Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_06-cv-00479/USCOURTS-alsd-1_06-cv-00479-0/pdf.json

Parties Involved:
Michael J. Astrue
Defendant
Jo Anne B. Barnhart
Defendant
Helena F. Scott
Plaintiff

Document Text:

1 Effective February 12, 2007, Michael J. Astrue was confirmed by the Senate to

serve as the Commissioner of Social Security. Accordingly, pursuant to the provisions of Rule

25(d)(1) of the Federal Rules of Civil Procedure, Astrue is substituted for Jo Anne B. Barnhart as

the proper defendant in this action.

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

HELENA F. SCOTT, :

Plaintiff, :

vs. : CA 06-0479-C

MICHAEL J. ASTRUE, :

Commissioner of Social Security,1

:

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action pursuant to 42 U.S.C. §§ 405(g) and

1383(c)(3), seeking judicial review of a final decision of the Commissioner of

Social Security denying her claims for disability insurance benefits and

supplemental security income. The parties have consented to the exercise of

jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all

proceedings in this Court. (Docs. 16 & 17 (“In accordance with the provisions

of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to

have a United States Magistrate Judge conduct any and all proceedings in this

Case 1:06-cv-00479-C Document 18 Filed 04/09/07 Page 1 of 12
2 Any appeal taken from this memorandum opinion and order and judgment shall

be made to the Eleventh Circuit Court of Appeals. (Docs. 16 & 17 (“An appeal from a judgment

entered by a Magistrate Judge shall be taken directly to the United States Court of Appeals for

this judicial circuit in the same manner as an appeal from any other judgment of this district

court.”))

2

case . . . and order the entry of a final judgment, and conduct all post-judgment

proceedings.”)) Upon consideration of the administrative record, plaintiff's

proposed report and recommendation, the Commissioner's proposed report and

recommendation, and the parties' arguments at the March 28, 2007 hearing

before the Court, it is determined that the Commissioner's decision denying

benefits should be reversed and remanded for further proceedings not

inconsistent with this decision.2

Plaintiff alleges disability due to status-post fracture of the tibia/fibula

with mild residual valgus to the ankle, a herniated disc with nerve root

compression, diabetes mellitus with peripheral neuropathy, asthma/COPD,

back pain, and depression. The Administrative Law Judge (ALJ) made the

following relevant findings:

3. The claimant possesses the impairments of status post

fracture of the tibia/fibula with mild residual valgus to the ankle,

lumbar strain, and mild lumbar degenerative disc disease, which

are “severe” impairments under the Act and Regulations.

4. The claimant’s impairments, when considered

individually and in combination, do not meet or medically equal

one of the listed impairments in 20 C.F.R. § 404, Subpart P,

Case 1:06-cv-00479-C Document 18 Filed 04/09/07 Page 2 of 12
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Appendix 1. 

5. The claimant did not allege a mental or emotional

medically-determinable impairment at the time of the hearing or

in conjunction with the current applications.

6. The claimant’s assertions relative to symptomatology,

functional limitations and restrictions of activities of daily living

have been considered in light of the factors set forth in 20 C.F.R.

§§ 404.1529 and 416.929 and Social Security Ruling 96-7p, and

are found to lack corroboration or substantiation in the medical

evidence, and are not credible as to a disabling impairment. 

7. The claimant possesses the residual functional capacity

to perform medium work activity on a regular and sustained

basis. Specifically, the claimant can occasionally lift up to 100

pounds, frequently lift up to 50 pounds and continuously lift up

to 25 pounds, occasionally carry up to 50 pounds, frequently

carry up to 25 pounds and continuously carry up to 20 pounds.

She can use both of her hands for repetitive action such as

simple grasping, pushing and pulling of arm controls and for

fine manipulation, and use both of her feet for repetitive

movements as in pushing and pulling of leg controls. She can

continuously reach and frequently bend, squat, crawl and climb,

and has no restriction of activities involving exposure to marked

changes in temperature and humidity or to exposure to dust,

fumes and gases, mild restriction to being around moving

machinery and driving automotive equipment and moderate

restriction of activities involving unprotected heights.

8. The claimant’s past relevant work as a fast food worker,

waitress and cook do not require the performance of workrelated activities precluded by her residual functional capacity

(20 C.F.R. §§ 404.1565 and 416.965).

9. The claimant was not under a “disability,” as defined in

the Social Security Act, at any time through the date of the

decision (20 C.F.R. §§ 404.1520(f) and 416.920(f)).

Case 1:06-cv-00479-C Document 18 Filed 04/09/07 Page 3 of 12
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(Tr. 23-24) The Appeals Council affirmed the ALJ's decision (Tr. 6-8) and

thus, the hearing decision became the final decision of the Commissioner of

Social Security.

DISCUSSION

In all Social Security cases, the claimant bears the burden of proving

that she is unable to perform her previous work. Jones v. Bowen, 810 F.2d

1001 (11th Cir. 1986). In evaluating whether the claimant has met this burden,

the examiner must consider the following four factors: (1) objective medical

facts and clinical findings; (2) diagnoses of examining physicians; (3) evidence

of pain; and (4) the claimant's age, education and work history. Id. at 1005.

Once the claimant meets this burden, it becomes the Commissioner's burden

to prove that the claimant is capable, given her age, education and work

history, of engaging in another kind of substantial gainful employment which

exists in the national economy. Sryock v. Heckler, 764 F.2d 834, 836 (11th

Cir. 1985).

The task for the Magistrate Judge is to determine whether the

Commissioner's decision to deny claimant benefits, on the basis that she can

perform her past relevant work as a fast food worker, waitress and cook and

therefore is not disabled, is supported by substantial evidence. Substantial

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evidence is defined as more than a scintilla and means such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion.

Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971).

"In determining whether substantial evidence exists, we must view the record

as a whole, taking into account evidence favorable as well as unfavorable to

the [Commissioner's] decision." Chester v. Bowen, 792 F.2d 129, 131 (11th

Cir. 1986).

In this case, the plaintiff contends that the ALJ committed the following

errors: (1) he erred in failing to properly evaluate plaintiff’s pain; (2) he erred

in failing to develop a full and fair record regarding plaintiff’s depression and

mental acuity; and (3) he erred in failing to find plaintiff’s insulin-dependent

diabetes mellitus with peripheral neuropathy and asthma/COPD to be severe

impairments. Because the Court finds that the ALJ erred in implicitly

determining that plaintiff’s insulin-dependent diabetes mellitus with peripheral

neuropathy is not a severe physical impairment, the other errors raised by

plaintiff are not discussed. See Pendley v. Heckler, 767 F.2d 1561, 1563 (11th

Cir. 1985) (“Because the ‘misuse of the expert’s testimony alone warrants a

reversal,’ we do not consider the appellant’s other claims.”).

The Commissioner's severity regulation requires the claimant to make

Case 1:06-cv-00479-C Document 18 Filed 04/09/07 Page 5 of 12
3 It is clear that in Yuckert, the Supreme Court did not impose a standard higher

than the de minimis standard set out in Brady. See Stratton v. Bowen, 827 F.2d 1447, 1451 n.7,

6

a threshold showing that she has an impairment which significantly limits her

physical or mental ability to perform basic work activities. 20 C.F.R. §§

416.920(c), 416.921(a) (1998); Bowen v. Yuckert, 482 U.S. 137, 147 n.5, 107

S.Ct. 2287, 2294 n.5, 96 L.Ed.2d 119 (1987). Basic work activities include

functions such as walking, standing, sitting, lifting, pushing, pulling, reaching,

carrying, or handling; understanding, carrying out and remembering simple

instructions; use of judgment, responding appropriately to supervision, coworkers, and usual work situations; and dealing with changes in a routine work

setting. 20 C.F.R. § 416.921(b). An impairment can be considered not severe

"only if it is a slight abnormality which has such a minimal effect on the

individual that it would not be expected to interfere with the individual's ability

to work, irrespective of age, education, or work experience." Brady v.

Heckler, 724 F.2d 914, 920 (11th Cir. 1984); see Yuckert, supra, 482 U.S. at

153, 107 S.Ct. at 2297 ("The severity regulation increases the efficiency and

reliability of the evaluation process by identifying at an early stage those

claimants whose medical impairments are so slight that it is unlikely they

would be found to be disabled even if their age, education and experience were

taken into account").3

 

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1452 n.9, 1452-1453 (11th Cir. 1987).

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Inherent in a finding of a medically not severe impairment or

combination of impairments is the conclusion that the

individual’s ability to engage in SGA [substantial gainful

activity] is not seriously affected. Before this conclusion can be

reached, however, an evaluation of the effects of the

impairment(s) on the person’s ability to do basic work activities

must be made. A determination that an impairment(s) is not

severe requires a careful evaluation of the medical findings

which describe the impairment(s) and the informed judgment

about its (their) limiting effects on the individual’s physical and

mental ability(ies) to perform basic work activities; thus, an

assessment of the function is inherent in the medical process

itself.

SSR 85-28. The claimant's burden at step two of the sequential evaluation

process is mild. McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986)

(“Step two is a threshold inquiry. It allows only claims based on the most

trivial impairments to be rejected."). 

The evidence of record in this case establishes for the claimant a long

history of Type II Diabetes Mellitus. (See, e.g., Tr. 151-153, 157-158, 161-

162, 168, 170, 174, 177, 180, 184, 186, 199-202, 208-209, 212, 215, 220, 235,

242A, 254, 273, 278 & 306A) By 1998, plaintiff already had a long history of

non-insulin dependent diabetes (Tr. 157; see also Tr. 339 (plaintiff’s testimony

that her diabetes began at age 18); see Tr. 151-153 & 168); her condition

became insulin-dependent in 1999 (Tr. 184 & 188). Associated with her

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4 Cellulitis is “an acute, diffuse, spreading, edematous, suppurative inflammation of

the deep subcutaneous tissues and sometimes muscle, which may be associated with abscess

formation.” The Sloane-Dorland Annotated Medical-Legal Dictionary, 112 (Supp. 1992).

5 Neuropathy is a general medical term “denoting functional disturbances and/or

pathological changes in the peripheral nervous system.” The Sloane-Dorland Annotated

Medical-Legal Dictionary, supra, at 375. “Peripheral neuropathy, or polyneuropathy, consists of

‘neuropathy of several peripheral nerves simultaneously.’” Mendoza v. Apfel, 88 F.Supp.2d

1108, 1109 n.1 (C.D. Cal. 2000) (citation omitted). Diabetic neuropathy is “a chronic,

symmetrical sensory polyneuropathy affecting first the nerves of the lower limbs and often

affecting autonomic nerves; pathologically, there is segmental demyelination of the peripheral

nerves.” The Sloane-Dorland Annotated Medical-Legal Dictionary, supra, at 376. 

8

diabetes, plaintiff has experienced cellulitis4 and abscesses (Tr. 199 (“The

patient was admitted to the hospital with a perineal abscess and associated

diabetes.”); see also Tr. 161)). In December of 2004, Dr. Lloyd May diagnosed

diabetes mellitus with peripheral neuropathy.5

 (Tr. 220 (“Neurologic: She has

decreased sensation distal upper extremities bilateral and lower extremities

bilateral.”)) During the administrative hearing, plaintiff testified that her

diabetes is the worse single problem she experiences (Tr. 350); it makes her

weak and lightheaded and that it causes numbness in her hands, legs and feet

(Tr. 339-340). The numbness she experiences in her hands causes her

difficulty with respect to lifting and grasping objects and the numbness in her

lower extremities, particularly on the right, makes walking and standing more

difficult. (Id. at 340; see also Tr. 344 (she has burned herself while cooking

because she could not feel the pan and held it too long after taking it off the

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stove); Tr. 346 (numbness presents a problem in terms of holding a pen to

write and picking up small objects)) 

In light of the foregoing evidence, this Court finds that the ALJ

committed reversible error in implicitly finding plaintiff’s insulin-dependent

diabetes mellitus with peripheral neuropathy to be a non-severe impairment.

(Compare Tr. 23, Finding 3 (“The claimant possesses the impairments of

status post fracture of the tibia/fibula with mild residual valgus to the ankle,

lumbar strain, and mild lumbar degenerative disc disease, which are ‘severe’

impairments under the Act and Regulations.”) with Tr. 21(“She testified at the

hearing that her main problem was with diabetes. However, she was not

specific as to how her diabetes keeps her from working. Furthermore, the

medical records from Franklin Primary Health Center in Exhibits 23F and 28F

indicate that on several occasions her diabetes mellitus was not controlled

because of medication non-compliance. At one time she even refused her

prescription.”)) Nowhere does the ALJ reject the December 2004 diagnosis

of Dr. May that plaintiff experiences diabetes mellitus with peripheral

neuropathy (see Tr. 22); therefore, the Court finds that the ALJ accepted that

diagnosis, see Marbury v. Sullivan, 957 F.2d 837, 840 (11th Cir. 1992)

(Johnson, J. concurring specially) (“Although the ALJ could have legitimately

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discounted the diagnoses, he could have done so only if he had clearly

articulated his reasons for such action. . . . Moreover, the ALJ’s proffered

reasons for discounting the diagnoses had to be supported by substantial

evidence. . . . In this case, the ALJ has not articulated any valid reasons for

calling into question the diagnoses–much less supported his medical

conclusions with substantial or considerable evidence.”). Moreover, contrary

to the conclusory determination made by the ALJ, the plaintiff specifically

identified how her diabetes affects her ability to perform basic work activities.

(Compare Tr. 21 (“However, she was not specific as to how her diabetes keeps

her from working.”) with Tr. 340 & 346 (plaintiff’s testimony that the

numbness she experiences in her lower extremities causes her difficulty in

standing and walking and that the numbness she experiences in her hands

makes it more difficult for her to grasp and pick up objects, particularly small

objects)) Because the ALJ failed to specifically reject the plaintiff’s testimony

regarding the impact of her diabetes on her ability to walk and stand and lift

and grasp objects, he accepted that testimony as true. See Hale v. Bowen, 831

F.2d 1007, 1012 (11th Cir. 1987) (“It is established in this circuit that if the

[Commissioner] fails to articulate reasons for refusing to credit a claimant’s

subjective pain testimony, then the [Commissioner], as a matter of law, has

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accepted that testimony as true.”). Accordingly, the evidence of record in this

case emphatically establishes that Scott’s diabetes mellitus with peripheral

neuropathy is not just a trivial impairment; instead, it is an impairment which

by her uncontradicted and uncontroverted testimony significantly limits her

physical ability to perform basic work activities. See, e.g., Oakes v. Barnhart,

400 F.Supp.2d 766, 773 (E.D. Pa. 2005) (“As Judge Hart noted in his Report

and Recommendation, the ALJ determined that Oakes suffered from a series

of severe impairments: lumbar disorder, diabetes mellitus with peripheral

neuropathy of the feet, and obesity[.]”); Higgins v. Barnhart, 294 F.Supp.2d

1206, 1209 (D. Kan. 2003) (“The ALJ in this case concluded that Plaintiff had

the severe impairments of stenosis of the aortic valve with left ventricular

hypertrophy, status post valve replacement in June 1998, insulin dependent

diabetes mellitus with some retinopathy as well as probable peripheral

neuropathy in the lower extremities.”); Ocasio v. Barnhart, 2002 WL 485691,

*2 (E.D. N.Y. 2002) (“The ALJ found that Plaintiff did have severe physical

impairments consisting of insulin-dependent diabetes mellitus and related

conditions and essential hypertension, and a severe mental impairment with

anxiety, depression, and history of substance abuse, now in remission.”).

Scott’s diabetes mellitus with peripheral neuropathy is a severe impairment

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which, on remand, must be considered in conjunction with all of her other

severe impairments in determining whether she retains the residual functional

capacity to perform her past relevant work or any other work existing in

significant numbers in the national economy.

CONCLUSION

The Court ORDERS that the decision of the Commissioner of Social

Security denying plaintiff benefits be reversed and remanded pursuant to

sentence four of § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct.

2157, 115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this

decision. The remand pursuant to sentence four of § 405(g) makes the plaintiff

a prevailing party for purposes of the Equal Access to Justice Act, 28 U.S.C.

§ 2412, Shalala v. Schaefer, 509 U.S. 292, 113 S.Ct. 2625, 125 L.Ed.2d 239

(1993), and terminates this Court’s jurisdiction over this matter.

DONE and ORDERED this the 5th day of April, 2007.

s/WILLIAM E. CASSADY 

 UNITED STATES MAGISTRATE JUDGE

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