless without plugging 

fibromyalgia into Steps 3-5, then re-weighing the evidence. To do that would require

Case 4:18-cv-01131-CLM Document 17 Filed 03/19/20 Page 15 of 16
conjecture that invades the province of the ALJ. See Moore v. Barnhart, 405 F.3d 

1208, 1214 (11th Cir. 2005) (per curiam) (remanding where the ALJ failed to 

consider certain factors and indicate their impact on his ultimate functional capacity 

conclusion); Mills v. Astrue, 226 Fed. Appx. 926, 927, (11th Cir. 2007) (remanding 

because the ALJ failed to give significant weight to findings made by the claimant's 

psychiatrist, concluding that his limitations were "excessive" and not supported by 

record evidence, even though the record showed that the claimant had reoccurring 

problems with depression.) As a result, this case is due to be remanded for 

reconsideration of whether Moore’s medical records and her testimony establish that

fibromyalgia is a medically determinable impairment under Rules 12-2p and 16-3P, 

and if so, whether that impairment is severe. 

IV. Conclusion

The ALJ’s Step 2 findings are not supported by substantial evidence. The 

decision of the SSA Commissioner is thus due to be VACATED AND 

REMANDED. A separate order will be entered.

DONE this 19th day of March, 2020.

 _________________________________

 COREY L. MAZE

 UNITED STATES DISTRICT JUDGE

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