Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-1_08-cv-00899/USCOURTS-almd-1_08-cv-00899-0/pdf.json

Parties Involved:
Michael J. Astrue
Defendant
Beverly Grundy
Plaintiff

Document Text:

1

IN THE UNITED STATES DISTRICT COURT 

FOR THE MIDDLE DISTRICT OF ALABAMA 

SOUTHERN DIVISION 

BEVERLY GRUNDY, ) 

 ) 

 Plaintiff, ) 

 ) 

v. ) CIVIL ACTION NO. 

 ) 1:08-CV-899-TFM 

MICHAEL J. ASTRUE, ) 

 ) 

 Defendants. ) 

 ) 

MEMORANDUM OPINION AND ORDER

 Following administrative denial of her application for disability insurance benefits 

under Title II of the Social Security Act (“the Act”), 42 U.S.C. §§ 401 et seq., and 

supplemental security income (SSI) benefits under Title XVI of the Act, 42 U.S.C. §§ 

1381 et seq., Beverly Grundy (“Grundy”) received a hearing before an administrative law 

judge (“ALJ”) who rendered an unfavorable decision. When the Appeals Council 

rejected review of this decision, it became the final decision of the Commissioner of 

Social Security (“Commissioner”). Judicial review proceeds pursuant to 42 U.S.C. §§ 

405(g) , 1383(c)(3), and 28 U.S.C. § 636 (c), and for reasons herein explained, the court 

REMANDS this case to the Commissioner. 

 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 1 of 12
 2

I. STANDARD OF REVIEW 

 Judicial review of the Commissioner’s decision to deny benefits is limited. The 

court cannot conduct a de novo review or substitute its own judgment for that of the 

Commissioner. Walden v. Schweiker, 672 F.2d 835 (11th Cir. 1982). This court must find 

the Commissioner’s decision conclusive “if it is supported by substantial evidence and 

the correct legal standards were applied.” Kelley v. Apfel, 185 F. 3d 1211, 1213 (11th Cir. 

1999), citing Graham v. Apfel, 129 F. 3d 1420, 1422 (11th Cir. 1997). 

 Substantial evidence is more than a scintilla — i.e., the evidence must do more 

than merely create a suspicion of the existence of a fact, and must include such relevant 

evidence as a reasonable person would accept as adequate to support the conclusion. 

Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995), citing Walden v. Schweiker, 672 

F.2d 835, 838 (11th Cir. 1982) and Richardson v. Perales, 402 U.S. 389, 401 (1971). 

 If the Commissioner’s decision is supported by substantial evidence, the district 

court will affirm, even if the court would have reached a contrary result as finder of fact, 

and even if the court finds that the evidence preponderates against the Commissioner’s 

decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991). The district court 

must view the evidence as a whole, taking into account evidence favorable as well as 

unfavorable to the decision. Foote, 67 F.3d at 1560. 

 The district court will reverse a Commissioner’s decision on plenary review if the 

decision applies incorrect law, or if the decision fails to provide the district court with 

sufficient reasoning to determine that the Commissioner properly applied the law. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 2 of 12
 3

Keeton v. Department of Health and Human Services, 21 F.3d 1064, 1066 (11th Cir. 

1994). 

II. ADMINISTRATIVE FINDINGS

 Grundy, age 49 at the time of the hearing, completed the twelfth grade.1

 Grundy’s 

past relevant work includes kitchen helper, chicken de-boner, and cashier.2

 She has not 

engaged in substantial gainful work activity since the alleged disability onset date of 

December 30, 2004.3

 Grundy’s disability application claims she is unable to work 

because of hypertension, anxiety and panic disorder, and depression.4

 Grundy testified that she stopped working in October of 2004 when she developed 

chest and back pains. A doctor attributed the pain to muscle spasms and tension, and 

prescribed muscle relaxants and pain medication.5

 At the time of the hearing, Grundy 

was no longer prescribed pain medication, but antidepressants.6

 She testified that her 

pain was continuous, estimated it at level eight on a scale of one to ten, and that she takes 

Tylenol PM, which provides slight relief.7

 Grundy stated she is able to care for herself 

and wash dishes, but does not shop or cook. She does not drive because of her pain, 

cannot walk a block, and can only stand or sit for ten to fifteen minutes.8

 Grundy 

testified that she leaned when seated to alleviate pain.9

 Grundy emphasized that she 

 

1

 R. at 431-32. 

2

 R. at 443-44. 

3

 R. at 18. Grundy’s disability application states the onset date of disability is December 24, 2004 (R. 68). 

Grundy’s hearing testimony placed the onset of disability in October, 2004 (R. 433.) 4

 R. at 73. 

5

 R. at 433-35. 

6

 R. at 435. 

7

 R. at 436-37. 

8

 R. at 438-39. 

9

 R. at 439, 442-43. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 3 of 12
 4

doesn’t like to leave her house for fear that she will have a panic attack and become 

unable to breathe, and her stress aggravates her hypertension.10 

Grundy was examined by David C. Ghostley, Psy.D., on September 2, 2005. Dr. 

Ghostley recommended psychiatric treatment based on his diagnosis of panic disorder 

with agoraphobia and major depressive disorder, mild. He estimated Grundy’s 

intellectual functioning to be in the low average range, but found her motivated and fully 

cooperative, with no discrepancies between her report and historical medical 

documents.11 

In October, 2005, state agency consultant William Simpson, Ph.D., used Grundy’s 

records to complete a Psychiatric Review Technique Form (PRTF) and Mental Residual 

Functional Capacity Assessment. The PRTF found a medically determinable impairment 

in the categories of affective and anxiety-related disorder.12 Dr. Simpson rated Grundy’s 

restriction of activities of daily living as mild, with moderate ratings in maintaining social 

functioning and maintaining concentration, persistence, or pace.13 The Mental Residual 

Functional Capacity Assessment found moderate limitations in Grundy’s abilities to 

understand/remember detailed instructions, carry out detailed instructions, maintain 

attention and concentration for extended periods, interact appropriately with the general 

public, and respond appropriately to changes in the work setting.14 The assessment 

concluded with Dr. Simpson’s opinions that Grundy can attend and concentrate for two-

 

10 R. at 441-42. 

11 R. at 289-90. 

12 R. at 274, 276. 

13 R. at 281. 

14 R. at 285-86. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 4 of 12
 5

hour periods, and a recommendation that she work in a setting which doesn’t require 

frequent contact with the general public.15 

Grundy was evaluated by Doug McKeown, Ph.D., in August of 2006. Dr. 

McKeown noted Grundy’s statement that she stopped working because of chest and back 

pain and lack of ongoing mental health-related treatment.16 Grundy reported her primary 

daily activity is watching television, that she does cook, but doesn’t clean or shop. Dr. 

McKeown found Grundy has some symptoms that are consistent with anxiety 

symptomatology that would likely improve with treatment.17

Dr. Donald Hinton, Ph.D. completed a PRTF from a review of Grundy’s records 

on September 28, 2006. Like Dr. Simpson, Dr. Hinton found medically determinable 

impairments in the categories of affective disorder and anxiety disorder.18 However, Dr. 

Hinton found only mild limitations in Grundy’s functional limitations.19 The PRTF 

concluded with a comment that Grundy is able to care for herself in addition to shopping, 

walking, and cooking. Dr. Hinton noted that Grundy does not drive because of anxiety.20

The record includes a Physical Residual Functional Capacity (RFC) Assessment 

completed by a state agency disability specialist on September 29, 2006. The RFC found 

normal results in Grundy’s chest with no limitation of motion from back pain and no 

postural limitations. She was deemed capable of occasionally lifting 50 pounds, 

frequently lifting 25 pounds, standing/walking for 6 hours in an 8-hour day, and sitting 

 

15 R. at 287. 

16 R. at 226-27. 

17 R. at 228. 

18 R. at 215, 217. 

19 R. at 222. 

20 R. at 224. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 5 of 12
 6

for 6 hours in an 8-hour day.21 Hypertension was cited as a basis for limiting Grundy’s 

exposure to extreme heat and cold.22 Finally, the clinical director of Spectra Care, Jamie 

Abshire, LPC, stated in a letter dated December 26, 2007, that Grundy was being treated 

for panic disorder with agoraphobia.23 

 Jody Skinner provided vocational expert (VE) testimony. The ALJ posed a 

hypothetical claimant to Skinner. The criteria for the hypothetical included a person with 

Grundy’s educational level who is capable of a full range of light work with mild to 

moderate postural limitations; has no manipulative limitations; must avoid hazards, 

dangerous machinery, and heights; and has mild to moderate situational depression. 

Skinner responded that such a person could perform Grundy’s past work as a cashier and 

chicken de-boner. Additionally, Skinner testified that such a person could work as an 

information clerk, usher, ticket taker, or security guard.24

 The ALJ found Gooden is severely impaired by hypertension, and her medically 

determinable mental impairments of anxiety/panic disorder and depression are nonsevere because they do not cause more than minimal limitations in her ability to perform 

basic mental work activities.25 The ALJ found Grundy’s hypertension does not meet or 

medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 

I.26 The ALJ gave no weight to the statement from Jamie C. Abshire concerning 

Grundy’s treatment at Spectra Care, but gave great weight to the consultative evaluation 

 

21 R. at 205. 

22 R. at 208. 

23 R. at 147. 

24 R. at 444. 

25 R. at 18. 

26 R. at 20. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 6 of 12
 7

from Dr. McKeown.27 The ALJ discussed his consideration of the four broad functional 

areas – daily living; social functioning; concentration, persistence and pace; and episodes 

of decompensation. The ALJ referenced Dr. McKeown’s report in discussing Grundy’s 

activities of daily living, but did not mention the conflicting conclusions of Drs. Hinton 

and Simpson in the areas of social functioning or concentration, persistence and pace. 

The decision found Grundy has no more than “mild” limitations in the first three 

functional areas.28

 The ALJ specifically stated that he gave careful consideration to the entire record 

before finding Grundy capable of the full range of medium work with the ability to 

lift/carry up to 50 pounds occasionally or 25 pounds frequently.29 This discussion 

acknowledged the role a claimant’s credibility plays in RFC assessments, as well as daily 

activities, treatment and medications. The ALJ found Grundy’s medically determinable 

impairments could reasonably be expected to produce the alleged symptoms, but that her 

statements concerning the intensity, persistence and limiting effects of the symptoms are 

not entirely credible. The ALJ found no record evidence of an orthopedic impairment or 

treatment despite Grundy’s complaints of multiple joint pain. Grundy’s use of nonprescription medication for pain relief was also noted, along with evidence that Grundy is 

noncompliant with the regimen prescribed for her hypertension.30 

 

27 R. at 18. 

28 R. at 19. 

29 R. at 20. 

30 R. at 21. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 7 of 12
 8

The ALJ found Grundy is able to perform her past work as a cashier and has not 

been under a disability from the alleged onset date through the date of decision.31 The 

finding that Grundy is able to perform past work led the ALJ to conclude she is not 

entitled to disability benefits under the Act.32

III. ISSUES

 Grundy raises two issues for judicial review: 

1. Whether substantial evidence supports the ALJ’s Step Two finding that she 

does not have a severe mental impairment; and 

2. Whether substantial evidence supports the ALJ’s Step Four RFC finding that 

did not include any mental limitations. 

IV. DISCUSSION

1. The ALJ committed reversible error at Step Two. 

 Grundy argues the ALJ did not comply with SSA regulations and policy because 

he did not adequately discuss the state agency opinions on Grundy’s mental health when 

making the required Step Two determination on whether she is severely impaired.33 The 

Commissioner responds that Grundy did not bear her burden of proving severe mental 

impairment, and that the ALJ properly resolved the conflict among the opinions. 

 Regulations at 20 C.F.R. § 404.1527(f) address an ALJ’s consideration of 

nonexamining sources. An ALJ is instructed to consider factors such as the 

psychologist’s specialty and expertise in SSA rules, supporting evidence in the record, 

 

31 R. at 21-22. 

32 R. at 22. The ALJ’s disability analysis followed the five-step sequential evaluation process set forth in 20 C.F.R. 

§404.1520 and summarized in Phillips v. Barnhart, 357 F. 3d 1232 (11th Cir. 2004). 33 The Step Two determination is whether a claimant is severely impaired. See Phillips, 357 F.3d at 1237. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 8 of 12
 9

and supporting explanations. 20 C.F.R. § 404.1527(f)(2)(ii). Specifically, this 

regulation states 

Unless the treating source’s opinion is given controlling weight, the 

administrative law judge must explain in the decision the weight given to 

the opinions of a State agency medical or psychological consultant or other 

program physician or psychologist, as the ALJ must do for any opinions 

from treating sources, nontreating sources, and other nonexamining sources 

who do not work for us. 

Id. Identical regulatory language addressing the evaluation of nonexamining opinion 

evidence in applications for SSI is found at 20 C.F.R. § 416.927(f)(2)(ii). 

Under the Court’s reading of these provisions, the ALJ’s decision to give no 

weight to the treating opinion from Specta Care should have triggered a discussion of the 

State agency opinions. The opinion from Dr. William Simpson is especially relevant to 

Grundy, as it found she has moderate limitations in her abilities to maintain social 

functioning and to maintain concentration, persistence and pace.34 These findings led Dr. 

Simpson to write that Grundy “would benefit from work which doesn’t require frequent 

contact with the general public.”35 The record shows that Dr. Donald Hinton’s 

conclusions differed from Dr. Simpson’s in that his report had only mild limitations in 

these areas.36 Although Dr. Hinton’s findings are consistent with the ALJ’s ultimate 

findings as to Grundy’s capacity for work, the ALJ did not indicate why one opinion was 

deemed more reliable than the other. Thus, he did not meet a regulatory obligation to 

address record evidence and explain why the State agency opinions were adopted or 

rejected, either in whole or in part. 

 

34 R. at 281. 

35 R. at 281. 

36 R. at 222. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 9 of 12
 10

 The Commissioner argues the ALJ considered the entire record and properly 

resolved the conflicting evidence in the record. His brief details the differences between 

Dr. Simpson’s 2005 opinion that Grundy has moderate functional limitations in two areas 

of social functioning, and Dr. Hinton’s later, 2006 opinion, which found only mild 

functional limitations.37 Although the ALJ explicitly stated that he considered the entire 

record, he did not discuss his resolution of the conflicting findings, or the weights he 

gave the opinions from Drs. Simpson and Hinton. The ALJ found Grundy can return to 

her past work as a cashier, an occupation which requires frequent contact with the general 

public.38 This finding poses a clear conflict with Dr. Simpson’s recommendation that 

Grundy avoid contact with the general public. The Court assumes Dr. Simpson’s 

findings were discounted by the ALJ, but the decision does not explain why, and the 

Court “may not supply a reasoned basis for [an] agency’s action that the agency itself has 

not given.” Dixon v. Astrue, 312 Fed.Appx 226, 229 (11th Cir. 2009), quoting Zahnd v. 

Sec’y, Dep’t of Agric., 479 F.3d 767, 773 (11th Cir. 2007). The treatment of Dr. 

Simpson’s opinion has a direct bearing on the ALJ’s ultimate conclusion that Grundy can 

work as a cashier and frequently interact with the general public. The record does not 

show the ALJ’s reasoning on this issue, and the Court cannot accept the Commissioner’s 

explanation of the ALJ’s logic. 

The Commissioner’s brief also submits strong argument for the proposition that 

the ALJ is not required to discuss every piece of evidence in the record.39 Though this 

 

37 Def. Br. at 7. 

38 R. at 21. 

39 Def. Br. at 8. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 10 of 12
 11

principle has a long history in this District and Circuit, a review of the cases cited leaves 

the Court with the belief that the omission of State agency opinions are not included in 

the types of evidence which were not discussed by ALJs, but nonetheless upheld in the 

appeal process. In Dyer v. Barnhart, 395 F.3d 1206 (11th Cir.), the Eleventh Circuit 

upheld an ALJ’s decision which omitted discussion of the plaintiff’s pain prescription for 

Lortab because it was prescribed on a single occasion for pain unrelated to the application 

for disability. Dyer, 395 F.3d at 1211. Similarly, in McCray v. Massanari, 175 F.Supp. 

1329 (M.D. Ala. 2001), this Court dismissed the plaintiff’s argument that the ALJ did not 

discuss his complaints of chronic back pain when the record contained passing reference 

to “a potential disc problem” without additional documentation, and plaintiff “did not 

indicate at the hearing that his claims of disability were premised on back pain or that he 

had functional limitations therefrom.” McCray, 175 F.Supp. at 1336. 

The most recent case cited by the Commissioner is also distinguishable from the 

ALJ’s treatment of record evidence in Grundy’s case. In Kemp v. Astrue, 308 Fed.Appx. 

423 (11th Cir. 2009), the Eleventh Circuit upheld an ALJ’s failure to specifically state his 

decision to give great weight to disability ratings issued by the Veteran’s Administration 

(VA). Citing Hutchinson v. Bowen, 787 F.2d 1461 (11th Cir. 1986), Kemp reiterated an 

ALJ’s power to make implicit findings. However, Kemp also emphasized the fact that 

the ALJ “continuously” referred to the “VA’s evaluations and disability rating throughout 

the evaluation process.” The full incorporation of the very evidence that was not 

specifically weighed by the ALJ therefore provided a firm basis to uphold the ALJ’s 

implicit findings on appeal. 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 11 of 12
 12

As stated in Dyer, this Court must “review the agency’s decision for substantial 

evidence” and it “may not decide facts anew, reweigh the evidence, or substitute [its] 

judgment for that of the Commissioner.” Dyer, 395 F.3d at 1210, citing Foote v. Chater, 

67 F.3d 1553, 1558 (11th Cir. 1995); Phillips, 357 F.3d at 1240 n.8. The Court 

emphasizes that the record in this case may well contain substantial evidence for the 

ALJ’s decision regarding Grundy’s application for disability and SSI benefits. However, 

because the Commissioner’s regulations set forth an evaluation process which becomes 

critical when the treating opinion is rejected, remand is required due to the ALJ’s failure 

to include a complete analysis as dictated by regulations. 

V. CONCLUSION 

 Pursuant to the findings and conclusions detailed in this Memorandum Opinion, 

the court concludes that the case should be remanded for compliance with applicable 

regulations. It is, therefore, ORDERED that the decision of the Commissioner is

REVERSED AND REMANDED. A separate judgment is entered herewith. 

 DONE this 2nd day of March, 2010. 

 /s/ Terry F. Moorer 

 TERRY F. MOORER 

 UNITED STATES MAGISTRATE JUDGE 

Case 1:08-cv-00899-TFM Document 24 Filed 03/02/10 Page 12 of 12