Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-1_13-cv-00691/USCOURTS-alnd-1_13-cv-00691-0/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

EASTERN DIVISION

TERESSA DAWN REID,

Plaintiff,

vs.

CAROLYN W. COLVIN,

Commissioner of Social Security,

Defendant.

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1:13-cv-00691-TMP

MEMORANDUM OPINION

I. Introduction

The plaintiff, Teressa Dawn Reid, appeals from the decision of the

Commissioner of the Social Security Administration (“Commissioner”) denying her

application for Supplemental Security Income (“SSI”). Ms. Reid timelypursued and

exhausted her administrative remedies and the decision of the Commissioner is ripe

for review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).

Ms. Reid was fifty years old at the time her application was filed, and she has

a high school education. (Tr. at 37-38.) Her past work experiences include semiskilled

employment as a dispatcher, inventory clerk and stocker. (Tr. at 37.) Ms. Reid claims

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FILED

 2014 Jul-11 PM 04:00

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 1:13-cv-00691-TMP Document 17 Filed 07/11/14 Page 1 of 17
that she became disabled on July 2, 2009, due to stroke, a spot on her brain, arthritis, 1

depression, and breast lumps. (Tr. at 13, Doc. 13 at 2. )

When evaluating the disability of individuals over the age of eighteen, the

regulations prescribe a five-step sequential evaluation process. See 20 C.F.R. §§

404.1520, 416.920; see also Doughty v.Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). The

first step requires a determination of whether the claimant is “doing substantial

gainful activity.” 20 C.F.R. §§ 404.1520(a)(4)(I), 416.920(a)(4)(I). If he or she is, the

claimant is not disabled and the evaluation stops. Id. If he or she is not, the

Commissioner next considers the effect of all of the physical and mental impairments

combined. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These impairments

must be severe and must meet the durational requirements before a claimant will be

found to be disabled.Id. The decision depends on the medical evidence in the record.

See Hart v. Finch, 440 F.2d 1340, 1341 (5th Cir. 1971). If the claimant’s impairments

are not severe, the analysis stops. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).

Otherwise, the analysis continues to step three, which is a determination of whether

the claimant’s impairments meet or equal the severity of an impairment listed in 20

C.F.R. pt. 404, Subpart P, Appendix 1. 20 C.F.R. §§ 404.1520(a)(4)(iii),

The Plaintiff originally alleged her disability onset date to be March 29, 2007, but moved 1 

to amend the date at the hearing. The motion was granted by the ALJ. (Tr. at 13.)

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416.920(a)(4)(iii). If the claimant’s impairments fall within this category, he or she

will be found disabled without further consideration. Id. If they do not, a

determination of the claimant’s residual functional capacity will be made and the

analysis proceeds to the fourth step. 20 C.F.R. §§ 404.1520(e), 416.920(e). Residual

functional capacity (“RFC”) is an assessment, based on all relevant evidence, of a

claimant’s remaining ability to do work despite his or her impairments. 20 C.F.R. §

404.945(a)(1).

The fourth step requires a determination of whether the claimant’s

impairments prevent him or her from returning to past relevant work. 20 C.F.R. §§

404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant can still do his or her past

relevant work, the claimantis not disabled and the evaluation stops. Id.If the claimant

cannot do past relevant work, then the analysis proceeds to the fifth step. Id. Step five

requires the court to consider the claimant’s RFC, as well as the claimant’s age,

education, and past work experience in order to determine if he or she can do other

work. 20 C.F.R. §§ 404.1520(a)(4)(v) 416.920(a)(4)(v). If the claimant can do other

work, the claimant is not disabled. Id. The burden is on the Commissioner to

demonstrate that other jobs exist which the claimant can perform; and, once that

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burden is met, the claimant must prove his or her inability to perform those jobs in

order to be found disabled. Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999).

Applying the sequential evaluation process, the ALJ determined that Ms. Reid 

has not engaged in substantial gainful activity since the alleged onset of her disability,

as amended. (Tr. at 15.) According to the ALJ, Plaintiff’s cervical and lumbar

degenerative joint disease; fibromyalgia; mood disorder, (NOS or not otherwise

specified) with features of anxiety and depression; residuals ofstroke; and personality

disorder, (NOS with borderline and antisocial features) are considered “severe”

based on the requirements set forth in the regulations. (Id.) The ALJ determined that

Plaintiff’s polydrug dependence, in remission; breast lumps; hypertension; and

migraine headaches are non-severe impairments. (Tr. at 17.) However, she found that

these impairments neither meet nor medically equal any of the listed impairments in

20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 18.) The ALJ did not find Ms.

Reid’s allegations to be totally credible, and she determined that the Plaintiff has the

residual functional capacity “to perform light work as defined in 20 CFR 416.967(c)

with no climbing ladders, ropes, or scaffolds. She is limited to simple work and no

more than casual and nonintense interaction with others.” (Tr. at 20, 33.)

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According to the ALJ, Ms. Reid is unable to perform any of her past relevant

work, she is an “individual closely approaching advanced age,” and she has “at least

a high school education,” as those terms are defined by the regulations. (Tr. at 37-38.)

The ALJ determined that “transferability of job skills is not material to the

determination of disability because using the Medical-Vocational Rules as a framework

supports a finding that the claimantis ‘not disabled,’ whether or not the claimant has

transferable job skills.” (Tr. at 38.) She found that Ms. Reid has the residual

functional capacity to perform a partial range of lightwork. (Id.) Even though Plaintiff

cannot perform the full range of light work, the ALJ used Medical-Vocation Rule

202.14 as a guideline for finding that there are a significant number of jobs in the

national economy that she is capable of performing, such as gate tender, carwash

attendant, and egg packer. (Id.) The ALJ concluded her findings by stating that

Plaintiff “has not been under a disability, as defined in the Social Security Act, since

July 2, 2009, the amended alleged onset date.” (Tr. at 39.)

II. Standard of Review

This Court’s role in reviewing claims brought under the Social Security Act is

a narrow one. The scope of its review is limited to determining (1) whether there is

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substantial evidence in the record as a whole to support the findings of the

Commissioner, and (2) whether the correct legal standards were applied. See

Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d

1219, 1221 (11th Cir. 2002). The Court approaches the factual findings of the

Commissioner with deference, but applies close scrutiny to the legal conclusions. See

Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996). The Court may not decide facts,

weigh evidence, or substitute its judgment for that of the Commissioner. Id. “The

substantial evidence standard permits administrative decision makers to act with

considerable latitude, and ‘the possibility of drawing two inconsistent conclusions

from the evidence does not prevent an administrative agency’s finding from being

supported by substantial evidence.’” Parker v. Bowen, 793 F.2d 1177, 1181 (11th Cir.

1986) (Gibson, J., dissenting) (quoting Consolo v. Fed. Mar. Comm’n, 383 U.S. 607,

620 (1966)). Indeed, even if this Court finds that the evidence preponderates against

the Commissioner’s decision, the Court must affirm if the decision is supported by

substantial evidence. Miles, 84 F.3d at 1400. No decision is automatic, however, for

“despite this deferential standard [for review of claims] it is imperative that the Court

scrutinize the record in its entirety to determine the reasonableness of the decision

reached.” Bridges v. Bowen, 815 F.2d 622, 624 (11th Cir. 1987). Moreover, failure to

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apply the correct legal standards is grounds for reversal. See Bowen v.Heckler, 748 F.2d

629, 635 (11th Cir. 1984).

The court must keep in mind that opinions such as whether a claimant is

disabled, the nature and extent of a claimant’s residual functional capacity, and the

application of vocational factors “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.” 20 C.F.R. §§ 404.1527(e), 416.927(d). Whether the plaintiff

meets the listing and is qualified for Social Security disability benefits is a question

reserved for the ALJ, and the court “may not decide facts anew, reweigh the evidence,

or substitute [its] judgmentfor that ofthe Commissioner.” Dyer v. Barnhart, 395 F.3d

1206, 1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ

about the significance of certain facts, the court has no power to reverse that finding

as long as there is substantial evidence in the record supporting it. 

III. Discussion

Ms. Reid alleges that the ALJ’s decision should be reversed and remanded for

two reasons. First, she believes that the ALJ failed to present her RFC determination

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in the format required under the Social Security Rules and failed to adequately address

each area of functioning – particularly postural functioning – on a function-byfunction basis. (Doc. 13 at 10.) Second, Plaintiff contends that the ALJ’s RFC

determination was inappropriate because it “lacked any input from a medical

consultant” and was “without regard to important objective findings.” (Id.)

 A. Did the ALJ Provide an Adequate Function-By-Function Analysis

Social Security Ruling 96-9p defines an RFC assessment as “a function-byfunction assessment based upon all of the relevant evidence of an individual’s ability

to perform work-related activities.” SSR 96-9p, 1996 WL 374185 ( July 2, 1996). The

functions of light work are:

lifting no more than 20 pounds at a time with frequent lifting or carrying

of objects weighing up to 10 pounds. Even though the weight lifted may

be very little, a job is in this category when it requires a good deal of

walking or standing, or when it involves sitting most of the time with

some pushing and pulling of arm or leg controls. To be considered

capable of performing a full or wide range of light work, you must have

the ability to do substantially all of these activities. If someone can do

light work, we determine that he or she can also do sedentary work,

unless there are additional limiting factors such as loss of fine dexterity

or inability to sit for long periods of time. 

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20 C.F.R. §§ 404.1567(b), 416.967(b). In her determination, the ALJ discussed Ms.

Reid’s claims, history, daily activities, and medical records. (Tr. at 20-37.) She then

discussed Ms. Reid’s impairments and subjective complaints and determined that the

evidence in the record indicated that Ms. Reid had an RFC that allowed her to

perform lightworkwith certain limitations. (Id.) The ALJ then made a determination

that, “[g]iven the claimant’s residual functional capacity, and the testimony of the

vocational expert, the undersigned finds that the claimant is unable to return to her

past relevant work.” (Tr. at 37.) Only after establishing that Ms. Reid could perform

light work so long as she did not have to climb ladders, ropes, or scaffolds, perform

complicated work, or have more than casual and nonintense interactions with others,

did the ALJ determine that other jobs exist in the national economy that Ms. Reid can

perform. (Tr. at 38.) 

The ALJ’s written opinion takes into account the medical and non-medical

evidence in the record prior to making the RFC determination. The purpose of the

“function-by-function analysis” requirement is to ensure that the ALJ determines,

based on the entire record, that the claimant is able to perform the functions required

in a particular classification of work. An “analysis of the evidence and statement that

[the claimant] could perform [light] work indicate[s] how much work-related activity

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[the claimant can] perform” because SSR 96-9p defines the amount and type ofworkrelated activity required for lightwork. Freeman v. Barnhart, 220 Fed.Appx. 957, 960

(11th Cir. 2007). In this jurisdiction, “there is no rigid requirement that the ALJ

specifically refer to every piece of evidence in his decision, so long as the ALJ’s

decision . . . is not a broad rejection which is not enough to enable [the district court

or this Court] to conclude that [the ALJ] considered her medical condition as a

whole.” Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (internal citations

omitted). A review of the ALJ’s RFC determination indicates to the court that the

ALJ did consider Ms. Reid’s medical condition as a whole in making her RFC

determination and, therefore, fulfilled the requirement of a function-by-function

analysis. Castel v. Commissioner of Social Security, 355 Fed. Appx. 260, 263 (11th Cir.

2009).

The Plaintiff further argues that the ALJ’s RFC lacks requisite specificity

because “it contains terms which are vocationally unquantifiable.” (Doc. 13 at 6). 

The Plaintiff argues that because limitations are not expressed “in a fraction or

percentage of the eight hour work day” and “‘[c]asual and nonintense’ [is] not

expressed in terms of time but rather degree,” the RFC is not an adequately specific

function-by-function analysis. However, in regard to the Plaintiff’s physical RFC, the

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ALJ determined that she was capable of light work “with no climbing ladders, ropes,

or scaffolds.” (Tr. at 20)(emphasis added). It is clear that the ALJ determined that

the Plaintiff can perform all activities described as light work in 20 C.F.R. §§

404.1567(b) and 416.967(b), but she can never climb ladders, ropes, or scaffolds. It

is not necessary for the ALJ to say that Plaintiff can perform lightwork for eight hours

but can climb ladders, ropes, or scaffolds for zero hours. 

Plaintiff is correct that the qualification of “casual and nonintense interaction

with others” is a degree of interaction rather than an expression of time. However,

the Plaintiff’s ability to interact with others is not conducive to expression by a

fraction or percentage of the eight-hour workday. If the ALJ expressed the Plaintiff’s

limitation in such a way, it would imply the Plaintiff has to work in solitude except for

whatever percentage of the eight-hour workday that the ALJ determined. This type

of finding would not adequately explain the ALJ’s RFC determination. The ALJ’s

opinion adequately represented the degree to which the Plaintiff can tolerate

interaction with others. Accordingly, the ALJ’s RFC fulfilled the requirement of a

2

function-by-function analysis and is adequately specific in that regard. 

By stating that the Plaintiff can tolerate only “casual and nonintense” interaction with 2 

other people, the ALJ indicates that the Plaintiff is not equipped to work in an environment where

she will be subjected to “intense” interaction with other people – whether that interaction occurs

for five minutes or five hours during the workday. 

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The Plaintiff also argues that “[t]he ALJ made no attempt to address postural

functioning affecting the spine as well as upper and lower extremities including

push/pulling, reaching, stooping and crouching, which are particularly relevant in this

instance.” (Doc. 13 at 8). This line of argument is without merit. The ALJ

specifically discussed issues relating to the Plaintiff’s spine and upper and lower

extremities on several pages of her opinion:

On orthopedic exam, the claimant had normal range of motion of the

cervical spine. Although there were earlier 2007 and 2008 imaging

studies showing some degeneration, there is nothing in this review that

suggested a functional limitation. She had normal range of motion of the

shoulders, elbows, wrists, hands, and fingers. There was no swelling,

erythema, tenderness, and no bogginess noted in any joints. Exam of the

lumbosacral spine revealed that the claimant had good posture. The

straight leg raising was negative to 60 degrees on the right and left. The

claimant had normal range of motion of hips, knees, ankles, and feet. 

There was no pain, swelling erythema, tenderness, and bogginess noted

in any of these joints. She can walk up and down the hall without any

difficulty. She can walk on her toes and heels. She can squat and arise. 

Her peripheral pulses were intact.

. . . 

[The Plaintiff] was diagnosed with joint pain low back and right hip, but

nomedically determinable evidence was offered to explain the diagnosis. 

A back x-ray was negative (Exhibit 27F16).

. . . 

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The claimant alleged also that she has arthritis in elbows and gets shots

in elbows. I found no documentation of complaints. Signs in Dr. Born’s

notes were negative. There is no documentation for such injections. 

In terms of the claimant’s alleged cervical and lumbar degenerative joint

disease, the claimanttestified that she has muscle spasms in her back and

she has degenerative disc disease in her neck. Findings at Exhibit 13F26

and 26F64 show only mild changes in 2007 and 2008. Although there

was some encroachment, later examinations showed no problems

affecting the neck or upper extremities. Dr. Thomas observed the

claimant has “arthritis” without referencing any specific site and

without providing clinical information to support this. I have found this

severe in combination with the fibromyalgia, but the report of Dr. Born,

who is the only doctor to perform a physical examination with acceptable

range of motion and other clinical information provided, found no

problems at this site. The examination of Dr. Born in October 2009

shows on orthopedic exam, the claimant had normal range of motion of

the cervical spine (Exhibit 19F). Neck problems were not alleged in the

most recent QOL notes throughout 2011.

(Tr. at 25, 28, 34-35.) If the Plaintiff is attempting to argue that the ALJ was required

to state in her RFC determination that the Plaintiff can push/pull, reach, stoop, and

crouch frequently within an eight-hour workday, or use some sort of other magical

language, the argument also is without merit. As discussed above, the ALJ specifically

and clearly stated that the Plaintiff can perform the activities required to perform light

work as it is defined in the Regulations, with the exception of the activities the ALJ

specifically stated the Plaintiff cannot do. Accordingly, the court finds that the ALJ’s

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determination with respect to the Plaintiff’s complaints of spinal problems and

problems in her upper and lower extremities fulfilled the function-by-function analysis

requirement and is supported by substantial evidence. 

B. Should the ALJ have sought a medical consultation?

Ms. Reid asserts that the ALJ should have ordered a Medical Source Opinion

(MSO) or a Medical Expert (ME) evaluation prior to making her RFC determination. 

Although Ms. Reid acknowledges that there is no specific requirement for a medical

consultation when an ALJ makes an RFC determination, she argues that “an MSO of

some kind is crucial to the analysis of functioning based on the medically

determinable impairments (MDIs). . .” (Doc. 13, p. 9.) However, the ALJ’s duty to

develop the record is not triggered when the record contains sufficient evidence to

make an informed decision. Ingram v. Commissioner of Social Security, 496 F.3d

1253, 1269 (11th Cir. 2007). At the hearing level, the Commissioner has delegated

that responsibility to the ALJ, and it is the ALJ who bears the responsibility for

assessing a claimant’s residual functional capacity based on the entirety of the

evidence presented, not just medical evidence. See, e.g., 20 C.F.R. § 404.1546(c). 

The Eleventh Circuit has determined that a consultative examination must be

ordered if one is needed to make an informed decision in regards to the claimant’s

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disability. Reeves v. Heckler, 734 F.2d 519, 522 n.1 (11th Cir. 1984) (citing Ford v.

Secretary of Health and Human Servs., 659 F.2d 66, 69 (5th Cir. 1981) (Unit B)). 

An ALJ may request a consultative examination “to secure needed medical evidence,

such as clinical findings, laboratory tests, a diagnosis, or prognosis” if the record

indicates “a change in [the claimant’s] condition that is likely to affect [the

claimant’s] ability to work, but the current severity of [the claimant’s] impairment is

not established.” 20 C.F.R. § 404.1519a(b)(4). However, if the record is sufficiently

developed for the ALJ to make a determination, it is not necessary for the ALJ to

order an additional consultative examination. Good v. Astrue, 240 Fed. Appx. 399,

403-404 (11th Cir. 2007). In the instant case, the ALJ had available: treatment notes

from Ms. Reid’s treating and examining physicians ranging fromSeptember 22, 2003

to April 19, 2011; Consultative Examination Reports from Dr. Jose Oblena, Dr.

Robert Summerlin, Dr. Henry Born, and Dana Davis; a Psychiatric Review from Dr.

Robert Estock; Medical Evaluations by Dr. Nancy J. Jennings and Adrianne Wright

Hawkins; Mental RFC AssessmentsfromDr. Robert Estock and Samuel D. Williams;

the Alabama Disability Determination Service Initial Claimant Contact Form; Ms.

Reid’s own testimony, and the testimony of the vocational expert. The record in this

case was sufficiently developed to allow the ALJ to make an RFC determination

without seeking an additional consultative examination. 

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Beyond the assertion that the ALJ should have obtained an MSO, the Plaintiff

asserts that the ALJ “omitted” X-ray findings dating from November 2007 and April

2008 “on the basis that this evidence predated the amended onset date.” (Doc. 13 at

9). However, the ALJ did not “omit” the X-ray evidence, in fact, she referred to it

specifically in her RFC discussion. The ALJ stated, “On orthopedic exam, the

claimant had normal range of motion of the cervical spine. Although there were

earlier 2007 and 2008 imaging studies showing some degeneration, there is nothing

in thisreview thatsuggested a functional limitation.” (Tr. at 25). The ALJ’s decision

to rely on the more recent examination does not constitute “omission” of evidence

and is within the ALJ’s prerogative. 

Opinions such as whether a claimant is disabled, the claimant’s residual

functional capacity, and the application of vocational factors “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.” 20 C.F.R. §§ 404.1527(e),

416.927(d); see Langley v. Astrue, 777 F. Supp. 2d 1250, 1253 (N. D. Ala. 2011). 

In Langley, Judge Guin provided an in-depth discussion of prior Eleventh Circuit law

and concluded that “the law of this Circuit does not require[] an RFC from a

physician” for an ALJ to be able to make an RFC determination. 777 F. Supp. 2d at

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1258. Judge Guin noted that “the Eleventh Circuit has implicitly refused to [require

a medical RFC].” Id. (citing Green v. Social Security Administration, 223 Fed. Appx.

915 (11th Cir. 2007). The Eleventh Circuit held that medical evidence from the

claimant’s physicians - even though that evidence did not contain a PCE or RFC

assessment - was “sufficient to support the ALJ’s finding that the claimant could

perform light work.” Green, 223 Fed. Appx. at 923-24. Because the ALJ had before

her a complete record with sufficient medical and non-medical evidence, she was

under no obligation to seek a further medical opinion, and this court finds that the

ALJ’s determination was supported by sufficient evidence. 

IV. Conclusion

Upon review of the administrative record, and considering all of Ms. Reid’s

arguments, the Court finds the Commissioner’s decision is supported by substantial

evidence and in accord with the applicable law. A separate order will be entered.

DONE this 11th day of July, 2014.

 

T. MICHAEL PUTNAM

U.S. MAGISTRATE JUDGE 

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