Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-1_10-cv-00518/USCOURTS-almd-1_10-cv-00518-0/pdf.json

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

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IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

SOUTHERN DIVISION

LOLA DAVIS, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 1:10CV518-SRW

) (WO)

MICHAEL J. ASTRUE, Commissioner )

of Social Security, )

)

Defendant. )

MEMORANDUM OF OPINION

Plaintiff Lola Davis bringsthis action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3)

seeking judicial review of a decision by the Commissioner of Social Security

(“Commissioner”) denying her application for a period of disability and disability insurance

benefits under Title II of the Social Security Act. The parties have consented to entry of final

judgment by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c). Upon review of the record

and briefs submitted by the parties, the court concludes that this action is due to be reversed

and remanded to the Commissioner pursuant to sentence four of 42 U.S.C. § 405(g).

BACKGROUND

Plaintiff Lola Davis was born on November 28, 1948, and was sixty-one years old at

the time of the ALJ’s decision. She obtained a GED in 1975 and worked at Phillips Van

Heusen Corporation in Ozark, Alabama, from 1986-2005 as a supervisor in the Finishing

Department. On February 14, 2008, plaintiff filed an application for a period of disability

and disability insurance benefits, pursuant to Title II of the Social Security Act. She alleged

Case 1:10-cv-00518-SRW Document 14 Filed 08/29/11 Page 1 of 9
disability since June 1, 2006, due to degenerative disc disease which resulted in pain in her

back, neck and legs and numbness and weakness in her arms. (R. 92-96, 111-23, 160). In

May 2008, she reported to her primary care physician, Dr. David Arnold, that she was

experiencing problems with her memory. Dr. Arnold ordered comprehensive laboratory

testing, the results of which he found to be normal, and scheduled plaintiff for follow-up in

three months. (R. 352-56). In February 2009, plaintiff told Dr. Arnold that she was confused

and disoriented at times and that she had become lost when going home a few days

previously. (R. 345). Dr. Arnold again ordered lab work. He found that all results were

normal, except that plaintiff’s B-12 levels were “significantly low.” He recommended weekly

B-12 injections for a period of one month and monthly injections thereafter, and also

recommended that plaintiff have a brain scan. (R. 344). The brain MRI revealed a minimal

amount of ethmoid sinusitis, a “questionable finding of a possible minimal amount of left

mastoiditis,” and a “slight degree of cerebellar and cerebral atrophy, no[t] entirely unusual

for patient’s age.” The MRI was otherwise unremarkable. (R. 433-34).

In August 2009, plaintiff reported that she continued to have memory problems, and

was forgetting conversations and losing her car keys. (R. 378-79). Dr. Arnold referred

plaintiff to Dr. Sher Ghouri, a neurologist, for evaluation. Plaintiff reported a two-year

history of memory loss, which had worsened progressively. Dr. Ghouri’s initial assessment

was “[m]inimal cognitive impairment,” which he stated could be due to her B-12 deficiency

or to “attention and concentration issues.” Dr. Ghouri noted that plaintiff’s complaints of

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memory loss were “out of proportion than the deficit documented on MMSE scores,” which

were 28/30. Dr. Ghouri performed an EEG, which was normal. (R. 383-86). Plaintiff

returned to Dr. Ghouri for follow-up on September 14, 2009. Dr. Ghouri reviewed the

results of the EEG and other lab results. Dr. Ghouri assessed “[m]inimal cognitive

impairment – could be due to B-12 deficiency.” He stated that, “[a]t this time there is not

enough impairment of cognition noted to make a definite diagnosis of dementia.” (R. 382).

He further noted that “[s]ometimes B-12 deficiency can take a long time to improve the

memory and at the same time it may not improve and the deficit could be permanent.”

(R. 381). He advised plaintiff to continue with B-12 supplements and to return for

reevaluation if her forgetfulness worsened. (R. 382).

At the administrative hearing on November 10, 2009, plaintiff testified that she had

experienced memory loss for “a good while now” which continued to get worse until “one

day [she] forgot [her] way home.” She testified that her memory was “some better, but not

to where [Dr. Arnold] wanted it” after six monthly B-12 shots, and that Dr. Arnold had

increased her B-12 to two shots each month. (R. 35-36). Plaintiff testified that she continues

to see Dr. Arnold every three to four months and that “[m]ost of the time lately he’s adjusted

[her] medication and tr[ied] to help [her] with memory loss.” (R. 27).

On December 8, 2009, the ALJ issued a decision concluding, at step four of the

sequential analysis, that plaintiff “is capable of performing past relevant work as a general

supervisor” and is not, therefore, under a disability as defined by the Social Security Act.

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(R. 16). The ALJ analyzed the evidence regarding plaintiff’s memory loss and concluded

that it “does not cause more than minimal limitation in the claimant’s ability to perform basic

mental work activities” and, therefore, that it is “non-severe.” (R. 12-13).

1

On December 18, 2009, plaintiff requested review of the ALJ’s decision. (R. 5). A

month later, on January 27, 2010, plaintiff returned to Dr. Arnold for treatment. Dr. Arnold

assessed pernicious anemia, osteoarthritis, lumbar degenerative disc disease, memory loss

and dementia. He stated that plaintiff’s “ability to carry out normal physical activities is

severely limited.” He further concluded that “her memory issues are improved but . . . her

short term memory problems make her unable to perform normal supervisory activities and

manage work situations.” Dr. Arnold expressed his opinion that plaintiff’s condition is not

likely to improve and is expected to last more than twelve months and, also, that plaintiff “is

unable to perform any type of work activity” and “is unable to participate in any type of

gainful employ[]ment.” (Doc. 11-1, attachment to plaintiff’s brief). Plaintiff submitted the

January 2010 treatment note including Dr. Arnold’s opinion to the Appeals Council on

February 23, 2010, along with a cover letter thanking the Appeals Council “for allowing

additional time to submit this evidence.” (Id., see cover letter and facsimile transmission

confirmation).

On April 19, 2010, the Appeals Council denied plaintiff’s request for review. (R. 1-

4). The Appeals Council did not consider Dr. Arnold’s opinion in reaching its decision on

The ALJ noted the vocational expert’s testimony that plaintiff “would have transferable 1

skills from her past work to other work,” but she made no alternative step five finding. (See R. 16). 

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the merits. (See R. 1(“In looking at your case, we considered the additional evidence listed

on the enclosed Order of Appeals Council) and R. 4 (order listing January 2009 records from

Southeast Alabama Medical Center,submitted to the Commissioner on February 3, 2010, and

omitting any reference to the January 27, 2010 treatment record)). There is no indication in

the record or in the briefs of the parties that the Appeals Council reviewed the evidence at

all, even to determine whether it was material to the pending request for review.

DISCUSSION

Plaintiff contends that this action is due to be remanded because the Appeals Council

“did not consider the new evidence from the claimant’s treating physician that attests to her

inability to do supervisory work due to memory problems.” (Plaintiff’s brief, p. 6). Plaintiff

2

has presented evidence to this court – unchallenged by the Commissioner – that she

submitted the January 2010 medical record containing Dr. Arnold’s opinion to the Appeals

Council on February 23, 2010. The cover letter transmitting the record indicates that the

Appeals Council granted plaintiff “additional time to submit this evidence.” (Doc. # 11-1).

The Commissioner does not contend that the submission to the Appeals Council was

untimely, nor has he offered evidence that the Appeals Council did not receive the additional

records. The evidence attached to plaintiff’s brief demonstrates that plaintiff submitted this

additional evidence to the Appeals Council properly and the Commissioner does not argue

 Plaintiff’s argument with regard to Dr. Arnold’s opinion appears to rest primarily, if not 2

exclusively, on Dr. Arnold’s assessment of her memory problems. The court has not, accordingly,

summarized the record regarding plaintiff’s musculoskeletal impairments.

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otherwise. Rather, the Commissioner argues that “[p]laintiff’s additional claim that remand

is necessary to consider new evidence from David Arnold, M.D., is unavailing and must fail”

because: (1) “the only issue before this Court is whether the ALJ’s decision is supported by

substantial evidence and free of legal error;” (2) since Dr. Arnold’s opinion is not contained

3

within the certified record, the court may not consider it; and (3) “even if Dr. Arnold’s

4

opinion that Plaintiff was unable to perform any type of work activity was part of the record,

it would not be entitled to any special significance since it was on an issue reserved to the

Commissioner” and, therefore, “there is no reasonable possibility that this evidence would

have changed the administrative result.” (Commissioner’s brief at pp. 5-6).

5, 6

 The court is tasked with reviewing the Commissioner’s final decision; that review is not 3

limited to the ALJ’s decision but extends, also, to the decision of the Appeals Council. Ingram v.

Commissioner of Social SecurityAdministration, 496 F.3d 1253, 1262-66 (11th Cir. 2007); see also

Sneed v. Barnhart, 214 Fed. Appx. 883, 885 (11th Cir. 2006)(“Because the Appeals Council’s

refusal to consider the submission of new evidence before denying review amounts to an error of

law, that decision is subject to judicial review.”)(citation omitted). 

As noted above, the Commissioner has not argued or demonstrated that it did not receive 4

Dr. Arnold’s January 2010 treatment note or that plaintiff submitted it outside of the time period

allowed by the Appeals Council. Accordingly, while the exhibit attached to plaintiff’s brief is not

included in the certified administrative transcript that the Commissioner filed with the court, it

should have been. Cf. Keeton v. Department of Health and Human Services, 21 F.3d 1064, 1067

(11th Cir. 1994)(“Each successive appeal contributes to the administrative process and, we believe,

the administrative record... . We find that the administrative process continues when a claimant seeks

review of an ALJ decision. Accordingly, we hold that new evidence first submitted to the Appeals

Council is part of the administrative record that goes to the district court for review when the

Appeals Council accepts the case for review as well as when the Council denies review.”). Thus, to

the extent that the Commissioner contends that the court may not consider the exhibit attached to

plaintiff’s brief for any purpose, the court cannot agree. 

Dr. Arnold’s opinion was not limited to his broad pronouncement that plaintiff is “unable 5

to perform any type of work activity.” (Doc. # 11-1). Plaintiff’s treating physician also diagnosed

dementia and offered his opinion that plaintiff’s “memory issues are improved but . . . her short term

memory problems make her unable to perform normal supervisory activities[.]” (Id.). While the

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The Commissioner’s regulations provide that, on review, “[t]he Appeals Council will

consider all the evidence in the administrative law judge hearing record as well as any new

and material evidence submitted to it which relates to the period on or before the date of the

administrative law judge hearing decision.” 20 C.F.R. § 404.976(b). Implicit in this

regulatory mandate is a requirement that the Appeals Council evaluate all of the evidence a

claimant submits properly on review and make a threshold determination regarding whether

the evidence is new, material, and chronologically relevant. See 20 C.F.R. § 404.976(b)(if

Appeals Council finds that evidence submitted to the Appeals Council does not relate to the

time period on or before the date of the ALJ’s decision, it will return evidence to the plaintiff

Commissioner might reject this opinion on legitimate grounds, the court cannot conclude that it is,

as a matter of law, immaterial. 

In support of his “newevidence” argument, the Commissioner cites Vega v. Commissioner 6

of Social Security, 265 F.3d 1214 (11th Cir. 2001). (Commissioner’s brief, pp. 4-6). The

Commissioner’s reliance on Vega suggests that the Commissioner believes that the sentence six

“new evidence” standard governs the court’s consideration of Dr. Arnold’s January 2010 treatment

note. Under the plain language of the judicial review provision of the statute, however, the court

may not order a sentence six “new evidence” remand without a showing “that there is good cause

for the failure to incorporate such evidence into the record in a prior proceeding.” 42 U.S.C.

§ 405(g); see also Melkonyan v. Sullivan, 501 U.S. 89, 98 (1991)(“Under sentence six, the district

court may remand in light of additional evidence without making any substantive ruling as to the

correctness of the [Commissioner’s] decision, but only if the claimant shows good cause for failing

to present the evidence earlier.”). In the circumstances of this case, it would defy logic to require

the claimant to demonstrate good cause for the Commissioner’s failure to incorporate the evidence

into the record. Additionally, evidence submitted properly by a claimant at the administrative level

is not “new evidence” within the meaning of sentence six, even if the Commissioner failed to

consider it or to incorporate it into the record. See Sullivan v. Finkelstein, 496 U.S. 617, 626

(1990)(“The sixth sentence of § 405(g) plainly describes an entirely different kind of remand [from

the fourth sentence], appropriate when the district court learns of evidence not in existence or

available to the claimant at the time of the administrative proceeding that might have changed the

outcome of that proceeding.”). 

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“with an explanation as to why it did not accept the additional evidence if it finds that the

evidence); see also HALLEX I-3-5-20 (“The Appeals Council only evaluates evidence that

is not new and material to the period through the date of the ALJ hearing decision to the

extent necessary to determine that it is not new and material.”). In its denial notice in the

7

present case, the Appeals Council makes no reference to the January 2010 evidence from Dr.

Arnold. (See R. 1-4).

In reviewing the Commissioner’s decision, the court is required to defer to the

Commissioner’s factual findings and scrutinize closely his legal conclusions. Cornelius v.

Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991)(citations omitted). “The [Commissioner’s]

failure to apply the correct law or to provide the reviewing court with sufficient reasoning

for determining that the proper legal analysis has been conducted mandates reversal.” Id. at

1145-46 (citation omitted). The court cannot conclude, on the present record, that the

Appeals Council made the required threshold determination that the evidence was not new

and material or, indeed, that it reviewed plaintiff’s evidentiary submission at all. Because

the Appeals Council’s decision lacks any basis for determining that the Appeals Council

The court does not here decide whetherthe HALLEX creates rights which may be enforced 7

judicially – a subject of some debate (see Cohan v. Commissioner of Social Security, 2011WL

3319608 (M.D. Fla. Jul. 29, 2011)(discussing cases) – because, as noted above, the requirement for

a threshold evaluation is implicit in the Commissioner’s regulation. Consistent with this implied

requirement, HALLEX I-3-5-20 directs the Appeals Council analyst who evaluates additional

evidence submitted by a claimant on review and finds it to be not new and/or not material to

“provide language for the denial notice” explaining why the evidence is not material and, for

evidence that is not “new,” describing how the submitted evidence duplicates evidence already of

record.

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conducted the required legal analysis of Dr. Arnold’s January 2010 treatment note and

opinion, the Commissioner’s decision is due to be reversed.

8

CONCLUSION

For the foregoing reasons, it is

ORDERED that the administrative transcript is hereby supplemented to include the

evidence attached to plaintiff’s brief, which the Commissioner erroneously omitted from the

certified transcript. Further, the court concludes that the decision of the Commissioner is due

to be REVERSED, and this action REMANDED to the Commissioner for further

proceedings consistent with this Memorandum Opinion. A separate judgment will be entered.

DONE, this 29 day of August, 2011.

th

/s/ Susan Russ Walker

SUSAN RUSS WALKER

CHIEF UNITED STATES MAGISTRATE JUDGE

In view of this conclusion, the court does not address the remaining issues raised by 8

plaintiff. The court expects that the Commissioner will consider plaintiff’s arguments as to these

issues on remand. 

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