Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_03-cv-00695/USCOURTS-alsd-1_03-cv-00695-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Collin J. Haines
Plaintiff

Document Text:

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

COLLIN J. HAINES, *

*

Plaintiff, *

*

vs. * Civil Action No. 03-0695-P-B

*

JO ANNE B. BARNHART, *

Commissioner of * 

Social Security, *

*

Defendant. *

REPORT AND RECOMMENDATION

Plaintiff brings this action under 42 U.S.C. § 405(g)

seeking judicial review of a final decision of the Commissioner

of Social Security denying his claim for Social Security

disability insurance benefits. This action was referred to the

undersigned for report and recommendation pursuant to 28 U.S.C.

§636(b)(1)(B). Oral argument was held on December 14, 2004.

Upon consideration of the administrative record, oral argument

and the memoranda of the parties, it is recommended that the

decision of the Commissioner be REVERSED and REMANDED. 

I. Procedural History

Plaintiff, Collin J. Haines, filed an application for

disability insurance benefits on November 10, 1998 alleging that

he has been disabled since August 31, 1998 due to seizures and

numbness in his hands and feet. (Tr. 105-107, 266).

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1

A supplemental hearing was held on April 11, 2000 to discuss Plaintiff’s

employment since his alleged onset of disability. (Tr. 48-54).

2

“A genetic disease characterized by pigmented skin lesions and multiple

skin neurofibromas, and sometimes accompanied by physical deformity and a

predisposition to brain tumors and various forms of cancer.” The American

Heritage Stedman’s Medical Dictionary (2002), p. 554.

2

Plaintiff’s application was initially denied on February 5,

1999, and upon reconsideration on April 7, 1999. (Tr. 82-86,

87-88, 89-90). Plaintiff filed a Request for Hearing on June

15, 1999, and thereafter, on December 2, 1999, Administrative

Law Judge (ALJ) James D. Smith conducted a hearing, which was

attended by Plaintiff. (Tr. 91-92, 39-47).1 On April 20, 2000,

ALJ Smith entered a partially favorable decision wherein he

found Plaintiff disabled for a closed period of disability from

August 31, 1998 through March 1, 2000. (Tr. 240-245).

Plaintiff requested review of the ALJ’s decision, and on March

21, 2002, the Appeals Council affirmed the ALJ’s finding of

disability, but remanded the matter to the ALJ to address issues

relating to medical improvement. (Tr. 246-247, 248-250). Upon

remand, a supplemental hearing was conducted on July 23, 2002.

(Tr. 55-74). On March 14, 2003, the ALJ entered a decision

wherein he found that, as of March 1, 2000, Plaintiff had the

severe impairments of lumbar degenerative disc disease,

degenerative joint disease of the knees, neurofibromatosis,2 and

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3

“A tumor that originates in the neuroglia of the brain or spinal cord.”

The American Heritage Stedman’s Medical Dictionary (2002), p. 336.

3

a history of left frontal low-grade glioma3 (status post

resection). (Tr. 16-31). The ALJ further determined that

Plaintiff was capable of performing work which exists in

significant numbers in the national economy. (Tr. 29, 31). On

August 15, 2003, Plaintiff’s request for review was denied by

the Appeals Council thus making the ALJ’s decision the final

decision of the Commissioner of Social Security. (Tr. 6-10).

The parties agree that this case is now ripe for review and is

properly before this Court pursuant to 42 U.S.C. § 405(g). 

II. Background Facts 

Plaintiff was born December 17, 1961 and was forty years old

at the time of the administrative hearing on July 23, 2002.

(Tr. 60). Plaintiff has a twelfth grade education and past

relevant work experience as a pipe fitter, welder helper and

yard worker. (Tr. 28, 267, 272, 280-287, 333-338, 359).

According to Plaintiff, he became unable to work on August 31,

1998 because of seizures and numbness in his hands and feet.

(Tr. 105-107, 266). In September 1998, Plaintiff underwent left

frontal craniotonmy surgery for the removal of a tumor. (Tr.

166). Plaintiff testified that in March, 2000, he began working

as a security guard, approximately thirty-six (36) hours a week.

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(Tr. 52-53). His job duties as a security guard entailed riding

around the property in a golf cart patrolling the parking lot,

and closing 6-foot tall, 30-foot long, gates at closing. (Tr.

53, 61). According to Plaintiff, he worked as a security guard

until May, 2000, when he quit because of pain in his shoulders

and back from closing the gates. (Tr. 61, 69-70). At the

administrative hearing on April 11, 2000, Plaintiff also

testified that he did yard work for a church. (Tr. 51-52). At

the administrative hearing on July 23, 2002, Plaintiff testified

that he still worked at the church doing housekeeping chores,

approximately forty-five (45) minutes a week during 2002, and an

average of approximately two (2) hours each week in 2001. (Tr.

70-72). 

Plaintiff testified that he had not experienced a seizure

from December 1999 through April 2000, or sought medical

treatment during that time. (Tr. 51). At the time of

administrative hearing on July 23, 2002, Plaintiff testified

that he had not had a seizure in over a year, and that he had

not seen a doctor regarding his seizures since 1998. (Tr. 42,

61-62). Plaintiff further testified that in February, 2002, he

had outpatient surgery on his knee to repair torn cartilage.

(Tr. 62, 68). As a result of his neurofibromatosis, Plaintiff

testified that he has growths on different parts of his body

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4

At the time of the administrative hearing on July 23, 2002, Plaintiff

testified that he had three (3) or four (4) epidural or Cortisone shots in his

knee that year. (Tr. 64). 

5

that ache and cause him problems. (Tr. 65). Plaintiff further

testified that he had a growth removed from his back in October,

2001, and from his right foot in November, 2001. (Tr. 62-63,

421-422, 450). Plaintiff also testified that he is unable to

work because of pain and stiffness in his knees, legs and lower

back. (Tr. 63, 66-67, 69). Plaintiff further testified that he

is in constant pain and is unable to bend over, stand, kneel, or

sit for long periods of time because of pain. Id. Plaintiff

also testified that he experiences numbness in his left hand and

left foot. (Tr. 66). Additionally, Plaintiff testified that he

has arthritis in his knees and lower back that causes him to

experience stiffness and sharp pains on a daily basis. (Tr.

68). Plaintiff testified that his pain medications include

Lortab, Hydrocortisone, Tylenol, Celebrex, and epidural or

Cortisone shots4, but that the medication only numbs the pain

before it returns again. (Tr. 63-64, 67-68). 

The ALJ determined that Plaintiff has not engaged in

substantial gainful activity since March 2000. (Tr. 23, 30).

The ALJ further determined that Plaintiff has the severe

impairments of lumbar degenerative disc disease, degenerative

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6

joint disease of the knees, neurofibromatosis and a history of

left frontal low-grade glioma (status post resection). (Tr. 23,

30). The ALJ concluded that Plaintiff does not have an

impairment or combination of impairments which meet or equal the

criteria for any of the impairments listed in 20 C.F.R. § 404,

App. 1, Subpt. P. Id. Next, the ALJ determined that there has

been improvement in Plaintiff’s impairments, and that such

improvement is related to Plaintiff’s ability to work, and that

no exception to the medical improvement standard applies. (Tr.

23-28, 30). The ALJ also found Plaintiff’s allegations

regarding symptomatology, functional limitations and

restrictions of daily living activities lacked corroboration or

substantiation in the medical evidence and were not credible as

to a disabling impairment. (Tr. 26-27, 30). The ALJ determined

that Plaintiff has the residual functional capacity to perform

light work activity, and could not return to his past relevant

work. (Tr. 28-31). Based on the Medical-Vocational Guidelines,

exertional capacity for light work, Plaintiff’s age, education,

and work experience, the ALJ concluded that Plaintiff is not

disabled and is capable of performing work that exists in

significant numbers in the national economy. (Tr. 29-31). 

III. Issues on Appeal

1. Whether the ALJ erred in finding that Plaintiff retains

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This court’s review of the Commissioner’s application of legal principles

is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

7

the residual functional capacity to perform a wide range of

light work?

2. Whether the ALJ erred in evaluating Plaintiff’s

testimony?

3. Whether the ALJ erred in evaluating the impact of

Plaintiff’s combination of impairments on his ability to work?

IV. Analysis

A. Standard of Review

In reviewing claims brought under the Act, this court’s role

is a limited one. The court’s review is limited to determining:

1) whether the decision of the Secretary is supported by

substantial evidence, and 2) whether the correct legal standards

were applied. Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir.

1990).5 A court may not decide the facts anew, reweigh the

evidence, or substitute its judgment for that of the

Commissioner. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir.

1986). The Commissioner’s findings of fact must be affirmed if

they are based upon substantial evidence. Brown v. Sullivan,

921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v. Heckler, 703

F.2d 1233, 1239 (11th Cir. 1983)(Substantial evidence is defined

as “more than a scintilla but less than a preponderance,” and

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Decisions of the former Fifth Circuit rendered prior to October 1, 1981,

are binding precedent on the Eleventh Circuit. Bonner v. City of Prichard,

Alabama, 661 F.2d 1206, 1209 (11th Cir.1981) (en banc).

8

consists of “such relevant evidence as a reasonable person would

accept as adequate to support a conclusion.”). In determining

whether substantial evidence exists, the court 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); Short v. Apfel, 1999

U.S. Dist. Lexis 10163 (S.D. Ala.).

B. Discussion

After a claimant has been awarded disability benefits, the

Commissioner is statutorily required to periodically review

whether entitlement to receive benefits continues. 20 C.F.R. §

404.1594(a). When a claimant presents evidence of continuing

disability, a presumption attaches that the disability

continues, until proven otherwise. Simpson v. Schweiker, 691

F.2d 966, 969 (11th Cir. 1982) (“However, it is also certain, as

the Fifth Circuit declared in Rivas v. Weinberger, 475 F.2d 255

(5th Cir. 1973),6 that ‘(o)nce evidence has been presented which

supports a finding that a given condition exists it is presumed

in absence of proof to the contrary that the condition has

remained unchanged.’”). Therefore, the burden is upon the

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“[O]nce the claimant has introduced evidence that his or her condition

remains essentially the same as it was at the time of the earlier determination,

the claimant is entitled to the benefit of a presumption that his or her

condition remains disabling.... The presumption of a continuing disability does

not affect the ultimate burden of proof. It imposes on the [Commissioner] only

the burden of going forward with evidence to rebut or meet the presumption.....

Once the burden to come forward has shifted to the SSA, the [Commissioner] must

present evidence that there has been sufficient improvement in the claimant's

condition to allow the claimant to undertake gainful activity.” Williams v.

Apfel, 73 F. Supp 2d 1325, 1337 (M.D. Fla. 1999), quoting Daring v. Heckler, 727

F.2d 64, 68-69 (3d Cir.1984). 

9

Commissioner to present evidence to support the decision to

terminate disability income benefits or supplemental security

income.7

In reviewing a decision to terminate benefits, the ALJ must

compare the original medical evidence to the new medical

evidence used to make a finding of medical improvement. Williams

v Apfel, 73 F. Supp. 2d 1325, 1337-1338 (M.D. Fla. 1999), citing

Vaughn v. Heckler, 727 F.2d 1040, 1043 (11th Cir. 1984). The

comparison begins with the “most recent favorable medical

decision, that is, the latest final decision involving

consideration of the medical evidence and the issue of whether

claimant was disabled or continued to be disabled.” Id., see 20

C.F.R. § 404.1594(b)(7); 20 C.F.R. § 416.994(b)(1)(C)(vii).

Review of the medical signs, the claimant’s statements of his or

her symptoms and complaints, and laboratory findings is

necessary to determine whether medical improvement has occurred.

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There are exceptions to the requirement of a finding of medical

improvement, which are not applicable here, that may also result in the

termination of disability benefits. 20 C.F.R. § 404.1594(d) and (e). 

10

Id., see 20 C.F.R. § 404.1594(b)(1); 20 C.F.R. §

416.994(b)(1)(I). Also, the medical improvement must be related

to the claimant’s ability to work, which means that along with

the decrease in severity of the claimant’s medical impairment,

there has been an increase in the claimant’s “residual

functional capacity to do basic work activities.” 20 C.F.R. §

404.1594(b)(3); 20 C.F.R. § 419.994(b)(1)(iv)(A). 

There must also be a showing that the claimant is able to

engage in substantial gainful activity. 20 C.F.R. §

404.1594(b)(5); 20 C.F.R. § 419.994(b)(1)(v). The regulations

state that “[w]hen new evidence showing a change in signs,

symptoms and laboratory findings establishes that both medical

improvement has occurred and [the claimant’s] functional

capacity to perform basic work activities, or residual

functional capacity, has increased, we say that medical

improvement which is related to [the claimant’s] ability to work

has occurred.” 20 C.F.R. § 404.1594(b)(4)(I);8 See also 20 C.F.R.

§ 416.994(b)(2). 

In a disability insurance benefits case, the regulations

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In cases wherein the plaintiff previously received supplemental security

income benefits, there is a seven-step process. 20 C.F.R. § 416.994(b)(5). 

10

The steps are as follows: 

1) Whether the claimant is engaging in substantial gainful activity.

2) Whether the claimant has an impairment or combination of impairments

which meets or equals the severity of an impairment in the Listing of

Impairments. 20 C.F.R. Pt. 404, Subpt. P, App. 1. 

3) If not, then whether the claimant has obtained medical improvement as

defined in paragraph (b)(1) of 20 C.F.R. § 404.1594. 

4) If the claimant has obtained medical improvement, is it related to his

or her ability to perform work; i.e., has there been an “increase in the residual

functional capacity based on the impairment(s) that was present at the time of

the most recent favorable medical determination.” 

5) If no medical improvement was found at step three or if medical

improvement was found at step four but it did not increase the claimant’s

residual functional capacity, then the Commissioner must consider whether any of

the exceptions listed in paragraphs (d) and (e) of 20 C.F.R. § 404.1594 apply.

6) If medical improvement is related to the ability to work, or if one of

the exceptions from paragraph (d) apply, the Commissioner must determine whether

all the claimant’s current impairments are severe. If not, then the disability

will terminate. 

7) If the claimant has current severe impairment(s), then the Commissioner

must assess the claimant’s residual functional capacity, and if the claimant can

still perform his or her past relevant work, then he or she will be found not

disabled, and the disability will terminate. 

8) If the claimant cannot perform past relevant work, then the Commissioner

must determine whether the claimant can perform other work. To do so, the

Commissioner must assess the claimant’s residual functional capacity, age,

education, and past work experience. If the claimant can perform other work, then

the disability will cease. 

20 C.F.R. § 404.1594(f)(1) through (8). 

11

require the Commissioner to follow an eight-step9 sequential

evaluation process to determine whether a claimant has obtained

medical improvement. 20 C.F.R. § 404.1594(f).10 In the case sub

judice, the ALJ applied the usual eight-step process for

evaluating medical improvement in disability claims, and found

that Plaintiff has not engaged in substantial gainful activity

since his alleged onset of disability, and that he suffers from

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12

lumbar degenerative disc disease, degenerative joint disease of

the knees, neurofibromatosis and a history of left frontal lowgrade glioma (status post resection). (Tr. 23, 30). Then, as

noted supra, the ALJ found that these impairments, when

considered individually, or in combination, do not meet or equal

the criteria listed in 20 C.F.R. Pt. 404, Subpt. P., App. 1.

Id. Next, the ALJ determined that there has been improvement in

Plaintiff’s impairments, that such improvement is related to

Plaintiff’s ability to work, and that no exception to the

medical improvement standard applies. (Tr. 23-28, 30). The ALJ

further determined that Plaintiff’s allegations regarding

symptomatology, functional limitations and restrictions of daily

living activities lacked corroboration or substantiation in the

medical evidence and were not credible as to a disabling

impairment. (Tr. 26-27, 30). Proceeding to the seventh step,

the ALJ determined that Plaintiff has the residual functional

capacity to perform light work activity, but is unable to return

to his past relevant work. (Tr. 28-31). At step eight, the ALJ

concluded that Plaintiff is capable of performing other work

that exists in the national economy, and is not disabled. (Tr.

29-31).

Plaintiff argues that the ALJ’s determination that Plaintiff

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11

Light work is defined as follows: 

Light work involves 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 long periods of time.

20 C.F.R. § 404.1567(b) (2001); 20 C.F.R. § 416.967(b) (2001). Light

exertional work is further explained in Social Security Ruling 83-10, Titles II

and XVI: Determining Capability To Do Other Work - The Medical-Vocational Rules

of Appendix 2, 1983 WL 31251 at *5-6, which sets forth as follows: 

 

“Frequent” means occurring from one-third to two-thirds of the time.

Since frequent lifting or carrying requires being on ones feet up to

two-thirds of a work day, the full range of light work requires

standing or walking, off and on, for a total of approximately 6

hours of an 8-hour work day. Sitting may occur intermittently

during the remaining time. The lifting requirement for the majority

of light jobs can be accomplished with occasional, rather than

frequent, stooping. Many unskilled light jobs are performed

primarily in one location, with the ability to stand being more

critical than the ability to walk. They require use of arms and

hands to grasp and to hold and turn objects, and they generally do

not require use of fingers for fine activities to the extent

required in much sedentary work.

13

is capable for performing a wide range of light work11 is not

supported by substantial evidence. Specifically, Plaintiff

argues that the medical evidence indicates that he suffers from

anxiety, depression, severe lumbar degenerative disease,

degenerative joint disease of the knees, neurofibromatosis,

numbness to the right upper extremity and left leg, a history of

left frontal low grade glioma (status post resection), seizure

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12

A consultative examination report should contain certain information as

listed in the regulations which set forth, in pertinent part, as follows: “(6)

A statement about what you can still do despite your impairment(s), unless the

claim is based on statutory blindness. This statement should describe the opinion

of the medical source about your ability, despite your impairment(s), to do work14

disorder and severe non-exertional impairments such as pain.

Plaintiff further avers that medical evidence indicates that

Plaintiff: can only sit, stand and walk for one (1) hour at a

time; should never lift/carry more than five (5) pounds; can

occasionally bend; and never squat, crawl, or climb. To that

end, Plaintiff argues that the ALJ failed to indicate what

specific jobs Plaintiff could perform with his alleged

impairments and limitations. 

The determination of a plaintiff’s residual functional

capacity is an administrative finding reserved to the

Commissioner, which must be based upon all the relevant evidence

such as objective medical evidence, medical acceptable signs and

clinical findings, effects of treatment, medical source

statements, plaintiff’s testimony and reports of daily

activities. 20 C.F.R. § 404.1245(a); 20 C. F.R. § 416.945(a);

Social Security Ruling 96-8p: Titles II and XVI: Assessing

Residual Functional Capacity in Initial Claims, 1996 WL 374184.

Medical source statements such as physical capacities

evaluations are medical evidence and must be considered by the

ALJ.12 However, as with any medical evidence, a physical

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related activities, such as sitting, standing, walking, lifting, carrying,

handling objects, hearing, speaking, and traveling; and, in cases of mental

impairment(s), the opinion of the medical source about your ability to

understand, to carry out and remember instructions, and to respond appropriately

to supervision, coworkers and work pressures in a work setting. Although we will

ordinarily request, as part of the consultative examination process, a medical

source statement about what you can still do despite your impairment(s), the

absence of such a statement in a consultative examination report will not make

the report incomplete.” 20 C. F. R. § 404.1527; 20 C.F.R. § 404.1519n; 20 C.F.R.

§ 416.919n.

15

capacities evaluation can be rejected if it is inconsistent with

the physician’s notes and other objective medical or clinical

evidence in record. The ALJ may also reject the opinion

regarding a plaintiff’s physical capacities when the evidence

supports a contrary conclusion or when the opinion is contrary

to other statements or reports of the physician. Crawford v.

Comm’r of Soc. Sec., 363 F.3d 1155, 1159-1160 (11th Cir. 2004)

(finding that the physician’s opinion that claimant is

permanently and totally disabled is inconsistent with his own

treatment notes, unsupported by medical evidence and based

primarily on the claimant’s subjective complaints of pain);

Phillips v Barnhart, 357 F. 3d 1232, 1240-1241 (11th Cir. 2004)

(good cause exists for not giving treating physician’s opinion

substantial weight when the opinion is not bolstered by the

evidence; the evidence supports a contrary finding; or the

opinion is conclusory or inconsistent with the doctor’s own

medical records). 

Furthermore, Social Security Ruling 96-5p Title II and XVI:

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Medical Source Opinions on Issue Reserved to the Commissioner,

1996 WL 374183, in the section entitled “Residual Functional

Capacity Assessments and Medical Source Statements” sets forth

as follows:

The regulations describe two distinct kinds of

assessments of what an individual can do despite the

presence of a severe impairment(s). The first is

described in 20 CFR 404.1513(b) and (c) and 416.913(b)

and (c) as a "statement about what you can still do

despite your impairment(s)" made by an individual's

medical source and based on that source's own medical

findings. This "medical source statement" is an

opinion submitted by a medical source as part of a

medical report. The second category of assessments is

the RFC assessment described in 20 CFR 404.1545,

404.1546, 416.945, and 416.946 which is the

adjudicator's ultimate finding of "what you can still

do despite your limitations." Even though the

adjudicator's RFC assessment may adopt the opinions in

a medical source statement, they are not the same

thing: A medical source statement is evidence that is

submitted to SSA by an individual's medical source

reflecting the source's opinion based on his or her

own knowledge, while an RFC assessment is the

adjudicator's ultimate finding based on a

consideration of this opinion and all the other

evidence in the case record about what an individual

can do despite his or her impairment(s). 

1996 WL 374183 at *6.

In making his determination regarding Plaintiff’s residual

functional capacity, the ALJ observed that Plaintiff sought very

little medical treatment for his alleged symptoms after March

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13

The ALJ noted that although Plaintiff’s earnings did not constitute

substantial gainful activity (Tr. 260, 264), Plaintiff’s ability to perform odd

jobs evidenced a desire and ability to perform work activity. (Tr. 26).

17

2000, and was able to do “odd jobs”.13 (Tr. 23, 26). The ALJ

further noted that, based upon a consultative examination of

Plaintiff on February 19, 2001, Dr. John W. Lowery, M.D. noted

that Plaintiff reported that he was not on any medication for

his alleged back, foot, hand and knee pain, and that he had not

had a seizure in two (2) years. (Tr. 23, 402). Dr. Lowery also

found Plaintiff’s lungs to be clear; heart rate regular and

without murmur; no signs of abdominal mass; “moderate”

tenderness in his right lower thoracic spine area; no sign of

diminished range of motion, except in index finger; fair

tenderness in knees; Plaintiff was capable of walking without

assistance, his gait was normal and he could walk on his heels

and toes, squat and rise; peripheral pulses were intact;

neurological functioning was appropriate; and that he had

“marked extremely numerous soft tissue tumors which are

extensive, large and scattered throughout his entire body”.

(Tr. 402-403). Dr. Lowery listed his impressions as:

neurofibromatosis, status post surgery for brain tumor, back

pain with history of epidural injections, arthritis of the knees

and possible arthritis in his hands. (Tr. 24, 403). 

Case 1:03-cv-00695-P-B Document 23 Filed 03/03/05 Page 17 of 26
14Some of Dr. Dempsey’s notes are not legible.

18

The ALJ noted that Plaintiff also sought treatment from

orthopedist, Dr. Thomas R. Dempsey, on October 8, 2001, who

indicated that he had not examined Plaintiff since October,

1999. (Tr. 24, 451). Upon examination of Plaintiff, Dr.

Dempsey found that Plaintiff had: 50% range of motion in his

back; paraspinous muscle spasms; and neurofibromas over his

back. Like Dr. Lowery, Dr. Dempsey diagnosed Plaintiff with

neurofibromatosis, low back pain, and knee pain. (Tr. 451-

45214). Dr. Dempsey prescribed medication for Plaintiff and

recommended that he undergo diagnostic studies and epidural, of

which Plaintiff underwent epidural injections in November and

December of 2001 on three (3) separate occasions. (Tr. 24, 447-

449). Additionally, Plaintiff underwent surgery on October 30,

2001 to remove a neurofibroma from his back. (Tr. 421-422). 

The ALJ further noted that subsequent MRIs, on October 11,

2001, revealed that Plaintiff suffered from degenerative disc

disease in the lumbosacral spine and subchondral cystic changes

in his right foot. (Tr. 24, 419-420). Additionally, X-rays of

Plaintiff’s knees showed mild patellofemoral arthritis in both

knees, and MRIs performed on both knees on January 21, 2002,

revealed “moderate sized undersurface tear of the posterior horn

and of the medial meniscus” and “[h]yaline thinning” at the

Case 1:03-cv-00695-P-B Document 23 Filed 03/03/05 Page 18 of 26
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medial femorotibial articulation. (Tr. 25, 423-424). Plaintiff

underwent surgery on his right knee on February 5, 2002. (Tr.

25, 436-437). The ALJ observed that treatment records of

subsequent examinations of Plaintiff by Dr. Dempsey indicate a

decrease in Plaintiff’s pain and improvement in Plaintiff’s

strength and range of motion in his right knee. (Tr. 25, 27,

425-435). During his last documented examination of Plaintiff

on June 26, 2002, Dr. Dempsey noted that Plaintiff had: full

extension and flexion motion in the knee; full lumbar range of

motion; normal knee/ankle reflexes; and no muscular atrophy and

no lower extremity weakness. The notes also reflect that

Plaintiff’s right knee had 1+ effusion and his back showed pain

on percussion over both posterior superior iliac crests with

grade I paraspinous muscle spasms. (Tr. 26, 438). 

The ALJ also relied upon Plaintiff’s reported daily

activities as support for his findings regarding Plaintiff’s

residual functional capacity to perform light work.

Specifically, the ALJ observed that Plaintiff is able to care

for his personal needs, cook, shop for his personal needs,

perform household chores, attend church, drive, and leave home

eight (8) to nine (9) times per week. (Tr. 27, 275-279, 302-

306, 346-349). Additionally, the ALJ noted that Plaintiff’s

alleged pain did not affect his ability to answer questions or

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20

remember facts at the administrative hearing, and he had not

been referred to a pain clinic, and had not had surgery on his

back. (Tr. 27, 55-74).

While the record evidence does reflect that as of March

2000, Plaintiff has shown medical improvement in that he

recovered from his brain tumor, his seizure activity has ceased,

and he went a sustained period of time without receiving medical

treatment or taking medication, the undersigned concludes, based

on the totality of the evidence, that the ALJ’s decision that

Plaintiff retains the residual functional capacity to perform

light duty work is not supported by substantial evidence. The

record reflects that from 2001 forward, Plaintiff has

consistently complained of low back pain, and pain in his knees,

and that there is objective medical evidence of an underlying

condition. Both of Plaintiff’s treating physicians, Dr. Dempsey

and Dr. Cecil Parker, as well as the consultative doctor, have

diagnosed Plaintiff with neurofibromatosis, low back pain and

knee pains. Additionally, MRIs revealed degenerative disc

disease in Plaintiff’s lumbosacral spine and “moderate sized

undersurface tear of the posterior horn and of the medial

meniscus” and “[h]yaline thinning” at the medial femorotibial

articulation in the Plaintiff’s knees. (Tr. 25, 423-424). 

Dr. Dempsey’s treatment plan for Plaintiff included epidural

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21

injections in November 2001 and December 2001, right knee

surgery, physical therapy and medication, including Lortab for

pain. While it appears that this treatment provided Plaintiff

some relief, Dr. Dempsey and Dr. Parker’s treatment notes

reflect that even after the surgery and physical therapy,

Plaintiff continued to complain about pain in his left knee and

his lower back, and was prescribed medication, including Lortab

for pain. (Tr. 228-232, 425-435, 436-452, 453-459). 

In an assessment dated June 26, 2002, Dr. Parker opined that

Plaintiff can only sit, stand and walk for one (1) hour during

an eight-hour day; should never lift/carry more than ten (10)

pounds; can occasionally bend; and never squat, crawl, or climb.

(Tr. 418). The ALJ, however, did not afford Dr. Parker’s

opinion determinative weight, as he concluded that the opinion

was not justified and was inconsistent with Dr. Parker’s

treatment records and the record as whole. (Tr. 29-30). Aside

from Dr. Parker’s assessment, the only other medical evidence in

the record which addresses the effect of Plaintiff’s conditions

on his ability to work is the Physical Residual Functional

Evaluation that was completed by the State agency physician in

March 2001. In the assessment, the agency physician opined that

Plaintiff could: occasionally lift/carry twenty (20) pounds, and

frequently lift/carry ten (10) pounds; stand/walk six (6) hours

Case 1:03-cv-00695-P-B Document 23 Filed 03/03/05 Page 21 of 26
15While the ALJ makes much of Plaintiff’s reported daily activities and

the fact that Plaintiff performed odd jobs, the undersigned finds that such is

not compelling. This is particularly true given Plaintiff’s testimony that

since his brain surgery, he has tried trial periods of work; however, due to

his back and leg pains, he has been unable to maintain gainful employment. 

According to Plaintiff, because of his pain, he left a security job after a

little over two months, and he was only able to work at a church doing

housekeeping chores, approximately forty-five (45) minutes a week during 2002,

and an average of approximately two (2) hours each week in 2001. (Tr. 70-72). 

22

during an eight-hour workday; sit six (6) hours during an eighthour workday; occasionally climb, stoop, kneel, crouch and

crawl; and frequently balance. (Tr. 406-414). This assessment,

which was not referenced by the ALJ, cannot constitute

substantial evidence for the ALL’s decision because it was

completed in March 2001; thus, it obviously does not take into

account Dr. Dempsey’s medical records which reflect treatment of

Plaintiff for knee and back pain from November 2001 through the

June 2002 time frame, nor the treatment records of Dr. Parker.

Accordingly, while the totality of the evidence reflects

that Plaintiff has problems with his back and right leg, what the

record does not clearly establish is the effect that these

conditions have on Plaintiff’s ability to work. Thus, the record

lacks substantial evidence to support the ALJ’s finding that

Plaintiff can perform light work15. Manso-Pizarro v. Secretary

of Health and Human Services, 76 F.3d 15 (lst Cir. 1996)(where

the ALJ’s conclusion that the plaintiff can continue to do her

prior medium-level work is not supported by substantial evidence,

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23

case remanded to the secretary for additional evidence of

functional ability.); Hernadez v. Barnhart, 203 F. Supp. 2d 1341

(S.D. Fla. 2002)(case should be remanded in order for the

examining consultants to render their opinion as to the

plaintiff’s functional capacity); Rohrberg v. Apel, 26 F. Supp.

2d 303, 311 (D. Mass. 1998) (stating that when the medical

findings merely diagnose the claimant’s impairments and do not

relate the impairments to specific residual functional

capabilities such as those set out in 20 C.F.R. §404, 1567(a),

the Commissioner may not make that connection himself).

Therefore, the undersigned recommends that this matter be

reversed and remanded for further proceedings to determine

Plaintiff’s residual functional capacity to work, as of March

2000. Thereafter, if required, the ALL shall proceed to the

remaining steps in the sequential analysis. To the extent it is

determined that Plaintiff is unable to perform a full range of

work at a given functional level or that he has both exertional

and nonexertional limitations, a vocational expert should be

utilized. Welch v. Bowen, 854 F.2d 436, 439-440 (llth Cir.

1988); Adams v. Apel, 1999 U.S. Dist. Lexis 6595 (S.D. Ala.

199)(preferred method of demonstrating job availability where the

plaintiff is unable to perform a full range of work at a given

functional level or has both exertional and nonexertional

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24

limitations is through the testimony of a vocational expert.)

V. Conclusion

For the reasons set forth, and upon consideration of the

administrative record, oral argument and the memoranda of the

parties, it is recommended that the decision of the Commissioner

of Social Security denying Plaintiff’s claim for disability

insurance benefits, as of March, 2000, be REVERSED and REMANDED

for further proceedings consistent with the undersigned findings.

The attached sheet contains important information regarding

objections to this report and recommendation.

DONE this 3rd day of March, 2005.

 s/ SONJA F. BIVINS 

 UNITED STATES MAGISTRATE JUDGE

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MAGISTRATE JUDGE’S EXPLANATION OF PROCEDURAL RIGHTS

AND RESPONSIBILITIES FOLLOWING RECOMMENDATION

AND FINDINGS CONCERNING NEED FOR TRANSCRIPT

1. Objection. Any party who objects to this recommendation or

anything in it must, within ten days of the date of service of

this document, file specific written objections with the clerk of

court. Failure to do so will bar a de novo determination by the

district judge of anything in the recommendation and will bar an

attack, on appeal, of the factual findings of the magistrate

judge. See 28 U.S.C. § 636(b)(1)(c); Lewis v. Smith, 855 F.2d

736, 738 (11th Cir. 1988). The procedure for challenging the

findings and recommendations of the magistrate judge is set out

in more detail in SD ALA LR 72.4 (June 1, 1997), which provides,

in part, that:

A party may object to a recommendation entered by a

magistrate judge in a dispositive matter, that is, a

matter excepted by 28 U.S.C. § 636(b)(1)(A), by filing

a “Statement of Objection to Magistrate Judge’s

Recommendation” within ten days after being served

with a copy of the recommendation, unless a different

time is established by order. The statement of

objection shall specify those portions of the

recommendation to which objection is made and the

basis for the objection. The objecting party shall

submit to the district judge, at the time of filing

the objection, a brief setting forth the party’s

arguments that the magistrate judge’s recommendation

should be reviewed de novo and a different disposition

made. It is insufficient to submit only a copy of the

original brief submitted to the magistrate judge,

although a copy of the original brief may be submitted

or referred to and incorporated into the brief in

support of the objection. Failure to submit a brief

in support of the objection may be deemed an

abandonment of the objection.

A magistrate judge’s recommendation cannot be appealed to a

Court of Appeals; only the district judge’s order or judgment

can be appealed.

2. Opposing party’s response to the objection. Any opposing

party may submit a brief opposing the objection within ten (10)

days of being served with a copy of the statement of objection.

Fed. R. Civ. P. 72; SD ALA LR 72.4(b). 

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3. Transcript (applicable where proceedings tape recorded).

Pursuant to 28 U.S.C. § 1915 and Fed.R.Civ.P. 72(b), the

magistrate judge finds that the tapes and original records in

this action are adequate for purposes of review. Any party

planning to object to this recommendation, but unable to pay the

fee for a transcript, is advised that a judicial determination

that transcription is necessary is required before the United

States will pay the cost of the transcript.

 s / SONJA F. BIVINS

UNITED STATES MAGISTRATE JUDGE

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