Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-1_08-cv-00411/USCOURTS-almd-1_08-cv-00411-0/pdf.json

Parties Involved:
Michael J. Astrue
Defendant
Susie A. Gary
Plaintiff

Document Text:

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.

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

SOUTHERN DIVISION

SUSIE A. GARY, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 1:08cv411-CSC

) (WO)

MICHAEL J. ASTRUE, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff, Susie Gary (“Gary”), applied for disability insurance benefits pursuant

to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and 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 1631(c)(3). Pursuant

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 1 of 11
 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.

2

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

States Magistrate Judge conducting all proceedingsin this case and ordering the entry of final

judgment. Based on the court’s review of the record in this case and the briefs of the parties,

the court concludes that the decision of the Commissioner should be reversed and this case

remanded to the Commissioner for further proceedings.

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 2

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.”

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 2 of 11
 McDaniel v. Bowen, 800 F.2d 1026 (11 Cir. 1986) is a supplemental security income case (SSI). 3 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

3

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11 Cir. 1986). th 3

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); Graham v. Apfel, 129 F.3d 1420, 1422 (11 Cir. 1997). “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.” Richardson v.

Perales, 402 U.S. 389, 401 (1971). 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 (11 Cir. 1986). th

[The court must] . . . scrutinize the record in its entirety to determine the

reasonableness of the [Commissioner’s] . . . factual findings . . . No similar

presumption of validity attaches 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. Gary was 37 years old at the time she applied for disability

benefits, (R. 67), and 39 years old at the time of the first hearing before the ALJ. (R. 547).

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 3 of 11
 Gary alleges that the ALJ erred when he found that Gary has “at least a high school education,” 4

(R. 22), because she alleges that she only completed the eleventh grade. (R. 89). Even if the court were to

conclude that the ALJ erred, Gary has failed to demonstrate that she was prejudiced by that error.

Consequently, the court concludes that any error regarding Gary’s educational background is immaterial. 

 The ALJ does not identify the location of Gary’s arthritis. 5

4

She completed the eleventh grade. (Id.). Following the hearing, the ALJ concluded that 4

the plaintiff has severe impairments of carpal tunnel syndrome, diabetes, and arthritis. (R. 5

19). The ALJ concluded that Gary could not perform her past relevant work as a sewing

machine operator and nursing home cook. (R. 22). However, the ALJ concluded that

because the plaintiff has the residual functional capacity to perform sedentary work, and that

there are jobs that exist in the national economy that she could perform, Gary is not disabled.

 (R. 22-23). 

B. Plaintiff’s Claims. Gary presents five issues for the Court’s review. As stated by

Gary, they are as follows:

1. Whether the ALJ erred by failing to properly evaluate Ms. Gary’s

residual functional capacity. 

2. Whether the ALJ erred by failing to properly apply the pain standard.

3. Whether the ALJ committed reversible error by failing to pose a

complete hypothetical to the vocational expert.

4. Whether the ALJ erred by failing to properly consider Ms. Gary’s depression.

5. Whether the ALJ erred by misclassifying Ms. Gary’s education.

(Pl’s Br. at 1).

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 4 of 11
 The plaintiff also argues that the ALJ failed to properly consider her diabetic retinopathy. While 6

the plaintiff has complained of blurred vision, no physician has diagnosed Gary with diabetic retinopathy.

However, on remand, the Commissioner is encouraged to consider whether Ms. Gary’s diabetes has

progressed to the point of causing retinopathy. 

5

IV. Discussion

The plaintiff raises several issues and arguments related to this court’s ultimate

inquiry of whether the Commissioner’s disability decision is supported by the proper legal

standards and substantial evidence. See Bridges v. Bowen, 815 F.2d 622 (11 Cir. 1987). th

However, the court pretermits discussion of the plaintiff’s specific arguments because the

court concludes that the ALJ erred as a matter of law at step two of the sequential analysis.

A. Obesity. The plaintiff argues that the ALJ failed to properly consider her obesity,

migraine headaches and depression. With respect to her obesity, the plaintiff argues as 6

follows. 

The ALJ also failed to properly consider Ms. Gary’s obesity. Ms. Gary

testified that she is five feet tall and 195 pounds. (R. 569). Her physicians

have diagnosed her with obesity. (R. 271, 284, 347, 486). Despite this

evidence of obesity, the ALJ’s decision does not mention obesity. (R. 14-24).

* * *

In the case at bar, the ALJ did not mention Ms. Gary’s obesity. (R. 19-14). He

did not explain how he reach (sic) a conclusion on whether Ms. Gary’s obesity

caused any physical or mental limitations. Therefore this case should be

remanded for proper consideration of Ms. Gary’s obesity.

(Pl’s Br. at 7). 

Beyond this generalized statement about her obesity, Gary alleges no facts and points

to no evidence in the record to support her position that her obesity places significant

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 5 of 11
 In April 1999, Gary complained to Dr. Hollobaugh of headaches “mostly at night.” (R. 230). Dr.

7

Hollobaugh prescribed Lortab. (Id.). She continued to complain of headaches, and in July, Dr. Hollobaugh

prescribed Elavil. (Id.) 

6

limitations on her ability to work. The burden is on the plaintiff to demonstrate that the

Commissioner’s decision is not supported by substantial evidence, and the argument of

counsel is simply insufficient to meet this burden. See generally Road Sprinkler Fitters

Local Union No. 669 v. Indep. Sprinkler Corp., 10 F.3d 1563, 1568 (11 Cir. 1994) (It is not th

the court’s responsibility to seek out facts in support of the plaintiff’s position.) More

importantly, however, the objective medical evidence of record does not demonstrate that any

treating or consultative physicians placed limitations on Gary due to her obesity.

Consequently, she is entitled to no relief on this basis. 

B. Migraine Headaches and Depression. However, with respect to her migraine

headaches and depression, the court concludes that the ALJ erred at step two of the

sequential analysis because he failed to properly consider whether these impairments

constitute severe impairments. It follows, therefore, that his determination that the plaintiff

is not disabled is not supported by substantial evidence. 

In her initial disability report dated March 11, 2000, the plaintiff complains about

headaches for which she takes medication. (R. 88, 92). On December 30, 2003, Gary 7

complained about constant headaches, three times a day, even though she was taking Lortab

and Tylenol. (R. 297). During her consultative examination on March 29, 2004, Gary

complained of generalized headaches. (R. 283). 

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 6 of 11
 The medical records demonstrate that, over the years, Gary has been prescribed Lortab, Lidoderm

8

patches, Topomax, Tramadol, Propoxy, Oxycodone, Ibuprofen, generic Darvocet, Robaxin, Flexeril,

Demerol, and Phenergamfor pain, although not necessarily prescribed for her headaches. (R. 163, 182, 202-

04, 207, 209-10, 230, 232, 282, 290, 316, 323, 388, 399, 438, 451, 483).

7

On February 5, 2005, Gary presented to the emergency room at Dale Medical Center

complaining of headaches. (R. 386). She was diagnosed with migraine headaches and

prescribed medication. (R. 388). On February 22, 2005, Dr. Hassan Kesserwani, a board

certified neurologist, diagnosed Gary with migraine headaches and recommended Topamax.

(R. 399). Dr. Kesserwani was still treating her headaches with Topamax in May 2005. (R.

189, 199, 428). Finally, during the supplemental administrative hearing in 2007, Gary

testified that she suffers from headaches and that she takes pain pills to manage the pain.8

(R. 581-82).

Q: Do you have any problems with headaches, and if so, what?

A: Yes, ma’am.

ALJ: All right, counselor, now you’re leading, we don’t need to go

there. If she has the problem, she’ll tell you. You’re not, she’s

not going to answer your question. Try again. Don’t lead.

BY ATTORNEY:

Q: What problems do you have? Just kind of start at your head and

come down. Think of everything that’s wrong with you.

A: With my head, my left side of my head hurts all the time where

I can’t stand the light, being in a noisy room, and it lasts for

about two, maybe three hours. And then I get so like twice a

day, then –

Q: What brings that on?

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 7 of 11
 The court is not suggesting that the mere fact that Gary is taking Lexapro requires that she be sent 9

for a consultative psychological evaluation. However, the ALJ does need to address the severity of the

alleged impairment, as well as its effect on Gary’s ability to work.

8

A: Stress mainly, I believe. That’s what I am thinking.

Q: What relieves it, if anything?

A: The medication I am taking. Pain pills or whatever I take, one of

those and go lay in a dark room.

(R. 581-82).

Although the record is replete with references to migraine headaches, the ALJ simply

ignored evidence that Gary suffers from migraine headaches.

Moreover, Dr. Chandler diagnosed Gary as suffering from depression and prescribed

Lexapro in November 2005. (R. 204, 415). Pharmacy records demonstrate that as late as

December 18, 2006, Gary was still taking Lexapro. (R. 212-213). At the initial

administrative hearing on December 21, 2006, the ALJ was informed that Gary was being

treated for depression but at that time, he declined to send her for a psychological

evaluation. (R. 564-65). In this circuit, depression can be a non-exertional restriction on 9

an individual’s ability to work. See Pendley v. Heckler, 767 F.2d 1561, 1563 (11 Cir. 1985) th

(reversing ALJ’s decision for failure to incorporate severe impairments of anxiety and

depression into hypothetical to vocational expert). In Pendley, the ALJ did not ask the

vocational expert to assume the claimant’s anxiety or depression, both of which he found to

be severe impairments, in his hypothetical question. The Eleventh Circuit found that the

ALJ’s decision was unsupported by substantial evidence and thus, the Commissioner had

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 8 of 11
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failed to meet its burden of showing the plaintiff could perform other work in the national

economy. The Eleventh Circuit, concluding the “misuse of the expert’s testimony alone

warrant[ed] reversal,” remanded the case. Id. at 1563. 

The ALJ does not mention Gary’s migraine headaches or her depression in his

disability determination, and thus, he makes no findings about whether her migraine

headaches or depression constitute severe impairments. The severity step is a threshold

inquiry which allows only “claims based on the most trivial impairment to be rejected.”

McDaniel, 800 F.2d at 1031. Indeed, a severe impairment is one that is more than “a slight

abnormality or combination of slight abnormalities which would have no more than a

minimal effect on an individual’s ability to work.” Bowen v. Yuckert, 482 U.S. 137, 154 n.

12 (1987) (citing with approval Social Security Ruling 85-28 at 37a). 

A physical or mental impairment is defined as “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. §

1382c(a)(3)(c). The plaintiff has the “burden of showing that [her] impairments are ‘severe’

within the meaning of the Act.” McDaniel, 800 F.2d at 1030-31. Once the plaintiff

establishes that she suffers from a severe impairment, the ALJ is not entitled to ignore that

evidence. 

Furthermore, because the ALJ simply ignored evidence that Gary suffers from

migraine headaches and depression, he could not have properly consider the effects of these

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 9 of 11
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impairments on Gary’s ability to work. Consequently, the court is unable to determine

whether the ALJ’s conclusion that Gary is not disabled is supported by substantial evidence.

In fact, that conclusion is contrary to the evidence. It is plain that the plaintiff suffers from

non-physical impairments. What is not plain is the effect of those impairments. “‘Even a

“mild” mental impairment may “prevent [a] claimant from engaging in the full range of jobs

contemplated by the exertional category for which the claimant otherwise qualifies.’” Allen

v. Sullivan, 880 F.2d 1200, at 1202 (11 Cir. 1989). th

For these reasons, the court concludes that the Commissioner erred as a matter of law,

and that the case should be remanded for further proceedings regarding the severity of the

plaintiff’s migraine headaches and depression, and their effect on her ability to work. The

ALJ must consider every impairment alleged by the plaintiff and determine whether the

alleged impairments are sufficiently severe – either singly or in combination – to create a

disability. See Gibson v. Heckler, 779 F.2d 619, 623 (11 Cir. 1986). All of the plaintiff’s th

impairments must be considered in combination even when the impairments considered

separately are not severe. Hudson v. Heckler, 755 F.2d 781, 785 (11 Cir. 1985). In light of th

the ALJ’s failure to fully and fairly consider the evidence in the record of the plaintiff’s

migraine headaches and depression, the court concludes that the ALJ failed to meet his

burden in this regard. As a result of his failure to consider the plaintiff’s impairments in

combination, doubt is necessarily cast upon the ALJ’s conclusion that the plaintiff is not

disabled.

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 10 of 11
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V. Conclusion

Accordingly, this case will be reversed and remanded to the Commissioner for further

proceedings consistent with this opinion.

A separate order will be entered.

Done this 22 day of September, 2009. nd

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

Case 1:08-cv-00411-CSC Document 20 Filed 09/22/09 Page 11 of 11