Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_07-cv-00710/USCOURTS-almd-2_07-cv-00710-0/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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 Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L. No.

103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social

Security matters were transferred to the Commissioner of Social Security.

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF ALABAMA

NORTHERN DIVISION

BRENDA M. COOPER, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:07cv710-CSC

) (WO)

MICHAEL J. ASTRUE, )

COMMISSIONER OF )

SOCIAL SECURITY, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff, Brenda M. Cooper (“Cooper”), applied for disability insurance benefits

pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq., and for

supplemental security income benefits under Title XVI of the Social Security Act, 42 U.S.C.

§ 1381, et seq., alleging that she was unable to work because of a disability. Her application

was denied at the initial administrative level. Cooper then requested and received a hearing

before an Administrative Law Judge (“ALJ”). Following the hearing, the ALJ also denied

the claim. The Appeals Council rejected a subsequent request for review. The ALJ’s

decision consequently became the final decision of the Commissioner of Social Security

(“Commissioner”).1

 See Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The case is

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 A “physical or mental impairment” is one resulting from anatomical, physiological, or psychological

abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.

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now before the court for review pursuant to 42 U.S.C. § 405 (g) and § 1631(c)(3). Pursuant

to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1, the parties have consented to entry of final

judgment by the United States Magistrate Judge. Based on the court’s review of the record

in this case and the briefs of the parties, the court concludes that the decision of the

Commissioner should be reversed and this case remanded to the Commissioner for further

proceedings.

II. Standard of Review

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. . . . 

To make this determination,2

 the Commissioner employs a five-step, sequential

evaluation process. See 20 C.F.R. § 404.1520, §416.920.

(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.”

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

same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately cited as

authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5th Cir. 1981) (Unit A).

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McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).3

The standard of review of the Commissioner’s decision is a limited one. This court

must find the Commissioner’s decision conclusive if it is supported by substantial evidence.

42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). “Substantial

evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence

as a reasonable person would accept as adequate to support a conclusion.” Richardson v.

Perales, 402 U.S. 389, 401 (1971). A reviewing court may not look only to those parts of

the record which support the decision of the ALJ but instead must view the record in its

entirety and take account of evidence which detracts from the evidence relied on by the ALJ.

Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986). 

[The court must] . . . scrutinize the record in its entirety to determine the

reasonableness of the [Commissioner’s] . . . factual findings . . . No similar

presumption of validity attaches to the [Commissioner’s] . . . legal conclusions,

including determination of the proper standards to be applied in evaluating

claims.

Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

III. Administrative Proceedings

Cooper was 50 years old at the time of the hearing before the ALJ. (R. 442.) She is

a high school graduate and attended four years of college. (Id.) Cooper’s prior work

experience includes working as a part-time kindergarten teacher, a nurse, and a medical

records clerk. (R. 83, 443.) Cooper alleges that she became disabled due to osteoporosis,

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multiple fractures, right shoulder replacement, fibromyalgia, anxiety, and depression. (R. 82,

444, 446, 448, 450.) The ALJ found that Cooper’s history of comminuted fracture of the

right humeral head (status post right shoulder hemiarthroplasty), fracture of the left distal

radius and ulna (status post closed reduction and external fixation), osteoporosis, and

fibromylagia were severe impairments. (R. 17.) Next, the ALJ determined that Cooper has

the residual functional capacity to perform light work activity and that she is capable of

performing her past relevant work as an outpatient clerk. (R. 22, 28.) Accordingly, the ALJ

concluded that Cooper is not disabled. (R. 29.)

IV. The Plaintiff’s Claims

As stated by Cooper, she presents the following issues for the court’s review:

(1) The Commissioner’s decision should be reversed, because the

ALJ’s RFC fining only finds support from the opinions

expressed by the non-examining State agency consultant.

(2) The Commissioner’s decision should be reversed, because the

Appeals Council erroneously denied Ms. Cooper’s request for

review in light of the material evidence submitted thereto that

further undermined the ALJ’s RFC finding. 

(3) The Commissioner’s decision should be reversed, because the

ALJ improperly acted as both judge and physician.

(4) The Commissioner’s decision should be reversed, because the ALJ

failed to conduct a proper credibility analysis.

(Doc. No. 17, p. 11.)

V. Discussion

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Cooper raises several issues and arguments related to this court’s ultimate inquiry of

whether the Commissioner’s disability decision is supported by the proper legal standards

and by substantial evidence. See Bridges v. Bowen, 815 F.2d 622 (11th Cir. 1987). However,

the court pretermits discussion of Cooper’s specific arguments because the court concludes

that the ALJ erred as a matter of law, and thus, this case is due to be remanded for further

proceedings. Specifically, the court finds that the Commissioner failed to resolve conflicts

in the evidence. 

In his decision, the ALJ discounted the opinion of Dr. Steven Davis, Cooper’s treating

physician, on the grounds that the general practitioner was not a specialist and that Cooper

had received the majority of her treatment from specialists, including Dr. Robert Dean

Lolley, an orthopaedic surgeon. (R. 27.) The ALJ noted that Dr. Davis’ opinion in a

physical capacities evaluation form that Cooper would rarely be able to perform pushing and

pulling movements, climbing, gross manipulation, overhead reaching, or other physical

activities during a work day was inconsistent with Dr. Lolley’s clinical findings. (Id.) The

ALJ specifically noted that Cooper was treated for her shoulder condition until September

22, 2005, and that 

[d]uring this period, the claimant was seen by Dr. Lolley six

times, and he characterized the claimant’s shoulder x-rays as

showing “good alignment.” . . . Dr. Lolley recommended the

claimant engage in physical therapy for her right shoulder. The

claimant’s physical therapy started with passive range of motion

immediately after her operation, but progressed to include active

range of motion and strengthening exercises. On January 17,

2005, Dr. Lolley told the claimant not to engage in any “heavy

activities,” but he had previously told the claimant that she could

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 The court notes that, in its list of additional evidence, the Appeals Council lists Exhibit AC-2 as a

physical capacities evaluation form and other medical records prepared by Dr. Davis. It is clear, however,

that the physical capacities evaluation form was prepared by Dr. Lolley and the treatment record was prepared

by Dr. Soh. (R. 425-427.) 

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perform her daily personal care tasks. The claimant complained

of discomfort, and examinations did show diminished range of

motion in the shoulder. However, the claimant remained

neurovascularly intact, and Dr. Lolley encouraged her to begin

exercising at home. Also after his last examination of the

claimant on September 22, 2005, Dr. Lolley recommended she

not return to him for at least two years, or before if she had acute

symptoms. . . .

(R. 26.)

After the ALJ entered his decision to deny benefits, Cooper submitted additional

evidence, including a June 28, 2006, physical capacities evaluation form completed by Dr.

Lolley, to the Commissioner. (R. 427.) The Appeals Council concluded that the additional

information did not provide a basis for changing the ALJ’s determination.4

 (R. 6.) Thus, the

proper inquiry is whether the Appeals Council’s decision to deny benefits is supported by

substantial evidence in the record as a whole, including the evidence submitted to the

Appeals Council. See Ingram v. Astrue, 496 F.3d 1252, 1262-64 (11th Cir. 2007).

This court, however, is unable to determine whether the Commissioner’s decision is

supported by substantial evidence because the Appeals Council failed to resolve

inconsistencies in the record. In his analysis, the ALJ relied on Dr. Lolley’s treatment

records between October 2004 and September 2005 to discount Dr. Davis’ opinion that

Cooper would be unable to lift more than five pounds occasionally, would be unable to sit

or stand more than two hours a day, and would rarely be able to perform pushing and pulling

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movements, climb stairs, perform gross manipulation, reach overhead, or work with

hazardous machinery, and that her right shoulder condition, as well as her marked arthralgia

and myalgia, would prevent her from performing activities. (R. 390.) The additional medical

records submitted to the Appeals Council indicate that, in June 2006, Dr. Lolley completed

a physical capacities evaluation form, in which he concluded that Cooper would never be

able to push or pull with her right arm, climb ladders, or do any overhead reaching or gross

manipulation. (R. 427.) An administrative law judge has a duty to develop a full and fair

record. Kelley v. Heckler, 761 F.2d 1538 (11th Cir. 1985). When there is a conflict,

inconsistency, or ambiguity in the record, the ALJ has an obligation to resolve the conflict,

giving specific reasons supported by the evidence as to why he accepted or rejected an

opinion regarding the plaintiff’s capacity for work. When affirming the ALJ’s decision to

discount the opinion of Dr. Davis by relying on the Dr. Lolley’s medical records, the Appeals

Council failed to reconcile the opinion expressed by Dr. Lolley in his June 2006 physical

capacities evaluation with his prior treatment records. Given these inconsistencies, this court

is unable to determine whether the Commissioner’s finding that Cooper can return to her past

work as an outpatient clerk is supported by substantial evidence.

The Commissioner argues that this additional evidence makes no difference because

the decision is supported by substantial evidence.

Dr. Lolley’s opinion is inconsistent with the record as a whole. Dr.

Lolley opined that Plaintiff could never reach overhead with her right arm but

Dr. Soh noted that Plaintiff had a normal range of motion in her right arm. (Tr.

427, 409). Plaintiff also had full muscle strength contrary to the assessment

indicating that she could only lift five pounds occasionally and one pound

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frequently. (Tr. 409, 427). Furthermore, Dr. Lolley indicated that he would

not need to see Plaintiff for two years, which is inconsistent with the

limitations imposed in the medical assessment. (Tr. 391).

(Comm’r Br. at 6)

The Commissioner’s argument proves the point. There are inconsistencies in the

record which the Commissioner through the ALJ has the responsibility to resolve. The

Commissioner’s argument essentially asks the court to ignore evidence which does not

support the Commissioner’s decision. However, it is the Commissioner’s responsibility

through the ALJ to resolve inconsistencies, not the court. See e.g., Newton v. Apfel, 209 F.3d

448, 454 (5th Cir. 2000).

Consequently, this case is due to be reversed and remanded to the Commissioner. 

V. Conclusion

Accordingly, the court concludes that this case be reversed and remanded to the

Commissioner for further proceedings consistent with this opinion.

A separate order shall accompany this opinion.

Done this 16th day of July, 2008.

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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