Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-5_12-cv-01750/USCOURTS-alnd-5_12-cv-01750-0/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

NORTHEASTERN DIVISION

ESTER RUTH COOKSEY,

Plaintiff,

v.

CAROLYN W. COLVIN,

Acting Commissioner of Social Security,

Defendant.

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CIVIL ACTION NO. 5:12-CV-1750-SLB

MEMORANDUM OPINION

The plaintiff, Ester Ruth Cooksey, brings this action pursuant to the provisions of

42 U.S.C. § 405(g), seeking judicial review of a final adverse decision of the

Commissioner of the Social Security Administration denying her application for disability

insurance benefits. Cooksey timely pursued and exhausted her administrative remedies

available before the Commissioner. Accordingly, this case is now ripe for judicial review

under 42 U.S.C. § 405(g). Based on the court’s review of the record and the briefs

submitted by the parties, the court finds that the decision of the Commissioner is due to be

affirmed.

I. STANDARD OF REVIEW

The sole function of this court is to determine whether the decision of the

Commissioner is supported by substantial evidence and whether the ALJ applied the

proper legal standards. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). 

FILED

 2014 Jul-25 PM 02:29

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 5:12-cv-01750-SLB Document 10 Filed 07/25/14 Page 1 of 14
To that end this court “must scrutinize the record as a whole to determine if the decision

reached is reasonable and supported by substantial evidence.” Id. (citations omitted). 

Substantial evidence is “such relevant evidence as a reasonable person would accept as

adequate to support a conclusion.” Id. This court may not decide the facts anew, reweigh

the evidence, or substitute its judgment for that of the Commissioner. Id. Even if the

court finds that the evidence preponderates against the Commissioner’s decision, the

court must affirm if the decision is supported by substantial evidence. Id.

Unlike the deferential review standard applied to the Commissioner’s factual

findings, “no similar presumption of validity attaches to the [Commissioner’s]

conclusions of law, including determination of the proper standards to be applied in

reviewing claims.” Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982) (quoting

Smith v. Schweiker, 646 F.2d. 1075, 1076 (5th Cir. Unit A Jun.1981)). Therefore, this

court reviews de novo the Commissioner’s conclusions of law. Ingram v. Comm’r of Soc.

Sec., 496 F.3d 1253, 1260 (11th Cir. 2007). 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.” Cornelius v.

Sullivan, 936 F.2d 1143, 1145-46 (11th Cir.1991).

II. STATUTORY AND REGULATORY FRAMEWORK

 To qualify for disability benefits, a claimant must be 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

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Case 5:12-cv-01750-SLB Document 10 Filed 07/25/14 Page 2 of 14
expected to last for a continuous period of not less than twelve months.” 42 U.S.C.

§§ 423(d)(1)(A), 1382c(a)(3)(A). A “physical or mental impairment” is “an impairment

that results from anatomical, physiological, or psychological abnormalities which are

demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42

U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).

Social Security regulations outline a five-step process that the Commissioner uses

to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v),

416.920(a)(4)(i)-(v). The Commissioner must determine in sequence: 

(1) whether the claimant is currently engaged in substantial gainful

activity;

(2) whether the claimant has a severe impairment or combination of

impairments;

(3) whether the claimant’s impairment meets or equals the severity of an

impairment in the Listing of Impairments;1

(4) whether the claimant can perform any of his or her past work; and

(5) whether there are significant numbers of jobs in the national

economy that the claimant can perform.

Winschel v. Comm’r of Soc. Sec, 631 F.3d 1176, 1178 (11th Cir. 2011). The evaluation

process continues until the Commissioner can determine whether the claimant is disabled. 

20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). A claimant who is doing substantial gainful

 The Listing of Impairments, (“Listings”) found at 20 C.F.R. Part 404, Subpart 1

P, Appendix 1, are used to make determinations of disability based upon the presence of

impairments that are considered severe enough to prevent a person from doing any

gainful activity. 20 C.F.R. § 404.1525.

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activity will be found not disabled at step one. 20 C.F.R. §§ 404.1520 (a)(i),

416.920(a)(4)(i). A claimant who does not have a severe impairment will be found not

disabled at step two. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). A claimant with

an impairment that meets or equals one in the Listing of Impairments will be found

disabled at step three. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).

Prior to considering steps four and five, the Commissioner must assess the

claimant’s residual functional capacity (RFC), which will be used to determine the

claimant’s ability to work. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). A claimant who

can perform past relevant work will be found not disabled at step four. 20 C.F.R.

§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). At step five the burden shifts to the

Commissioner to show other work the claimant can do. Foot v. Chater, 67 F.3d 1553,

1559 (11th Cir. 1995). To satisfy this burden the Commissioner must produce evidence

of work in the national economy that the claimant can do based on the claimant’s RFC,

age, education, and work experience. 20 C.F.R. §§ 404.1512(f), 416.912(f). A claimant

who can do other work will be found not disabled at step five. 20 C.F.R.

§§ 404.1520(a)(4)(v), 416.920 (a)(4)(v). A claimant who cannot do other work will be

found disabled. Id.

In the present case, the Administrative Law Judge (ALJ) determined Cooksey was

not engaged in substantial gainful activity, and found she had the following severe

impairments: “type 2 diabetes mellitus with severe insulin resistance, essential

hypertension, ‘mild’ diastolic dysfunction, congestive heart failure (compensated), and

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morbid obesity (BMI of 46 percent).” R. 22. The ALJ concluded Cooksey did not suffer

from a listed impairment. R. 24. She found Cooksey had the residual functional capacity

(RFC) to perform “a full range of sedentary work as defined in 20 CFR 404.1567(a).” R.

25. With this RFC, the ALJ found Cooksey unable to perform her past relevant work. R.

32. However, the ALJ found Cooksey was not disabled under Medical-Vocational Rule

201.27, which directs a finding of not disabled for an individual of Cooksey’s age and

educational background who is able to perform a full range of sedentary work. R. 33. 2

III. FACTUAL BACKGROUND

Cooksey filed applications for a period of disability, disability insurance benefits,

and Supplemental Security Income (SSI) on August 18, 2008, and alleges she became

disabled on July 19, 2007. R. 20. Cooksey was 41 years old at the time of the ALJ’s

decision. R. 33-33. She has a high school education, and past relevant work as a

“daycare worker/teacher, door greeter (Wal-Mart), and cashier (grocery store).” R. 32. 

Cooksey alleges she is disabled due to “diabetes, back problems, stomach, high blood

pressure, mitral valve prolapse, severe pain in left hand and right foot.” Pl.’s Br. 2.

Treatment records show Cooksey has been treated extensively for type II diabetes

mellitus and essential hypertension. These records show Cooksey’s essential

 The Medical-Vocational Guidelines, found at 20 C.F.R. Part 404, Subpart P,

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Appendix 2, are used to make determinations of disability based upon vocational factors

and the claimant’s residual functional capacity when the claimant is unable to perform

his vocationally relevant past work. 20 C.F.R. Part 404, Subpart P, Appendix 2,

§ 200.00(a). Such determinations, however, are only conclusive when all of the criteria

of a particular rule are met. 20 C.F.R. Part 404, Subpart P, Appendix 2, § 200.00(a).

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Case 5:12-cv-01750-SLB Document 10 Filed 07/25/14 Page 5 of 14
hypertension was generally well controlled when she was compliant with prescribed

medications. See, e.g., R. 598. However, her diabetes was less well controlled, at least in

part due to Cooksey’s failure to follow prescribed treatment. For example, on December

3, 2008, Dr. Coccia noted Cooksey reported her blood sugar levels were better, and she

reported that her blood pressure medication seemed to be working well. R. 484. 

However, on January 28, 2009, Dr. Coccia counseled Cooksey that her weight and

noncompliance with a diabetic diet made control of her diabetes difficult. R. 482. In any

event, the medical records do not show Cooksey’s diabetes had caused any end organ

damage, neuropathy, retinopathy, or neprhopathy.

In 2007 Cooksey was treated for a breast abscess. Her treating doctor completed a

return to work form indicating she could return to work with no restrictions on September

4, 2007. R. 232. The abscess ultimately required surgical drainage on November 1,

2001. R. 313. On November 19, 2007, Dr. McLaury noted Cooksey had done well after

the abscess was removed. R. 261.

In April 2009 an ultrasound of the thyroid gland showed a well-defined solid mass. 

R. 445. After further testing, Cooksey underwent a total thyroidectomy on October 29,

2009. R. 562-65. Surgical pathology revealed the presence of two papillary carcinomas. 

R. 560. On November 1, 2009, Cooksey received a dose of radioactive iodine. R. 569. 

A December 21, 2009, treatment note states that a recent PET scan “was okay,” and Dr.

Coccia’s assessment was that things were going well with Cooksey’s thyroid cancer. R.

598.

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Case 5:12-cv-01750-SLB Document 10 Filed 07/25/14 Page 6 of 14
After complaining of chest pain in July 2009, Dr. Wu-Varquez ordered a graded

exercise test and myocardial perfusion scan. R. 508. The scan showed no evidence of

ischemia. R. 506.

Cooksey was treated for a variety of other complaints during the relevant time

period. However, treatment for those conditions was sporadic, and the treatment notes do

not suggest they caused a lasting and significant impairment to Cooksey’s ability to work.

IV. ISSUES PRESENTED

Cooksey raises the following issues on appeal: 1) whether the ALJ erred in

rejecting the opinion of Dr. Coccia, one of her treating physicians; 2) whether the ALJ

was required to obtain a medical source opinion from either a consultative examiner or a

medical expert; and 3) whether the ALJ erred by failing to properly consider her obesity

under Social Security Ruling 02-1p.

V. DISCUSSION

A.

Cooksey argues the ALJ improperly rejected the opinions of Dr. Coccia, one of her

treating physicians. Pl.’s Br. 7-8. On February 24, 2009, Dr. Coccia wrote a letter to the

Cullman Department of Human Resources stating Cooksey was “unable to dependably

report for work and perform for a six to eight-hour day.” R. 448. He also stated Cooksey

would “be happier than anyone to get back to work as soon as possible but currently, with

her medical situation, that is not a realistic expectation.” R. 448. In addition, Dr. Coccia

completed a Food Stamp form on which he indicated Cooksey was unable to work, and

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Case 5:12-cv-01750-SLB Document 10 Filed 07/25/14 Page 7 of 14
stated that morbid obesity, wide fluctuations in blood sugar, and hypoglycemia were the

medical conditions that prevented her from working. R. 496. On that form he also wrote

that Cooksey could return to work within a year if she lost weight and got her blood sugar

under control. R. 496.

In determining how much weight to give to each medical opinion, the ALJ must

consider several factors, including (1) whether the doctor has examined the claimant; (2)

whether the doctor has a treating relationship with the claimant; (3) the extent to which

the doctor presents medical evidence and explanation supporting his opinion; (4) whether

the doctor's opinion is consistent with the record as a whole; and (5) whether the doctor is

a specialist. 20 C.F.R. §§ 404.1527(c), 416.927(c). Under the Commissioner’s

regulations, a treating physician’s opinion will be given controlling weight if it is well

supported and not inconsistent with other substantial evidence in the record.

If we find that a treating source's opinion on the issue(s) of the nature and

severity of your impairment(s) is well-supported by medically acceptable

clinical and laboratory diagnostic techniques and is not inconsistent with the

other substantial evidence in your case record, we will give it controlling

weight.

20 C.F.R. § 404.1527(c)(2).

In considering whether an ALJ has properly rejected a treating physician’s opinion,

this court is not without guidance. “The law of this circuit is clear that the testimony of a

treating physician must be given substantial or considerable weight unless ‘good cause’ is

shown to the contrary.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11 Cir. 1997). “Good th

cause” exists when the evidence does not bolster the treating physician's opinion; a

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contrary finding is supported by the evidence; or the opinion is conclusory or inconsistent

with the treating physician's own medical records. Id. If a treating physician’s opinion is

rejected, the ALJ must clearly articulate the reasons for doing so. Id. (“The ALJ must

clearly articulate the reasons for giving less weight to the opinion of a treating physician,

and the failure to do so is reversible error.”).

The ALJ articulated a number of reasons why she gave Dr. Coccia’s opinions little

weight. She found that Dr. Coccia’s “opinions contrast sharply with the other evidence of

record, including his own office notes.” R. 31. She also noted that Dr. Coccia’s opinions

were inconsistent with his treatment notes both before and after the time he rendered his

opinions. The ALJ observed that in January 2009 Cooksey “reported she was doing well

on her diet and [her] A1C level was ‘much better’ at 8.3.” R. 31, 453, 482. The ALJ 3

noted that subsequently Cooksey’s A1C level continued to improve to 7.5. R. 31, 452. 

She noted that in June and July 2009, Dr. Coccia’s notes reflected Cooksey had lost

weight, was doing well on Lantus, and required less insulin. R. 31, 473, 465. The ALJ

also observed that during Dr. Coccia’s “actual examinations and long-term treatment of

[Cooksey] he never mentioned such limitations in his treatment notes.” R. 32.

 “The A1C test is a common blood test used to diagnose type 1 and type 2 3

diabetes and then to gauge how well you’re managing your diabetes. . . . The A1C test

result reflects your average blood sugar level for the past two to three months.

http://www.mayoclinic.org/tests-procedures/a1c-test/basics/definition/prc-2001258

Someone who's had uncontrolled diabetes for a long time might have an A1C level

above 8 percent. . . . For most people who have previously diagnosed diabetes, an A1C

level of 7 percent or less is a common treatment target.”

http://www.mayoclinic.org/tests-procedures/a1c-test/basics/results/prc-20012585

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The inconsistencies between Dr. Coccia’s opinions and his treatment notes provide

“good cause” for rejecting those opinions. Lewis, 125 F.3d at 1440. Because this court

does not reweigh the evidence, there is no reversible error in the ALJ’s decision not to

credit Dr. Coccia’s opinions.

B.

Although Cooksey acknowledges there is no express requirement for an RFC

assessment from a medical source, she argues that one is required as a practical matter to

avoid an ALJ substituting his judgment for that of a physician. Pl.’s Br. 9. However,

neither the Commissioner’s regulations nor the law of this circuit require that an RFC be

based upon a medical source statement from a doctor.

The regulations provides that opinions on issues reserved to the Commissioner,

such as a claimant’s RFC, are not medical opinions.

Opinions on some issues, such as the examples that follow, are not medical

opinions, . . . but are, instead, opinions on issues reserved to the

Commissioner because they are administrative findings that are dispositive

of a case; i.e., that would direct the determination or decision of disability.

§ 404.1527(d). One of the specifically excluded examples is a claimant’s RFC.

Although we consider opinions from medical sources on issues such as . . .

your residual functional capacity . . . the final responsibility for deciding

these issues is reserved to the Commissioner.

§ 404.1527(d)(2). Therefore, under the regulations, a claimant’s RFC is not a medical

opinion, and a doctor’s opinion was not required for the ALJ to assess Cooksey’s RFC.

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The Eleventh Circuit has also recognized that determining a claimant’s residual

functional capacity and ability to work is a task for the ALJ, and not doctors. See

Robinson v. Astrue, 365 F. App’x 993, 999 (11th Cir. 2010) (unpublished) (“[T]he task of

determining a claimant's residual functional capacity and ability to work is within the

province of the ALJ, not of doctors.”). It has also found an ALJ’s RFC finding can be

supported by substantial evidence even if there is no medical source statement in the

record. In Green v. Social Security Administration, the Court found the ALJ had properly

refused to credit a Physical Capacities Evaluation (“PCE”) from the claimant’s treating

physician. 223 F. App’x 915, 922-23 (11 Cir. 2007) (unpublished). The Court in Green th

rejected the claimant’s argument that without that PCE, there was nothing in the record

upon which the ALJ could base his RFC finding. Id. at 923. The Court held that other

evidence from the claimant’s doctors (which did not contain a PCE or RFC assessment)

was sufficient to support the ALJ’s finding that the claimant could perform light work. 

Id. at 923-24; see also Langley v. Astrue, 777 F Supp. 2d. 1250, 1258 (N.D. Ala. 2011)

(holding RFC is not a medical opinion and need not be based upon a doctor’s RFC

opinion).

In the present case, there was sufficient medical and other evidence in the record to

allow the ALJ to assess Cooksey’s RFC. The ALJ noted that one of Cooksey’s treating

doctors provided a note indicating she would be able to return to work with no restrictions

on September 4, 2007. R. 27, 232. She also relied on Cooksey’s reported daily activities,

which included cooking, cleaning, mopping weekly and shopping for groceries with her

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husband. R. 30, 115-16. The ALJ noted Cooksey reported she “can stand and bend but

just not for prolonged periods or as often as she used to, she can walk for about one-half

mile or 20 minutes at a time, and lift 15-20 pounds for short periods.” R. 30, 118. She

found these activities were evidence that Cooksey can do sedentary work. R. 30. This

evidence is sufficient to allow a reasonable fact finder to conclude Cooksey was able to

perform sedentary work. Therefore, the ALJ’s RFC finding was based on substantial

evidence.

Cooksey also argues the ALJ should have ordered a consultative examination or

utilized a medical expert to obtain a medical source opinion. Pl.’s Br. 9. However,

before remanding for further development of the record, a reviewing court must consider

“whether the record reveals evidentiary gaps which result in unfairness or ‘clear

prejudice.’” Smith v. Schweiker, 677 F.2d 826, 830 (11th Cir.1982) (quoting Ware v.

Schweiker, 651 F.2d 408, 413 (5th Cir. Unit A July 1981). Therefore, “although the ALJ

has a duty to develop a full and fair record, there must be a showing of prejudice before [a

reviewing court] will remand for further development of the record.” Robinson v. Astrue,

365 F. App’x 993, 995 (11th Cir. 2010) (unpublished) (citing Brown v. Shalala, 44 F.3d

931, 935 (11th Cir. 1995).

In the present case, there are extensive treatment records and other evidence

documenting the extent of Cooksey’s impairments. Cooksey has not identified any gaps

in the evidence that cause unfairness or prejudice in the absence of a consultative

examination or testimony from a medical expert. Therefore, she has not demonstrated the

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ALJ committed a reversible error by failing to order a consultative examination or elicit

testimony from a medical expert.

C.

Cooksey argues the ALJ failed to adequately consider her obesity under Social

Security Ruling 02-1p. Pl.’s Br. 10-11. Social Security Ruling (SSR) 02-01p provides

guidance in the evaluation of obesity. It provides that “[t]here is no specific level of

weight or BMI that equates with a ‘severe’ or ‘not severe’ impairment,” and that

“descriptive terms for levels of obesity (e.g., ‘severe,’ ‘extreme,’ or ‘morbid’ obesity)”

will not establish whether obesity is a “severe” impairment. SSR 02-1p, 2002 WL

34686281, *4 (S.S.A.). Rather, an ALJ must “do an individualized assessment of the

impact of obesity on an individual’s functioning.” Id. It also provides that obesity must

be considered in assessing a claimant’s RFC by assessing “the effect obesity has upon the

individual’s ability to perform routine movement and necessary physical activity within

the work environment.” Id. at * 6.

The ALJ discussed Cooksey’s obesity in her decision and found that it did not

result in restrictions that would prevent Cooksey from performing sedentary work. R. 27-

28. The ALJ noted Cooksey had been obese “during the period when she successfully

worked,” and that her weight “has essentially remained the same for years.” R. 27. The

ALJ also observed that Cooksey “has not specifically alleged any functional limitations

due to weight and the records of her treating physician likewise are not reflective of any.” 

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R. 27. Although Cooksey cites to Social Security Ruling 02-1p in her brief, she cites to

no evidence showing her obesity prevents her from performing sedentary work. 

Therefore, the ALJ properly considered Cooksey’s obesity in accordance with SSR

02-01p. She gave reasons supported by substantial evidence for finding that Cooksey’s

obesity did not impose limitations on her ability to work greater than those reflected in the

RFC finding. Therefore, the ALJ did not err in her consideration of Cooksey’s obesity.

VI. CONCLUSION

The court concludes the ALJ’s determination that Cooksey is not disabled is

supported by substantial evidence, and that the ALJ applied the proper legal standards in

arriving at this decision. Accordingly, the Commissioner’s final decision is due to be

affirmed. An appropriate order will be entered.

DONE this 25th day of July, 2014.

 

SHARON LOVELACE BLACKBURN

UNITED STATES DISTRICT JUDGE 

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