Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_08-cv-00853/USCOURTS-almd-2_08-cv-00853-0/pdf.json

Parties Involved:
Michael J. Astrue
Defendant
Tamera McCall
Plaintiff

Document Text:

Pursuant to the Social Security Independence and Program Improvements Act of 1

1994, Pub. L. No. 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

NORTHERN DIVISION

TAMERA McCALL, for WM, )

)

Plaintiff, )

) CIVIL ACTION NO. 2:08cv853 -WC

v. )

)

MICHAEL J. ASTRUE, ) 

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. INTRODUCTION

Tamera McCall (“Plaintiff”) applied forsupplementalsecurity income benefits under

Title XVI of the Social Security Act, 42 U.S.C. § 1381 et seq. (2000), on behalf of her

brother and legal dependent, W.M. (“Claimant”), alleging he was disabled. Plaintiff’s

application was denied at the initial administrative level. 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 (the Commissioner). See Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). 1

The case is now before the Court for review pursuant to 42 U.S.C. § 405(g). Pursuant to 28

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A “physical or mental impairment” is one resulting from anatomical, 2

physiological, or psychological abnormalities which are demonstrable by medically

acceptable clinical and laboratory diagnostic techniques.

Part A of the Listing of Impairments applies to children and adults; Part B applies 3

to children only. In dealing with a child’s case, the Commissioner looks first to Part B,

then to Part A. 20 C.F.R. § 416.925(b); Wilkinson v. Bowen, 847 F.2d 660, 661 (11th Cir.

1987). 

2

U.S.C. § 636(c), both parties have consented to the conduct of all proceedings and entry of

a final judgment by the undersigned United States Magistrate Judge. Pl.’s Consent to

Jurisdiction (Doc. #9); Def.’s Consent to Jurisdiction (Doc. #8). Based on the Court’s review

of the record and the briefs of the parties, the Court AFFIRMS the Commissioner’s decision.

II. STANDARD FOR CHILDHOOD DISABILITY

Under 42 U.S.C. § 1382c(a)(3)(C)(i), a person under the age of 18 is disabled (and

hence entitled to disability benefits) if the person “has a medically determinable physical or

mental impairment, which results in marked and severe functional limitations, and 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.” In determining whether a child is disabled, the 2

Commissioner employs the following three-step sequential evaluation process. See 20 C.F.R.

§ 416.924 (2007).

(1) Is the person presently not engaged in substantial gainful activity?

(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 (the “Listing of

Impairments”), and also meet the twelve-month duration requirement?3

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If the answer to each of the three questions is “yes,” then the child is entitled to benefits.

In order for a severe impairment to meet or equal one of the listed impairments, the

impairment must “cause[] marked and severe functional limitations” for the child claimant.

20 C.F.R. § 416.911(b). 

A child’s impairment is recognized as causing “marked and severe functional

limitations” if those limitations meet[], medically equal[], or functionally

equal[] the [L]istings. A child’s limitations “meet” the limitations in the

Listings if the child actually suffers from the limitations specified in the

Listings for that child’s severe impairment. A child’s limitations “medically

equal” the limitations in the Listings if the child’s limitations are at least of

equal medical significance to those of a listed impairment.

Shinn ex rel. Shinn v. Comm’r of Soc. Sec., 391 F.3d 1276, 1278 (11th Cir. 2004) (internal

quotations and citations omitted). Even if the child’s impairment does not meet or medically

equal a listing, it may still functionally equal a listing. In assessing functional equivalence,

the ALJ considers the “degree to which the child’s limitations interfere with the child’s

normal life activities. The C.F.R. specifies six major domains of life:

(I) Acquiring and using information;

(ii) Attending and completing tasks;

(iii) Interacting and relating with others;

(iv) Moving about and manipulating objects;

(v) Caring for [one]self; and

(vi) Health and physical well-being.”

Id. at 1279. “The C.F.R. contains various ‘benchmarks’ that children should have achieved

by certain ages in each of these life domains.” Id. (citing 20 C.F.R. §§ 416.926a(g)-(l)). “A

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child’s impairment is ‘of listing-level severity,’ and so ‘functionally equals the listings,’ if[,]

as a result of the limitations stemming from that impairment[,] the child has ‘marked’

limitations in two of the domains, or an ‘extreme’ limitation in one domain.” Id. (citing 20

C.F.R. § 416.926a(d) and § 416.925(a)). A marked limitation is one that interferes seriously

with the child’s “ability to independently initiate, sustain, or complete activities.” 20 C.F.R.

§ 416.926a(e)(2)(I). An “extreme limitation” is one that “interferes very seriously with [the

child’s] ability to independently initiate, sustain, or complete activities.” 20 C.F.R. §

416.926a(e)(3)(I). 

III. SCOPE OF REVIEW

The Court’s 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 (11th Cir. 1997). “Substantial

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). See also Crawford v. Comm’r of Soc. Sec., 363 F.3d

1155, 1158 (11th Cir. 2004) (“Even if the evidence preponderates against the

Commissioner’s findings, [a reviewing court] must affirm if the decision reached is

supported by substantial evidence.”). 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.

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Indeed, the ALJ found that the claimant suffers either “less than marked” or 4

no limitations in all of the domains of functioning. Tr. 22-26.

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Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986). 

[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 (11th Cir. 1987).

IV. ADMINISTRATIVE PROCEEDINGS

The claimant was twelve years old at the time of Plaintiff’s application for

supplemental security income. Tr. 49. Following the administrative hearing, the ALJ found

the claimant had not engaged in substantial gainful activity at any time during the period

under adjudication (Step 1). Tr. 18. The ALJ also found the claimant had two severe

impairments under Step 2: attention deficit hyperactivity disorder and borderline intellectual

functioning. Tr. at 19. Nonetheless, the ALJ concluded that these impairments do not meet

or equal in severity the criteria for any impairment in the Listing of Impairments, and that the

claimant did not have an “extreme” limitation in any areas of functioning or “marked”

limitation in two areas of functioning. Tr. 19-26. Consequently, the ALJ found the claimant 4

was not disabled. Tr. 26.

V. PLAINTIFF’S CLAIM

Plaintiff presents one issue for review: whether the ALJ’s decision should be reversed

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Notably, Plaintiff does not contend that the ALJ’s ultimate decision denying 5

Plaintiff’s disability claim is not supported by substantial evidence.

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because “the ALJ failed to state with particularity the weight he gave the medical opinions

expressed by Dr. DeMuth and the reasons therefor.” Pl.’s Brief (Doc. #13) at 3.

VI. ANALYSIS

Plaintiff contends that, in denying benefits, the ALJ improperly failed to articulate the

weight he attributed to the opinion rendered by Dr. DeMuth in a consultative examination.

Pl.’s Brief (Doc. #13) at 4-7. Plaintiff asserts that “the ALJ’s decision completely ignores

Dr. DeMuth’s evaluation and examination findings.” Id. at 5 (emphasis in original). Plaintiff

contends that the ALJ’s failure to properly describe the weight afforded Dr. DeMuth’s

opinion, as well as the reasoning supporting that decision, violates applicable law and

requires reversal. While conceding that the ALJ does not expressly discuss Dr. DeMuth’s 5

ultimate opinion, Defendant contends that the ALJ implicitly rejected Dr. DeMuth’s opinion

and that such rejection is supported by substantial evidence. Def.’s Brief (Doc. #14) at 9.

Defendant also asserts that any error in failing to specifically address Dr. DeMuth’s opinion

was harmless, as it is clear from the ALJ’s opinion that the ALJ would not have reached a

different decision. Id. at 10.

Dr. DeMuth conducted a consultative disability examination of the claimant on March

18, 2005. Tr. 182. Based on his evaluation of the claimant, Dr. DeMuth opined that the

claimant “appears to be severely impaired in his ability to function in an age appropriate

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Dr. DeMuth reached this conclusion after relating a number of observations 6

about the claimant’s demeanor, affect, and behavior, as well as the results of the

“sensorium” Dr. DeMuth administered to the claimant. While Dr. DeMuth’s observations

speak for themselves, it is noteworthy that he never described any of the claimant’s

limitations or difficulties as “severe” until he gave his summary opinion. Indeed,

crediting Dr. DeMuth’s own observations, the claimant presented as essentially normal in

several aspects of his behavior and demeanor, and also gave correct or appropriate

responses to some of the problems posed in the “sensorium.” Tr. 183-84. 

The Eleventh Circuit has recognized that the obligation to discuss probative 7

medical opinion evidence is not satisfied where, as here, the ALJ simply mentions the

physician’s report in some capacity but fails to address the physician’s ultimate opinion. 

Luckey v. Astrue, 2009 WL 1362988 at *6 (11th Cir. 2009).

7

manner cognitively, communicatively, socially, adaptively, behaviorally, and in

concentration, persistence, and pace.” Tr. 184-85. In his opinion, the ALJ did cite to Dr. 6

DeMuth’s report in recounting prior diagnoses of the claimant’s severe impairments, Tr. 19,

but indeed did not further elaborate upon Dr. DeMuth’s opinion that the claimant is “severely

impaired” in the areas described by Dr. DeMuth. However, the ALJ did give “significant

weight” to the “State agency medical opinions,” specifically the opinion of the physician

examiner, Dr. Rankart, see Tr. 21, who, in reviewing all of the medical evidence, found Dr.

Demuth’s opinion “not adequately supported by collective evidence.” Tr. 193.

When deciding a claim of disability, the ALJ is “required to state with particularity

the weight he gave the different medical opinions and the reasons therefor.” Sharfarz v.

Bowen, 825 F.2d 278, 279 (11th Cir. 1987). “In the absence of such a statement, it is 7

impossible for a reviewing court to determine whether the ultimate decision on the merits of

the claim is rational and supported by substantial evidence.” Cowart v. Schweiker, 662

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Fed.2d 731, 735 (11th Cir. 1981). However, in certain circumstances, the ALJ’s failure to

strictly comply with this requirement may be deemed harmless error. Caldwell v. Barnhart,

261 Fed. App’x 188, 190 (11th Cir. 2008) (“An ALJ’s failure to state with particularity the

weight given different medical opinions is reversible error. When, however, an incorrect

application of the regulations results in harmless error because the correct application would

not contradict the ALJ’s ultimate findings, the ALJ’s decision will stand.”) (citations

omitted). Courts have generally found that an ALJ’s failure to state what weight is accorded

a particular piece of medical opinion evidence is harmless when the ALJ has relied upon

other opinion evidence which is consistent with the omitted evidence or the omitted opinion

is consistent with the ALJ’s ultimate findings. See, e.g., id. at 191; Wright v. Barnhart, 153

Fed. App’x 678, 684 (11th Cir. 2005). Other courts have recognized that the ALJ’s failure

to specify the weight given particular medical evidence might be considered harmless when

“the Commissioner has met the goal of [20 C.F.R.] § [404.]1527(d)(2) - the provision of the

procedural safeguard of reasons - even though she has not complied with the terms of the

regulation.” Nelson v. Comm’r of Soc. Sec., 195 Fed. App’x 462, 470 (6th Cir. 2006). Under

this rationale, the ALJ achieves the goal established by the regulations, without formal

compliance, by providing sufficient reasons for the rejection of the omitted opinion by

indirectly attacking its “supportability” or “consistency” with the record as a whole. Id.

Under circumstances similar to those inhering in this case, the Eleventh Circuit

appears to have recognized that such “implicit” rejection of medical opinion evidence is

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viable provided that the ALJ articulates the reasons for affording the omitted opinion less

weight and such reasons are supported by the record. Snyder v. Comm.’r of Soc. Sec., 2009

WL 1492653 at *4 (11th Cir. 2009) (“Here, the ALJ did not specify expressly the weight

given to Dr. Oliverio’s opinion. The most the ALJ said is that he was giving greater weight

to Dr. Bhatia’s opinion. If that implicitly meant that he gave less weight to Dr. Oliverio’s

opinion, then the ALJ failed to articulate clearly the reasons for giving less weight to his

opinion. This problem alone requires reversal.”). In this instance, given Dr. Rankart’s

statement that Dr. DeMuth’s opinion is not supported by all of the medical evidence, it

appears the omitted medical evidence is inconsistent with the relied-upon medical opinion

evidence and, hence, the ALJ’s ultimate findings. Thus, this Court must determine whether,

despite failing to specify what weight he afforded Dr. DeMuth’s opinion and the reasons

therefor, the ALJ nevertheless provided clear and adequate reasons for his apparent decision

to afford less weight to such opinion.

The Court concludes that the ALJ did adequately state the reasons supporting his

implicit decision to afford Dr. DeMuth’s opinion less weight and that those reasons are

supported by substantial evidence. It should first be noted that Dr. DeMuth’s opinion, though

instructive, is not specifically tailored toward resolving the inquiry before the ALJ, i.e., the

severity of the claimant’s limitations in the discrete domains of functioning identified in the

regulations. Thus, Dr. DeMuth’s opinion that the claimant is “severely impaired in his ability

to function in an age appropriate manner cognitively, communicatively, socially, adaptively,

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For example, Dr. Rankart’s report makes note of the SSA Function Reports 8

which indicate, inter alia, that the claimant has unlimited communication skills (Tr. 69),

that he can make friends and has friends his own age and generally gets along with adults

and school teachers (Tr. 71). Tr. 191. While these reports also reinforce some of the

claimant’s limitations regarding concentration and intellectual functioning, it is apparent

that, in other aspects, they conflict with Dr. DeMuth’s opinion about the claimant’s

purported limitations in some areas of functioning. 

As part of an earlier-administered “behavioral evaluation,” the claimant’s

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“cognitive ability” was tested. Tr. 231. In this testing, the claimant scored in the

“Extremely Low range” in “reasoning abilities on verbal tasks,” “while his nonverbal

reasoning abilities are significantly higher and in the Low Average range.” Tr. 231. The

prevailing impression from this round of testing is that the claimant’s performance does

not correspond with his overall abilities (Tr. 232-35), and that addressing the claimant’s

“attention and behavioral needs” may ameliorate some of the claimant’s demonstrated

limitations in learning and intellectual functioning. Tr. 232. 

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behaviorally, and in concentration, persistence, and pace” is of questionable relevance due

to its generality and strained compatibility with the mandated test. On the other hand, Dr.

Rankart’s Childhood Disability Evaluation Form specifically addresses each of the domains

of functioning and provides a detailed overview of the then-available evidence before

concluding that Dr. DeMuth’s opinion is not wholly supported by the evidence. More 8

importantly, the ALJ cites to substantial evidence in the record supporting his finding that,

while the claimant suffers severe impairments, such impairments do not functionally equal

the listings. In particular, the ALJ cites to the following: objective intellectual functioning

testing administered in 2007 which indicates “average” noverbal ability functioning (Tr.

222) ; a January, 2005, intake evaluation by Montgomery Area Mental Health Authority 9

which, as reported by Plaintiff, indicates that claimant makes As and Bs in school, has

essentially normal mental status and average intelligence, and that the claimant has a GAF

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The record before the ALJ contains numerous teacher evaluations of the 10

claimant’s functional capacities in the given domains. Tr. 125-165. In their earnest

assessments of the claimant’s functioning in the given domains, the teachers present

differing views on the claimant’s limitations. For example, some teachers view the

claimant’s difficulties in aspects of acquiring and using information as “serious” or “very

serious,” while others consider them less serious. In sum, the evaluations reinforce what

is apparent from a global view of the evidence - the claimant suffers from limitations due

to the severe impairments found by the ALJ, but substantial evidence supports the ALJ’s

conclusion that the claimant’s limitations are not functionally equivalent to the listings. 

11

of 61, denoting “moderate” symptoms or limitations (Tr. 174-75, 178); a 2000 evaluation

which concluded that the claimant’s overall functioning is in the “Mid to Uppermost Range

of Borderline Intellectual Functioning with adaptive capabilities being higher than

cognitive/academic capabilities” (Tr. 170); and various reports from the claimant’s teachers

who present, at best, a mixed picture of the claimant’s limitations in the given domains (Tr.

124-165). In sum, there is substantial evidence in the record relied upon by the ALJ in his 10

implicit rejection of Dr. DeMuth’s opinion. This circumstance, combined with the

questionable probative value of Dr. DeMuth’s opinion, renders any failure by the ALJ to

specifically discount Dr. DeMuth’s opinion harmless. 

VII. CONCLUSION

The Court has carefully and independently reviewed the record and concludes the

decision of the Commissioner is AFFIRMED. 

A separate judgment will issue.

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DONE this 30th day of September, 2009.

/s/ Wallace Capel, Jr.

WALLACE CAPEL, JR.

UNITED STATES MAGISTRATE JUDGE

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