Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-2_06-cv-00147/USCOURTS-alsd-2_06-cv-00147-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Steven Lucy
Plaintiff

Document Text:

1 Linda S. McMahon became the Acting Commissioner of Social Security on

January 20, 2007. Accordingly, pursuant to Rule 25(d)(1) of the Federal Rules of Civil

Procedure, McMahon is substituted for Jo Anne B. Barnhart as the proper defendant in this case.

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

NORTHERN DIVISION

STEVEN LUCY, :

Plaintiff, :

vs. : CA 06-0147-C

LINDA S. MCMAHON, :

Acting Commissioner of Social 

Security,1 :

Defendant.

MEMORANDUM OPINION AND ORDER

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

judicial review of a final decision of the Commissioner of Social Security

terminating his entitlement to disability insurance benefits as of August, 2003.

The parties have consented to the exercise of jurisdiction by the Magistrate

Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc.

21 (“In accordance with provisions of 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73,

the parties in this case consent to have a United States magistrate judge

conduct any and all proceedings in this case . . . and order the entry of a final

Case 2:06-cv-00147-C Document 23 Filed 02/06/07 Page 1 of 13
2 The Court granted the defendant’s unopposed motion to submit her position in the

case on the record. (Docs. 19 & 20)

3 Any appeal taken from this memorandum opinion and order and judgment shall

be made to the Eleventh Circuit Court of Appeals. (Doc. 21 (“An appeal from a judgment

entered by a magistrate judge shall be taken directly to the United States court of appeals for this

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

2

judgment, and conduct all post-judgment proceedings.”); see also Doc. 22

(order of reference)) Upon consideration of the administrative record,

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

report and recommendation, and the arguments of plaintiff’s counsel at the

January 26, 2007 hearing before the Court,2

 it is determined that the

Commissioner's decision terminating benefits should be reversed and

remanded for further proceedings not inconsistent with this decision.3

Plaintiff alleges continuing disability due to a history of renal failure,

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

following relevant findings:

1. The claimant is not engaging in substantial gainful

activity.

2. The claimant has experienced medical improvement since

the most recent favorable disability determination.

3. The claimant’s medical improvement is related to his

ability to work.

4. No exception to medical improvement is applicable in

Case 2:06-cv-00147-C Document 23 Filed 02/06/07 Page 2 of 13
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this matter.

5. The claimant has “severe” impairments, including back

problems with pain, and status post chronic renal failure.

6. The claimant’s impairments, considered individually and

in combination, do not meet or equal in severity any impairment

set forth at 20 C.F.R. Part 404, Subpart P, Appendix 1.

7. The claimant’s allegations of pain and functional

limitations are not credible.

8. The claimant retains the . . . following residual functional

capacity: no limitations with standing, walking, sitting, lifting

and carrying without restrictions; no postural, manipulative or

environmental limitations.

9. The claimant can perform past relevant work.

10. The claimant is not disabled within the meaning of the

Social Security Act.

(Tr. 24-25) The Appeals Council affirmed the ALJ's decision (Tr. 5-7) and

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

Social Security.

DISCUSSION

The standard for termination of benefits in this circuit has long been

established. See McAulay v. Heckler, 749 F.2d 1500 (11th Cir. 1985).

This court has held that there can be no termination of

benefits unless there is substantial evidence of improvement to

the point of no disability. Simpson v. Schweiker, 691 F.2d 966,

969 (11th Cir. 1982). Additionally, this court has held that a

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4 As part of this issue, plaintiff challenges the ALJ’s conclusion that he does not

have a severe mental impairment. 

4

comparison of the original medical evidence and the new

medical evidence is necessary to make a finding of

improvement. Vaughn v. Heckler, 727 F.2d 1040, 1043 (11th

Cir. 1984).

Id. Plaintiff contends that the following errors were made in this case: (1) the

ALJ erred in rejecting the opinions of two examining mental health

professionals, same being consistent with plaintiff’s testimony and

uncontroverted by any other evidence of record; (2) the ALJ erred in failing

to adopt the functional limitations indicated by the medical expert who

testified at the hearing, despite claiming to give substantial weight to that

doctor’s opinion regarding functional abilities; and (3) the ALJ and Appeals

Council erred in failing to consider the opinion of the treating physician

regarding the level of pain plaintiff experiences. Because the Court finds that

the ALJ erred in rejecting the opinions of the two examining mental health

professionals,4

 this Court does not address the other assignments of error raised

by the plaintiff. See Pendley v. Heckler, 767 F.2d 1561, 1563 (11th Cir. 1985)

(“Because the ‘misuse of the expert’s testimony alone warrants a reversal,’ we

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

In a Report of Contact dated March 17, 2004, Lucy complained to a

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5 In a form completed by plaintiff on January 19, 2005, he alleged nerve problems

and difficulty sleeping. (Tr. 147)

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disability specialist with the Social Security Administration that he was having

sleep problems due to nervousness. (Tr. 134) On January 6, 2005, Lucy

complained to his treating physician, Dr. Wallace Purdy, that he had been

depressed for a long time; Purdy’s diagnoses include a diagnosis of depression

and contains the notation “Appointment with psychiatry.” (Tr. 226)5

 Dr.

Purdy’s partner, Dr. Reid Christopher, noted, on July 15, 2005, that plaintiff

had a history of depression. (Tr. 234)

In light of the foregoing evidence, Lucy’s attorney referred his client to

Dr. Donald W. Blanton and Dr. David Hodo for evaluations in August of

2005. (Tr. 205-213) Dr. Blanton performed a mental status examination on

August 3, 2005, and as well administered a battery of tests. (Tr. 210-211)

Blanton’s diagnostic impressions included: (1) post traumatic stress disorder

with anxiety and depression; (2) major depression due to bronchitis and

chronic pain; and (3) borderline intelligence. (Tr. 211) Blanton completed a

mental medical source opinion form and thereon indicated that Lucy had a

“marked” degree of limitation with respect to the following activities: (1)

understanding detailed or complex instructions; (2) carrying out detailed or

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complex instructions; (3) remembering detailed or complex instructions; (4)

using judgment in detailed or complex work-related decisions; and (5)

maintaining attention, concentration or pace for periods of at least two hours.

(Tr. 212) Blanton indicated on this form that the noted limitations had lasted

for 12 continuous months and that, in fact, the same level of severity had

existed for four years. (Tr. 213) 

Following a mental status examination of Lucy on August 24, 2005, Dr.

Hodo made the following diagnoses: (1) post traumatic stress disorder; (2)

major depression, rule out delusional disorder; and (3) borderline mental

retardation. (Tr. 206) Hodo noted marked or extreme limitations in all areas

rated on the mental medical source form, save for the areas of activities of

daily living and deterioration of personal habits (Tr. 207-208), and indicated

that those limitations had lasted for 12 months or longer (id. at 208).

At the administrative hearing on September 28, 2005, plaintiff testified

that he had nightmares which prevented him from sleeping (Tr. 245), the

subject of same being “[s]ometimes dead folks, sometimes killing.” (Tr. 247)

He also complained of seeing things (id.): “Like when I drive up, I see

something big in the road. But when I get to it, it won’t be nothing there.” (Tr.

248)

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This was the entirety of the evidence regarding plaintiff’s mental status

before the ALJ for review. In determining that plaintiff did not have a severe

mental impairment, the ALJ performed the following analysis:

I have next considered all of the claimant’s current impairments

to determine whether he has a medically determinable

impairment or combination of impairments that is severe, i.e.,

one that more than minimally impacts functioning. . . .

I find that the claimant did not allege any mental impairments

from the time he filed for disability nor did he claim any mental

impairments from December 2000 through his consultative

evaluation with Dr. Lindman in January 2004. I find his

testimony at the Disability Hearing Officer’s hearing on January

2004, reflects he stated that he continued to be disabled due to

renal failure, history of rhabdomyolsis, back pain, bronchitis and

numbness of his legs and feet. He stated he was unable to work

due to chronic back pain; however, he did not mention

depression and only stated that he was unable to handle stress

and became angry when stressed. On January 11, 2005, the

claimant’s representative submitted the claimant’s Request for

Hearing. The claimant presented for an evaluation on August 24,

2005, at the request of the claimant’s representative, before Dr.

David Hodo, psychiatrist, who found the claimant had post

dramatic (traumatic) stress disorder, major depression, rule out

delusional disorder and borderline mental retardation. Dr. Hodo

found that the claimant had “marked” and “extreme” limitations

in his ability to function. On August 3, 2005, the claimant

attended an evaluation by Dr. Donald Blanton, PhD., at the

request of his representative, in which Dr. Blanton diagnosed

post traumatic stress disorder with anxiety and depression and

major depression due to bronchitis and chronic pain. No weight

is given to the evaluations or Dr. Hodo or Dr. Blanton. There are

no other treatment records that support the opinions of these two

evaluations that were made at the request of the claimant’s

representative. The claimant has not attended mental health and

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has not made claims of mental problems to his treating and

consultative physicians before the dates set out above. I do not

find that the claimant’s mental impairments including post

traumatic stress disorder with anxiety and depression and major

depression are severe impairments. Even if I were to give

plaintiff the benefit of the doubt, there is no supporting evidence

(outside of the two evaluations requested by his representative);

his claims of mental problems with severe limitations have not

met the duration requirements, and there is no record of

treatment for such.

(Tr. 22) 

The Court finds the ALJ’s analysis of both the severity issue and the

weight to be accorded the evaluations of Drs. Blanton and Hodo is flawed.

Taking the consultative evaluation/examination issue first, the Commissioner’s

regulations make clear that every medical opinion received is evaluated and

that “more weight [is given] to the opinion of a source who has examined” the

claimant. 20 C.F.R. § 404.1527(d)(1) (2006). 

(3) Supportability. The more a medical source presents

relevant evidence to support an opinion, particularly medical

signs and laboratory findings, the more weight we will give that

opinion. The better an explanation a source provides for an

opinion, the more weight we will give that opinion.

Furthermore, because nonexamining sources have no examining

or treating relationship with you, the weight we will give their

opinions will depend on the degree to which they provide

supporting explanations for their opinions. We will evaluate the

degree to which these opinions consider all of the pertinent

evidence in your claim, including opinions of treating and other

examining sources.

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(4) Consistency. Generally, the more consistent an

opinion is with the record as a whole, the more weight we will

give to that opinion.

(5) Specialization. We generally give more weight to the

opinion of a specialist about medical issues related to his or her

area of specialty than to the opinion of a source who is not a

specialist.

(6) Other factors. When we consider how much weight

to give to a medical opinion, we will also consider any factors

you or others bring to our attention, or of which we are aware,

which tend to support or contradict the opinion. For example,

the amount of understanding of our disability programs and their

evidentiary requirements that an acceptable medical source has,

regardless of the source of that understanding, and the extent to

which an acceptable medical source is familiar with the other

information in your case record are relevant factors that we will

consider in deciding the weight to give to a medical opinion.

Id. The Eleventh Circuit has underscored the consistency principle, holding

that “the ALJ may reject the opinion of any physician when the evidence

supports a contrary conclusion.” Harwell v. Heckler, 735 F.2d 1292, 1293

(11th Cir. 1984); see also Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir.

1981) (“[A]lthough the opinion of an examining physician is generally entitled

to more weight than the opinion of a non-examining physician, the ALJ is free

to reject the opinion of any physician when the evidence supports a contrary

conclusion.”); cf. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)

(“We have found ‘good cause’ to exist where the doctor’s opinion was not

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6 The ALJ seems to stress the fact that plaintiff’s attorney referred him to Drs.

Blanton and Hodo; such referrals suggest nothing suspect to this Court.

10

bolstered by the evidence, or where the evidence supported a contrary finding.

. . . We have also found good cause where the doctors’ opinions were

conclusory or inconsistent with their own medical records.”). The problem in

this case is that the ALJ failed to analyze the mental evaluations performed by

Drs. Blanton and Hodo in the manner prescribed by the Commissioner’s own

regulations, 20 C.F.R. § 404.1527; this failure constitutes an improper

application of legal standards, see King v. Barnhart, 320 F.Supp.2d 1227, 1233

(N.D. Ala. 2004) (ALJ’s failure to follow the standards for evaluating opinion

evidence set out in 20 C.F.R. § 404.1527 constituted an improper application

of a legal standard).

Moreover, the reasons the ALJ gives for not giving these evaluations

any weight amount to nothing more than the ALJ’s substitution of his own

impressions for those of the medical professionals. The suggestion that

plaintiff made no complaints of mental problems to treating or consulting

physicians before August of 2005 is belied by the evidence of record; plaintiff

complained of depression to his treating physician, Dr. Prudy, on January 6,

2005 (Doc. 226) and Purdy’s partner, Dr. Christopher, noted plaintiff’s history

of depression on July 15, 2005 (Tr. 234).6

 In addition, the fact that there are no

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7 The evaluations of these two mental health professionals clearly establish that the

limitations imposed by plaintiff’s mental impairments meet the durational requirement. (Tr. 205-

213)

11

mental health treatment records to support the mental evaluations of Drs.

Blanton and Hodo does nothing to help the Commissioner because the crucial

fact here is that no medical evidence of record contradicts the diagnoses and

findings of these two evaluators; therefore, it was inappropriate for the ALJ to

give no weight to the evaluations. See Bennett v. Barnhart, 288 F.Supp.2d

1246, 1255 (N.D. Ala. 2003) (“There is no medical evidence of record

contradicting the findings of Drs. Bray and Blotcky. The ALJ merely refused

to credit their opinions based upon his own diagnostic impression. This is

impermissible.”).

The evaluations of Drs. Blanton and Hodo establish that Lucy suffers

from a severe mental impairment (if not several severe mental impairments)

which has lasted twelve continuous months.7 Compare id. at 207-208 & 212-

213 with 20 C.F.R. § 404.1521(a) & (b) (“An impairment or combination of

impairments is not severe if it does not significantly limit your physical or

mental ability to do basic work skills. . . . When we talk about basic work

activities, we mean the abilities and aptitudes necessary to do most jobs.

Examples of these include– . . . (3) Understanding, carrying out, and

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8 The ALJ failed to evaluate the severity of Lucy’s mental impairments as required

in the regulations and by Eleventh Circuit precedent. In Moore v. Barnhart, 405 F.3d 1208 (11th

Cir. 2005), the Eleventh Circuit held that “where a claimant has presented a colorable claim of

mental impairment, the social security regulations require the ALJ to complete a PRTF, append

it to the decision, or incorporate its mode of analysis into his findings and conclusions[,]” and

that the “[f]ailure to do so requires remand.” Id. at 1214 (citations omitted). The Commissioner’s

regulations specifically provide that the PRTF or functional analysis contained therein must be

completed before an ALJ makes the determination about whether a mental impairment is severe

or not severe. 20 C.F.R. § 404.1520a(d)(1) & (2) (2006) (“After we rate the degree of functional

limitation resulting from your impairment(s), we will determine the severity of your mental

impairment(s). (1) If we rate the degree of your limitation in the first three functional areas

[activities of daily living; social functioning; and concentration, persistence, or pace] as ‘none’

or ‘mild’ and ‘none’ in the fourth area [episodes of decompensation], we will generally conclude

that your impairment(s) is not severe, unless the evidence otherwise indicates that there is more

than a minimal limitation in your ability to do basic work activities . . . . (2) If your mental

impairment(s) is severe, we will then determine if it meets or is equivalent in severity to a listed

mental disorder.”). The ALJ’s failure in this case to incorporate the PRTF mode of analysis into

his decision represents yet another reason to remand this case to the Commissioner of Social

Security for further proceedings.

12

remembering simple instructions; (4) Use of judgment; (5) Responding

appropriately to supervision, co-workers and usual work situations; and (6)

Dealing with changes in a routine work setting.”) and McDaniel v. Bowen, 800

F.2d 1026, 1031 (11th Cir. 1986) (“Step two is a threshold inquiry. It allows

only claims based on the most trivial impairments to be rejected.”).8

CONCLUSION

In consideration of the foregoing, the Court ORDERS that the decision

of the Commissioner of Social Security denying plaintiff benefits be reversed

and remanded pursuant to sentence four of § 405(g), see Melkonyan v.

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Sullivan, 501 U.S. 89, 111 S.Ct. 2157, 115 L.Ed.2d 78 (1991), for further

proceedings not inconsistent with this decision. The remand pursuant to

sentence four of § 405(g) makes the plaintiff a prevailing party for purposes

of the Equal Access to Justice Act, 28 U.S.C. § 2412, Shalala v. Schaefer, 509

U.S. 292, 113 S.Ct. 2625, 125 L.Ed.2d 239 (1993), and terminates this Court’s

jurisdiction over this matter.

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

s/WILLIAM E. CASSADY 

 UNITED STATES MAGISTRATE JUDGE

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