Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_11-cv-00134/USCOURTS-almd-3_11-cv-00134-0/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

EASTERN DIVISION

STEVEN RAY COOPER, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 3:11cv134-WC

)

MICHAEL J. ASTRUE, ) 

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. INTRODUCTION

Plaintiff, Steven RayCooper, applied for supplemental securityincome benefits under

Title XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 1381 et seq. His application

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

before an Administrative Law Judge (“ALJ”). Following the hearing, the ALJ issued a

decision in which he found Plaintiff not disabled from February 19, 2008, the application

date, to the date of the decision. Tr. 33. The Appeals Council rejected Plaintiff’s request for

review of the ALJ’s decision. The ALJ’s decision consequently became the final decision

of the Commissioner of Social Security (Commissioner). See Chester v. Bowen, 792 F.2d 1

129, 131 (11th Cir. 1986). The case is now before the Court for review under 42 U.S.C. §

405(g). Pursuant to 28 U.S.C. § 636(c), both parties have consented to the conduct of all

 Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub. L.

1

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.

Case 3:11-cv-00134-WC Document 16 Filed 02/06/12 Page 1 of 14
proceedings and entryof a final judgment bythe undersigned United States Magistrate Judge. 

Pl.’s Consent to Jurisdiction (Doc. #15); Def.’s Consent to Jurisdiction (Doc. #14). Based

on the Court’s review of the record and the briefs of the parties, the Court REVERSES the

decision of the Commissioner.

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.

42 U.S.C. § 423(d)(1)(A).2

To make this determination, the Commissioner employs a five-step, sequential

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920 (2006).

(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? [the Listing of

Impairments]

(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

 A “physical or mental impairment” is one resulting from anatomical, physiological, or 2

psychological abnormalities which are demonstrable by medically acceptable clinical and

laboratory diagnostic techniques.

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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).3

The burden of proof rests on a claimant through Step 4. See Phillips v. Barnhart, 357

F.3d 1232, 1237-39 (11th Cir. 2004). A claimant establishes a prima facie case of qualifying

disability once they have carried the burden of proof from Step 1 through Step 4. At Step 5,

the burden shifts to the Commissioner, who must then show there are a significant number

of jobs in the national economy the claimant can perform. Id. 

To perform the fourth and fifth steps, the ALJ must determine the claimant’s Residual

Functional Capacity (RFC). Id. at 1238-39. RFC is what the claimant is still able to do

despite his impairments and is based on all relevant medical and other evidence. Id. It also

can contain both exertional and nonexertional limitations. Id. at 1242-43. At the fifth step,

the ALJ considers the claimant’s RFC, age, education, and work experience to determine if

there are jobs available in the national economy the claimant can perform. Id. at 1239. To

do this, the ALJ can either use the Medical Vocational Guidelines (grids) or call a vocational 4

expert (VE). Id. at 1239-40.

The grids allow the ALJ to consider factors such as age, confinement to sedentary or

McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986), is a supplemental security income case 3

(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).

See 20 C.F.R. pt. 404 subpt. P, app. 2. 4

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light work, inability to speak English, educational deficiencies, and lack of job experience. 

Each factor can independently limit the number of jobs realistically available to an

individual. Phillips, 357 F.3d at 1240. Combinations of these factors yield a statutorilyrequired finding of “Disabled” or “Not Disabled.” Id. 

The Court’s 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). See also Crawford v. Comm’r of Soc. Sec., 363 F.3d

1155, 1158 (11th Cir. 2004) (“Even if the evidence preponderates against the

Commissioner’s findings, [a reviewing court] must affirm if the decision reached is

supported by substantial evidence.”). 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 validityattaches 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). 

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III. ADMINISTRATIVE PROCEEDINGS

Plaintiff was thirty-four years old at the time of the hearing before the ALJ. Tr. 64,

152. Plaintiff received special education classes, Tr. 66, 186, and has a tenth grade

education. Tr. 65, 186. Plaintiff’s past relevant work experience was as a roustabout and

brake repairer. Tr. 91, 183, 220. Following the administrative hearing, and employing the

five-step process, the ALJ found Plaintiff had not engaged in substantial gainful activity

since February 19, 2008, the application date (Step 1). Tr. 16. At Step 2, the ALJ found that

Plaintiff suffers from the following severe impairments: “Facet arthropathy, Grade I

spondylosis, mild degenerative changes at L3-4, depression, borderline intellectual

functioning, and status post closed head injury.” Tr. 16. The ALJ then found that “[t]he

claimant does not have an impairment or combination ofimpairments that meets or medically

equals one of the listed impairments . . . .” (Step 3) Tr. 17. Next, the ALJ found that

Plaintiff

has the residual functional capacity to perform the exertional demands of light

work . . . with the following non-exertional limitations. He can frequently use

his hands for repetitive action such as in simple grasping, occasionally use his

hands for repetitive action such as in the pushing and pulling of arm controls,

and continuously use his hands for repetitive action such as for fine

manipulation. He can occasionally use his feet for repetitive movement such

as in the pushing and pulling of leg controls. He can frequently climb stairs

and ramps and balance. He can occasionally stoop, kneel, crouch, or crawl and

frequently reach overhead. He can never work around unprotected heights;

frequently work around moving machinery, drive automotive equipment, and

exposure to dust, fumes, and gases; and occasionally work around exposure to

marked changes in temperature and humidity. He experiences a moderate

degree of pain. He has a moderate limitation in his ability to respond

appropriately to supervisors. He has a moderate limitation in his ability to

respond appropriately to co-workers. He has a moderate limitation in his

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ability to respond appropriately to customers or other members of the general

public. He has a moderate limitation in his ability to use judgment in simple

one or two step work related decisions. He has a marked limitation in his

ability to use judgment in detailed or complex work-related decisions. He has

a moderate limitation in his ability to deal with changes in a routine work

setting. He has a moderate limitation in his ability to understand, remember,

and carry out simple, one and two step instructions. He has a marked

limitation in his ability to understand, remember, and carry out detailed or

complex instructions. He has a moderate limitation in his ability to maintain

attention, concentration or pace for periods of at least two hours. He has a

mild limitation in his ability to maintain social functioning. He has a moderate

limitation his ability to maintain activities of daily living. He has no episodes

of decompensation, each of extended duration. 

Tr. 20. After consulting with a VE, the ALJ found Plaintiff “is unable to perform any past

relevant work.” (Step 4) Tr. 31. Considering Plaintiff’s “age, education, work experience,

and [RFC],” and after consulting the VE, the ALJ determined that “there are jobs that exist

in significant numbers in the national economy” that Plaintiff can perform, including: 

“Sorter I,” “Ticketer/Tagger,” “ClothFolder,” “AcetoneButton Paster,” “Button Reclaimer,”

“Hander In.” (Step 5) Tr. 32-33. Accordingly, the ALJ determined that Plaintiff “has not

been under a disability . . . since February 19, 2008, the date the application was filed.” Tr.

33.

IV. PLAINTIFF’S CLAIMS

Plaintiff presents four issues for this Court’s consideration in review of the ALJ’s

decision: (1) whether “the ALJ erred by improperly acting as both Judge and medical

professional[;]” (2) whether “the Appeals Council erroneously denied [Plaintiff’s] request

for review in light of the material objective evidence findings submitted thereto[;]” (3)

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whether “the ALJ failed to properly evaluate the effects and resulting limitations of

[Plaintiff’s] medication side effects[;]” and (4) whether “the ALJ did not properly evaluate

[Plaintiff’s] mental allegations.” Pl.’s Brief (Doc. #10) at 4. The Court finds that the new

evidence submitted to the Appeals Council, but not considered by the ALJ, warrants remand. 

Because the Court is unable to review the ALJ’s decision without his consideration of the

new evidence, the Court declines consideration of the other issues raised by Plaintiff. 

V. DISCUSSION

A. Plaintiff’s submission of new evidence.

Plaintiff argues that “the Appeals Council erroneously denied [Plaintiff’s] request for

review in light of the material objective evidence findings submitted thereto.” Pl.’s Brief

(Doc. #10) at 8. Plaintiff essentially argues that the evidence presented to the Appeals

Council, but not the ALJ, renders the ALJ’s decision to deny benefits unsupported by

substantial evidence and that the Appeals Council erred in denying review. Defendant

maintains that the additional evidence presented to the Appeals Council did not significantly

undermine the ALJ’s decision and that reversal on the basis of the new evidence is

unwarranted because: 1) “the new evidence did not pertain to the time period considered by

the ALJ”; 2) “the new evidence did not show a significant deterioration of Plaintiff’s

condition”; and 3) “the new evidence is not relevant because it did not clearly show that the

ALJ’s residual functional capacity assessment was unreasonable.” Def.’s Brief (Doc. #12)

at 11-12. The Court disagrees.

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Plaintiff challenges both the ALJ’s decision to deny him benefits and the Appeals

Council’s decision to deny review on the basis of the new evidence. Under Ingram, “when

a claimant properly presents new evidence to the Appeals Council [and the Appeals Council

denies review], a reviewing court must considerwhether that new evidence renders the denial

of benefits erroneous.” Ingram v. Comm’r of Social Sec. Admin., 496 F.3d 1253, 1262 (11th

Cir. 2007). Ingram held that “the denial of a request for review by the Appeals Council is

part of the ‘final decision’ of the Commissioner.” Id. at 1263. As to Plaintiff’s second

challenge, when reviewing the Appeals Council’s denial of review, the Court must “look at

the pertinent evidence to determine if the evidence is new and material.” Robinson v. Astrue,

365 F. App’x 993, 996 (11th Cir. 2010) (quoting Falge v. Apfel, 150 F.3d 1320, 1324 (11th

Cir. 1998)). “‘New’ evidence is evidence that is non-cumulative, and ‘material’ evidence is

evidence that is ‘relevant and probative so that there is a reasonable possibility that it would

change the administrative result.’” Id. (quoting Milano v. Bowen, 809 F.2d 763, 766 (11th

Cir. 1987)). Upon review of the record and the evidence submitted to the Appeals Council,

the Court finds that Plaintiff satisfies both standards. The Court addresses the Appeals

Council’s denial of review first. 

Plaintiff underwent an MRI on March 8, 2010, approximately two months after the

ALJ rendered his decision. Tr. 387. The MRI was submitted to the Appeals Council on June

18, 2010. The Appeals Council considered the evidence before it denied review on January

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28, 2011. Tr. 1-2. The MRI is non-cumulative new evidence because it is the only MRI on 5

the record and it shows changes to Plaintiff’s condition when compared to the x-rays the ALJ

had before him during the administrative proceedings. The 2010 MRI indicated the 6

following:

Multi-planar, multi-echo images obtained without contrast. 

There is mild anterolisthesis of L3 relative to L4 approximately 6mm. There

is associated disc space narrowing at this level. There is also disc space

narrowing at L1-2. There is desiccation of the disc at L1-2, L3-4 and L4-5. 

Small Schmorl’s nodes are noted at L1-2. The conus medullaris lies at L1. 

The disc at L1-2 shows mild diffuse protrusion and there is hypertrophic

change of the facet joints with moderate neural foraminal impingement. The

disc at L2-3 is intact and there is moderate hypertrophic change of the facet

joints and neural foramina are patent. The disc at L3-4 shows diffuse

protrusion with marked hypertrophic change of the facet joints and there

is severe neural foraminal stenosis bilaterally. The disc at L4-5 shows mild

posterior protrusion eccentric to the right and there is hypertrophic change of

the facet joints with moderate neural foraminal stenosis. The disc at L5-S1 is

intact. There is hypertrophic change of the facet joints and neural foramina are

patent.

 The Appeals Council indicated that “[i]n looking at [Plaintiff’s] case, [it] considered . . . the 5

additional evidence. [It] found that this information does not provide a basis for changing the

[ALJ’s] decision.” Tr. 1-2. 

 During the administrative proceedings, the medical evidence of record contained only x-rays

6

indicating: 

“Slight scoliosis and multilevel degenerative changes.” Tr. 291, x-ray dated June 23,

2009; 

“Grade I spondylolisthesis with chronic spondylolysis of L3 on L4” and “mild discogenic

degenerative change at L3-4,” Tr. 336, x-ray dated July 09, 2009; 

“There is slight scoliosis. There are five lumbar type vertebrae. There are only minor

multilevel degenerative changes. There is a minor grade I anterolisthesis of L3 upon L4. 

There are minor old compression fractures at the T12 and L1 levels.” Tr. 384, x-ray

dated October 20, 2009. 

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Tr. 387 (emphasis added). Dr. Turner’s medical impression of the MRI indicated “multilevel

degenerative disc disease with disc protrusions, facet arthrosis and neural foraminal

stenosis.” Id. Thus, the new information in the 2010 MRI, which reveals “diffuse protrusion

with marked hypertrophic change” and “severe neural foraminal stenosis,” is significantly

different from previous x-rays that revealed only minor abnormalities, such as “slight

scoliosis” and “minor multilevel degenerative changes.”

The Court now turns to the materiality of the new evidence. The Court finds that the

evidence is relevant and probative in that it pertains to a condition that Plaintiff listed in his

application at the administrative level as a source of his disability. The evidence also 7

confirms a medical opinion on the severity of the impairment during the time period for

which benefits are sought. Indeed, Plaintiff did not develop back problems overnight. The 8

ALJ gave “controlling weight” to Dr. Hakim’s medical opinion and gave “little weight” to

the opinion of Dr. Bartel, indicating that Dr. Bartel’s “reports fail to reveal the type of

significant clinical and laboratory abnormalities one would expect if the claimant were

in fact disabled” and “[h]is opinion is not supported by clinical evidence.” Tr. 30 (emphasis

added). The new evidence, however, provides objective support for Dr. Bartel’s medical

 In his application and related documentation, as well as during the hearing, Plaintiff alleged 7

disability due to his back problems. Tr. 21, 69, 83, 272. 

For example, on October 20, 2009, Dr. Bartel completed a clinical assessment of pain “indicating 8

that pain was present to such an extent as to be distracting to adequate performance of daily

activities; physical activity greatly increased the pain to such a degree as to cause distraction from

task or total abandonment of task; and drug side effects could be expected to be severe and limit

effectiveness due to distraction, inattention, drowsiness, etc.” Tr. 27; 374.

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assessment of Plaintiff’s level of pain and limitations. 

Additionally, there is a reasonable possibility that the new evidence would change the

administrative outcome because it consists of medical evidence that relates directly to one

of Plaintiff’s principal alleged impairments, about which there was inadequate evidence

presented to the ALJ. In this case, the new evidence could reasonably be expected to

influence the ALJ’s finding regarding Plaintiff’s RFC. The ALJ’s opinion expresses a

concern that 

[Plaintiff’s] testimony of disabling pain and functional restrictions is

disproportionate to the objective medical evidence. The record does not

contain objective signs and findings that could reasonably be expected to

produce the degree and intensity of pain and limitations alleged. There are no

diagnostic studies to show abnormalities that could be expected to produce

such severe symptoms. The physical findings in the record do not establish the

existence of neurological deficits, significant weight loss, muscle atrophy, or

other observable signs often indicative of protracted pain of the intensity,

frequency, and severity alleged.

Tr. 29. Plaintiff’s 2010 MRI scan provides the precise sort of “objective medical evidence”

identified by the ALJ as lacking in the record before him. Additionally, had the ALJ been

confronted with the sort of “objective medical evidence” provided by the 2010 MRI, as well

as corresponding medical opinion evidence in light of the MRI, perhaps the ALJ would have

reassessed his credibility findings with respect to Plaintiff’s testimony regarding his pain and

his limitations. See Hyde v. Bowen, 823 F.2d 456, 459 (11th Cir. 1987) (finding that new

evidence is “material” when it offers an objective medical explanation for previously

unexplained subjective complaints of pain and inability to work). For example, Plaintiff

indicated that “he has problems concentrating/remembering every so often which is usually

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due to back pain.” Tr. 289. As Plaintiff argues, the “multi-level disc protrusions, including

a diffuse protrusion at L3-4 with marked hypertrophic change of the facet joints and severe

neural foraminal stenosis bilaterally, could reasonably be expected to produce the degree and

intensity of pain and limitation as testified to by [Plaintiff].” Pl.’s Brief (Doc. #10) at 10. 

Indeed, during the hearing, the VE indicated that if Plaintiff’s testimony were found to be

fully credible, he would not be able to perform any past relevant work nor would he be able

to perform other work in the national economy. Tr. 92-93.9

The Court turns now to Plaintiff’s challenge of the ALJ’s denial of benefits. Plaintiff

argues that the new evidence “renders the ALJ’s denial of benefits erroneous.” Pl.’s Brief

(Doc. #10) at 9. Plaintiff notes that in “arriving at his physical RFC findings[,] the ALJ

assigned ‘controlling weight to Dr. Hakim’s assessment’ (Tr. 30),” but “Dr. Hakim’s

assessment was based upon his review of an x-ray in which he noted revealed ‘minor grade

 The following exchange took place between the ALJ and the VE:

9

Q: All right. Please assume that I find fully credible the claimant’s testimony at

this hearing. First, do have an opinion whether he could perform any of the past

relevant work you identified as he performed them?

A: I have an opinion and I do not believe that he could.

Q: Why?

A: He indicates that he has a seven or above level of pain at least three to four

hours a day.

Q: Do you have an opinion whether he could perform any of the past relevant

work as general performed in the national economy?

A: I do not believe that he could.

Q: Same reason?

A: Yes, sir.

Q: Do you have an opinion whether he could perform other work existing in the

regional economy?

A: I do not believe that he could.

Q: Same reason?

A: Yes, sir.

Tr. 92-93.

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I anterolisthesis of L3 upon L4. There is only minor multilevel degenerative changes’ (Tr.

292).” Pl.’s Brief (Doc. #10) at 9. Plaintiff argues that the new MRI “reveals that [Plaintiff]

suffers from far greater objective abnormalities than Dr. Hakim thought.” Id. (emphasis in

original). Consequently, Plaintiff contends that “[t]he Commissioner’s denial of benefits

herein should not be based upon Dr. Hakim’s assessment, which was based upon an x-ray

which he interpreted to evidence only minor abnormalities when a later MRI reveals

significant multi-level degenerative disc disease with disc protrusions, facet arthrosis and

neural foraminal stenosis.” Id. (emphasis in original). The Court agrees with Plaintiff and 10

rejects Defendant’s argument that “the new evidence did not show a significant deterioration

of Plaintiff’s condition.” Def.’s Brief (Doc. #12) at 11. The 2010 MRI clearly reveals

significant changes in Plaintiff’s condition from the time the 2009 x-rays were performed. 

The Court finds Defendant’s argument that “the March 2010 MRI . . . was essentially the

same finding as in June 2009, when x-rays revealed slight scoliosis and multilevel

degenerative changes (Tr. 301),” Def.’s Brief (Doc. #12) at 11, is unpersuasive. 

The Court notes that even though the ALJ posed hypotheticals to the VE limiting

Plaintiff to sedentary work, the hypotheticals posed to the VE were not based on an accurate

RFC since the ALJ’s opinion relies on medical evidence that does not accurately present the

severity of Plaintiff’s condition and calls into doubt Plaintiff’s testimony. 

11

The ALJ noted that “X-rays of [Plaintiff’s] lumbar spine revealed slight scoliosis and minor grade 10

I anterolisthesis of L3 upon L4. There are only minor multilevel degenerative changes.” Tr. 26.

 The Court also notes that when asked whether her responses would change if the 11

hypothetical individual experienced “moderately severe degree of pain” lasting “three to

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Thus, for the reasons stated above, the Court finds that remand is warranted in this

case. While the Court does not make a finding regarding what, if any, effect consideration

of the 2010 MRI may have on the ultimate determination of disability, the evidence must be

considered in the Commissioner’s examination of the totality of the evidence.

VI. CONCLUSION

The Court has carefully and independently reviewed the record and concludes that,

for the reasons given above, the decision of the Commissioner is REVERSED and this case

is REMANDED to the Commissioner for proceedings consistent with this decision. A

separate judgment will issue.

Done this 6th day of February, 2012.

/s/ Wallace Capel, Jr.

WALLACE CAPEL, JR.

UNITED STATES MAGISTRATE JUDGE

four hours daily,” the VE indicated “that would take that individual out of competitive

employment.” Tr. 96-97.

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