Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_11-cv-00961/USCOURTS-almd-3_11-cv-00961-0/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)

---

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

EASTERN DIVISION

BRENDA S. PIKE, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 3:11cv961-CSC

) (WO)

MICHAEL J. ASTRUE, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff, Brenda S. Pike (“Pike”), applied 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. The plaintiff 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). See Chester v. Bowen, 792 F.2d 129, 131 (11 Cir. 1986). The case is 1 th

now before the court for review pursuant to 42 U.S.C. §§ 405 (g) and 1383(c)(3). Based on

the court’s review of the record in this case and the briefs of the parties, the court concludes

Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L. No. 1

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-00961-CSC Document 17 Filed 07/18/12 Page 1 of 11
that the decision of the Commissioner should affirmed.2

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, the Commissioner employs a five-step, sequential 3

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.”

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11 Cir. 1986). th 4

Pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1, the parties have consented to the United 2

States Magistrate Judge conducting all proceedings in this case and ordering the entry of final judgment. 

A “physical or mental impairment” is one resulting from anatomical, physiological, or 3

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.

McDaniel v. Bowen, 800 F.2d 1026 (11 Cir. 1986) is a supplemental security income case (SSI). 4 th

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 (5 Cir. 1981) (Unit A).

th

2

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 2 of 11
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); Dyer v. Barnhart, 395 F.3d 1206, 1210 (11 Cir. 2005). Substantial th

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.”

Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158-59 (11 Cir. 2004) (quotation marks th

omitted). The court “may not decide the facts anew, reweigh the evidence, or substitute . .

. [its] judgment for that of the [Commissioner].” Phillips v. Barnhart, 357 F.3d 1232, 1240

n. 8 (11 Cir. 2004) (alteration in original) (quotation marks omitted). th

[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 (11 Cir. 1987). th

III. The Issues

A. Introduction. Pike was 50 years old at the time of the administrative hearing, and

on the alleged date of onset. (R. 14, 30). She has completed eighth grade. (R. 169). The

ALJ concluded that Pike has severe impairments of “degenerative disk disease of the lumbar

spine and obesity,” but concluded that Pike’s carpal tunnel syndrome, migraine headaches,

and osteoarthritis in her knees and legs did not constitute severe impairments because there

was a lack of objective diagnostic evidence confirming the existence of these conditions. (R.

16). Her prior work experience includes work “as a fast food worker at the light level.” (R.

3

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 3 of 11
24). Following the hearing, the ALJ concluded that the plaintiff could return to her past

relevant work, and thus, she is not disabled. (R. 24-25). 

B. Plaintiff’s Claims. Pike presents two issues for the Court’s review. As stated by

Pike, they are as follows:

1. The Commissioner’s decision should be reversed, because the ALJ

failed to evaluate Dr. Durant’s medical opinions in accordance with

Social Security Ruling 96-2p.

2. The Commissioner’s decision should be reversed, because the ALJ

failed to fulfill his duty to develop the record.

(Doc. # 12, Pl’s Br. at 3). It is to these two issues that the court now turns.

IV. Discussion

A disability claimant bears the initial burden of demonstrating an inability to return

to her past work. Lucas v. Sullivan, 918 F.2d 1567 (11 Cir. 1990). In determining whether th

the claimant has satisfied this burden, the Commissioner is guided by four factors: (1)

objective medical facts or clinical findings, (2) diagnoses of examining physicians, (3)

subjective evidence of pain and disability, e.g., the testimony of the claimant and her family

or friends, and (4) the claimant’s age, education, and work history. Tieniber v. Heckler, 720

F.2d 1251 (11 Cir. 1983). The ALJ must conscientiously probe into, inquire of and explore th

all relevant facts to elicit both favorable and unfavorable facts for review. Cowart v.

Schweiker, 662 F.2d 731, 735-36 (11 Cir. 1981). The ALJ must also state, with sufficient th

specificity, the reasons for his decision referencing the plaintiff’s impairments. 

Any such decision by the Commissioner of Social Security which involves a

determination of disability and which is in whole or in part unfavorable to such

4

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 4 of 11
individual shall contain a statement of the case, in understandable language,

setting forth a discussion of the evidence, and stating the Commissioner’s

determination and the reason or reasons upon which it is based.

42 U.S.C. § 405(b)(1) (emphases added).

A. Treating Physician’s Opinion. Pike argues that the ALJ failed to properly

evaluate the opinion of her treating physician, Dr. Durant. (Doc. # 12, Pl’s Br. at 4). In

essence, the plaintiff argues that even if the ALJ did not give Dr. Durant’s opinion great

weight, he should not have completely rejected Dr. Durant’s assessment about her

impairments. “[T]he ALJ’s opinion does not provide the required rationale as to why Dr.

Durant’s medical opinions were not entitled to controlling weight or ifsuch standard was not

met, why Dr. Durant’s medical opinions should not be adopted nonetheless considering his

extensive treatment relationship with his patient.” (Doc. # 12, Pl’s Br. at 6).

Of course, the law in this circuit is well-settled that the ALJ must accord “substantial

weight” or “considerable weight” to the opinion, diagnosis, and medical evidence of the

claimant’s treating physician unless good cause exists for not doing so. Jones v. Bowen, 810

F.2d 1001, 1005 (11 Cir. 1986); Broughton v. Heckler, 776 F.2d 960, 961 (11 Cir. 1985). th th

The Commissioner, as reflected in his regulations, also demonstrates a similar preference for

the opinion of treating physicians.

Generally, we give more weight to opinions from your treating sources, since

these sources are likely to be the medical professionals most able to provide

a detailed, longitudinal picture of your medical impairment(s) and may bring

a unique perspective to the medical evidence that cannot be obtained from the

objective medical findings alone or from reports of individual examinations,

such as consultive examinations or brief hospitalizations.

5

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 5 of 11
Lewis v. Callahan, 125 F.3d 1436, 1440 (11 Cir. 1997) (citing 20 CFR § 404.1527 (d)(2)). th

The ALJ’s failure to give considerable weight to the treating physician’s opinion is reversible

error. Broughton, 776 F.2d at 961-2.

However, there are limited circumstances when the ALJ can disregard the treating

physician’s opinion. The requisite “good cause” for discounting a treating physician’s

opinion may exist where the opinion is not supported by the evidence, or where the evidence

supports a contrary finding. See Schnorr v. Bowen, 816 F.2d 578, 582 (11 Cir. 1987). Good th

cause may also exist where a doctor’s opinions are merely conclusory, inconsistent with the

doctor’s medical records, or unsupported by objective medical evidence. See Jones v. Dep’t.

of Health & Human Servs., 941 F.2d 1529, 1532-33 (11 Cir. 1991); Edwards v. Sullivan,

th

937 F.2d 580, 584-85 (11 Cir. 1991); Johns v. Bowen, 821 F.2d 551, 555 (11 Cir. 1987). th th

The weight afforded to a physician’s conclusorystatements depends upon the extent to which

they are supported by clinical or laboratory findings and are consistent with other evidence

of the claimant’s impairment. Wheeler v. Heckler, 784 F.2d 1073, 1075 (11 Cir. 1986). th

The ALJ “may reject the opinion of any physician when the evidence supports a contrary

conclusion.” Bloodsworth v. Heckler, 703 F.2d 1233, 1240 (11 Cir. 1983). The ALJ must th

articulate the weight given to a treating physician’s opinion and must articulate any reasons

for discounting the opinion. Schnorr, 816 F.2d at 581. 

On January 24, 2011, Dr. Durant completed a medical source statement, assessing

Pike’s ability to do work-related activities. (R. 328-334). Dr. Durant indicated that Pike

could lift 10 to 20 pounds occasionally, sit for 20 minutes without interruption, stand for 30

6

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 6 of 11
minutes without interruption, and sit, stand and walk for a total of one hour during a work

day. (R. 328-29). Dr. Durant indicated that Pike suffered from carpal tunnel syndrome

which resulted in her being able to use her hands only occasionally. Her degenerative disk

disease affected her ability to use her feet. (R. 330). He opined that while Pike could

perform a number of daily activities including shopping, traveling, ambulating, climbing

stairs and preparing meals, she could not sort or handle paper or files. (R. 333). Dr. Durant

concluded that Pike could not work 8 hours a day, 5 days a week. (Id.) Finally, in a clinical

assessment of pain, Dr. Durant opined that Pike had pain that “greatly increased . . . to such

a degree as to cause distraction from task or total abandonment of task.” (R. 334). 

The ALJ reviewed all the medical records, and he thoroughly detailed Dr. Durant’s

treatment notes. After reviewing the medical evidence, the ALJ gave the opinion of Dr.

Durant “little weight” because “apparently, he relied quite heavily on the subjective report

of symptoms and limitations provided by the claimant.” (R. 23). If this were the only reason

the ALJ’s rejected Dr. Durant’s opinion, the plaintiff might be entitled to some relief. 

However, the ALJ continued.

Quite simply there is a lack of objective evidence including diagnostic and

laboratory testing to support Dr. Durant’s diagnoses of carpal tunnel, heart

disease and osteoarthritis of the knees. As referenced in the medical records

above, the x-rays, MRI and assessments by specialists, Dr. Ryan and doctors

at the Orthopaedic Clinic, showed the claimant did not have heart disease,

arthritis of knees and did not find her degenerative disc disease of the lumbar

spine was sufficient to warrant a recommendation of surgery. There is no

evidence of testing to confirm carpal tunnel syndrome (CTS) or any

neuropathy although Dr. Durant references CTS in his MMS [Medical Source

Statement] and neuropathy in his treatment notes. The claimant does have a

herniated disc, but she was “cleared for full activities” as of May 2010 by the

7

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 7 of 11
orthopedic specialist.

(R. 23-24).

The ALJ acknowledged that Pike suffers fromdegenerative disc disease ofthe lumbar

spine but concluded that “there is a lack of evidence that this condition results in total

disability.” (R. 20). The ALJ also contrasted Dr. Durant’s opinion that Pike was disabled

with the opinion of Dr. Shiels, the doctor at the Orthopadic Clinic. (R. 23). Dr. Shiels

evaluated Pike and concluded that he had

nothing to offer here in regards to what she has not already tried. We could try

some physical therapy but that could run up some bills and she is definitely not

interested in any epidural steroid shots. She is cleared for all activities. I do

not see anything that needs operative intervention.

(R. 260) (emphasis added).

The ALJ’s decision to give Dr. Durant’s opinion little weight is supported by

substantial evidence. In her initial disability report, Pike completed a functions report

indicating that she is able to care for her personal needs without assistance; she cooks daily;

she does household chores; she shops twice a week; and she goes out two to three times a

day. (R. 180-183). It is clear that Dr. Durant’s treatment notes reflect Pike’s complaints as

told to him by Pike. Dr. Durant diagnosed Pike with carpal tunnel syndrome even though

there is no evidence in his notes to indicate that Pike ever complained to him of hand pain.5

It is undisputed that the plaintiff suffers from a herniated disk that gives rise to some pain. 

The court more fully addresses Pike’s argument that the ALJ should have ordered testing to 5

ascertain the extent of her carpal tunnel syndrome in a separate section of this opinion.

8

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 8 of 11
However, Dr. Durant’s treatment notes do not support the level of disability he attributes to

Pike. 

The ALJ may disregard the opinion of a physician, provided that he states with

particularity reasons therefor. Sharfarz v. Bowen, 825 F.2d 278 (11 Cir. 1987). The ALJ th

examined and evaluated the medical records for evidence supporting Dr. Durant’s assessment

of Pike’s ability to work, and he considered the medical opinion of other doctors, including

an orthopaedic specialist who examined Pike. Only then did the ALJ discount Dr. Durant’s

opinion that Pike was totally disabled. Based upon its review of the ALJ’s decision and the

objective medical evidence of record, the court concludes that the ALJ properly rejected Dr.

Durant’s opinion that Pike is totally disabled.

B. Failure to develop the record. The plaintiff argues that the ALJ failed in his duty

to develop a full and fair record when he did not order any objective medical testing to

establish that she suffers from carpal tunnel syndrome. (Doc. # 12, Pl’s Br. at 7). In

considering a disability claim, the ALJ must fully and fairly develop the facts, including

ordering a consultative examination if necessary to make an informed decision. See Reeves

v. Heckler, 734 F.2d 519, 522 (11 Cir. 1984); Ford v. Secretary of Health and Human Servs.,

th

659 F.2d 66, 69 (5 Cir. Unit B 1981). However, an administrative law judge is not required th

to order a consultative examination unless the record establishes that such an examination is

necessary to enable the administrative law judge to render a decision. Holladay v. Bowen,

6

At the administrative hearing, Pike’s former counsel stated that the reason there was no testing of 6

Pike’s hands was because she could not afford testing. (R. 30). It is the law in this circuit that poverty

9

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 9 of 11
848 F.2d 1206, 1210 (11 Cir. 1988). The regulations do not require the Commissioner to th

secure a consultative evaluation, nor do they create a right to a consultative examination. 

Here the record does not support Pike’s contention that carpal tunnel testing was

necessary. Pike testified at the administrative hearing that she had been diagnosed with carpal

tunnel syndrome 10 or 12 years ago by a doctor in Georgia. (R. 37, 40). No medical records

support this statement. Dr. Durant’s treatment note of January 24, 2011 is the only medical

record that contains that diagnosis, and on that day, Pike did not complain of pain in her

hands. (R. 270-71). The court has scoured Pike’s medical records and is unable to find one 7

instance in which she complained to her treating physician, the orthopaedic specialist or the

consultative physician about pain in her hands or wrists. During the administrative hearing,

Pike testified that she dropped things when she tried to hold anything in her right hand, and

that her problem with her hand contributed to disability. (R. 37, 40). When she applied for

benefits, Pike did not mention pain in her hands as a condition that limited her ability to work.

(R. 164). In her functions report, when describing how her daily activities are affected by her

impairments, she indicated that when she does housework including cooking, laundry, and

making beds. (R. 182). Although Pike underwent a consultative physical examination on

excuses noncompliance with prescribed medical treatment or the failure to seek treatment. Dawkins v.

Bowen, 848 F.2d 1211 (11 Cir. 1988). However, in Dawkins, the claimant was denied supplementalsecurity th

income benefits because of her failure to follow prescribed medical treatment. 848 F.2d at 1212. The

Eleventh Circuit held that a claimant cannot be denied benefits due to her failure to secure medical treatment

when poverty may excuse non-compliance. Id. at 1213-14. In this case, the ALJ did not deny the plaintiff

benefits based on her non-compliance with treatment. Therefore, Dawkins, supra, is inapposite

It is, however, the same day that Dr. Durant completed the medical source statement in which he 7

opined that her carpal tunnel syndrome contributed to her disability.

10

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 10 of 11
November 11, 2009, she did not report any problems with her hands or wrists. (R. 238-240). 

Consequently, the court concludes that the medical evidence in the record is simply

insufficient to demonstrate that additional testing was necessary for the ALJ to render an

informed decision in this case. On this record, the ALJ did not err by failing to secure testing.

V. Conclusion

This court must accept the factual findings of the Commissioner if they are supported

by substantial evidence and based upon the proper legal standards. Bridges v. Bowen, 815

F.2d 622 (11 Cir. 1987). The court has carefully and independently reviewed the record and th

concludes that substantial evidence supports the ALJ’s conclusion that plaintiff is not

disabled, and is due to be affirmed.

A separate order will be entered.

Done this 18 day of July 2012. th

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

11

Case 3:11-cv-00961-CSC Document 17 Filed 07/18/12 Page 11 of 11