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Case No.: 1:20cv22/EMT

UNITED STATES DISTRICT COURT FOR THE

NORTHERN DISTRICT OF FLORIDA

GAINESVILLE DIVISION

TORRI A. BRACKINS,

Plaintiff,

vs. Case No.: 1:20cv22/EMT

ANDREW SAUL, 

Commissioner of Social Security,

Defendant.

____________________________/

MEMORANDUM DECISION AND ORDER

This case has been referred to the undersigned magistrate judge for disposition 

pursuant to the authority of 28 U.S.C. § 636(c) and Fed. R. Civ. P. 73, based on the 

parties’ consent to magistrate judge jurisdiction (see ECF Nos. 4, 8). It is now 

before the court pursuant to 42 U.S.C. § 405(g) of the Social Security Act (Act) for 

review of a final determination of the Commissioner of the Social Security 

Administration (Commissioner) denying Plaintiff’s applications for disability 

insurance benefits (DIB) under Title II of the Act, 42 U.S.C. §§ 401–34, and 

supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381–

83.1

 Upon review of the record before the court, I find the Administrative Law 

1As the Eleventh Circuit recently recognized, “because the Commissioner has delegated his 

authority to make the finding at the hearing level to an administrative law judge, the finding is 

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Judge (ALJ) erred with respect to the hypothetical questions posed to the vocational 

expert and that the ALJ’s decision therefore should be reversed and the matter 

remanded for further proceedings consistent with this Memorandum Decision and 

Order. 

ISSUES ON REVIEW

Plaintiff raises two issues on appeal, arguing the ALJ erred in (1) assigning

no functional mental limitations despite finding mild mental impairments and failing 

to incorporate functional mental limitations in a hypothetical question posed to the 

vocational expert; and (2) giving little weight to the opinions of treating physician 

John Charles Stevenson, M.D. (ECF No. 13 at 1, 33–34).

PROCEDURAL HISTORY

On June 23, 2016, Plaintiff filed applications for DIB and SSI, alleging 

disability beginning June 8, 2016 (tr. 223–31). 2 The applications were denied 

initially and on reconsideration (tr. 77–150, 153–69). Plaintiff appeared for a 

effectively reserved to the administrative law judge.” Walker v. Soc. Sec. Admin., Comm’r, No. 

19-15039, 2021 WL 503280, at *3 (11th Cir. Feb. 11, 2021).

2 The administrative record, as filed by the Commissioner, consists of thirty-three volumes (ECF 

Nos. 10–1 through 10–33) and has 1977 consecutively numbered pages. References to the record 

will be by “tr.,” for transcript, followed by the page number. The page numbers refer to those 

found on the lower right-hand corner of each page of the transcript, as opposed to those assigned 

by the court’s electronic docketing system or any other page numbers that may appear.

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hearing before an ALJ on January 22, 2019 (id. at 37–76). On February 4, 2019, 

the ALJ issued a decision finding Plaintiff not disabled under the Act (id. at 12–28). 

Plaintiff petitioned the Appeals Council for review of the ALJ’s decision (id. at 1, 

219–21). The Appeals Council denied the request (id. at 1–5). The ALJ’s decision 

thus became the final determination of the Commissioner. That determination is 

now ripe for review in this court. 

FINDINGS OF THE ALJ

The ALJ made the following findings in his written decision (see id. at 12–

36): 

• Plaintiff meets the insured status requirements of the Act through December 

31, 2021 (id. at 17).

• Plaintiff has not engaged in substantial gainful activity since June 8, 2016, the

alleged onset date (id.).

• Plaintiff has the following severe impairments: disorders of the spine and 

fracture of the left arm (id.). 

• Plaintiff does not have an impairment or combination of impairments that 

meets or medically equals the severity of one of the listed impairments in 20 

C.F.R. Part 404, Subpart P, Appendix 1 (id. at 20).

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• Plaintiff has the residual functional capacity (RFC) to perform light work as 

defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), except she can 

occasionally lift/carry up to twenty pounds and frequently lift ten pounds; 

stand and/or walk and sit for six hours in an eight-hour workday with normal 

breaks; frequently push/pull with the left arm; frequently climb ramps/stairs, 

ladders, ropes, and scaffolds; frequently stoop; balance, kneel, crouch, crawl, 

and reach overhead in all directions without limitation; and frequently handle

on the left and engage in frequent gross manipulation with the left hand. She 

needs to avoid concentrated exposure to extreme cold; vibrations; and 

hazards, including machinery and heights (id.).

• Plaintiff is unable to perform any past relevant work (id. at 26).

• Plaintiff has acquired skills from past relevant work (id.).

• Considering Plaintiff’s age, education, work experience, and RFC, the skills 

Plaintiff has acquired from past relevant work are transferrable to other 

occupations with jobs existing in significant numbers in the national economy 

(id.). 

• Plaintiff has not been under a disability, as defined in the Act, from June 8, 

2016, through February 4, 2019, the date of the decision (id. at 27).

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STANDARD OF REVIEW

A federal court reviews the “Commissioner’s decision to determine if it is 

supported by substantial evidence and based upon proper legal standards.” Lewis 

v. Callahan, 125 F.3d 1436, 1439 (11th Cir. 1997); see also Carnes v. Sullivan, 936 

F.2d 1215, 1218 (11th Cir. 1991) (“[T]his Court may reverse the decision of the 

[Commissioner] only when convinced that it is not supported by substantial evidence 

or that proper legal standards were not applied.”). Substantial evidence is “‘such 

relevant evidence as a reasonable mind might accept as adequate to support a 

conclusion.’” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. 

Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). “Substantial evidence is 

something ‘more than a mere scintilla, but less than a preponderance.’” Dyer v. 

Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005) (quoting Hale v. Bowen, 831 F.2d 

1007, 1011 (11th Cir. 1987)). Even if the evidence preponderates against the 

Commissioner’s decision, the decision must be affirmed if supported by substantial 

evidence. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir. 1986).

When reviewing a Social Security disability case, the court “‘may not decide 

the facts anew, reweigh the evidence, or substitute [its] judgment for that of the 

[Commissioner.]’” Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990) 

(quoting Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)); see also 

Hunter v. Soc. Sec. Admin., Comm’r, 808 F.3d 818, 822 (11th Cir. 2015) (“In 

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determining whether substantial evidence supports a decision, we give great 

deference to the ALJ’s factfindings.”) (citing Black Diamond Coal Min. Co. v. Dir., 

OWCP, 95 F.3d 1079, 1082 (11th Cir. 1996)). A reviewing court also may not look 

“only to those parts of the record which support the ALJ” but, instead, “must view 

the entire record and take account of evidence in the record which detracts from the 

evidence relied on by the ALJ.” Tieniber v. Heckler, 720 F.2d 1251, 1253 (11th 

Cir. 1983). Review is deferential to a point, but the reviewing court conducts what 

has been referred to as “an independent review of the record.” Flynn v. Heckler, 

768 F.2d 1273 (11th Cir. 1985).3

The Act defines disability as an “inability to engage in any substantial gainful 

activity by reason of any medically determinable physical or mental impairment 

which can be expected to result in death, or which has lasted or can be expected to 

last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). 

To qualify as a disability, the physical or mental impairment must be so severe that 

the plaintiff not only is unable to do her previous work “but cannot, considering [her]

age, education, and work experience, engage in any other kind of substantial gainful 

work which exists in the national economy[.]” 42 U.S.C. § 423(d)(2)(A). An 

3 The Eleventh Circuit not only speaks of an independent review of the administrative record, but 

it also reminds us that it conducts a de novo review of the district court’s decision on whether 

substantial evidence supports the ALJ’s decision. See Ingram v. Comm’r of Soc. Sec. Admin., 496 

F.3d 1253, 1260 (11th Cir. 2007); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002).

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individual claiming Social Security disability benefits must prove she is disabled. 

Adams v. Comm’r, Soc. Sec. Admin., 586 F. App’x 531, 533 (11th Cir. 2014). She 

also must prove she became disabled prior to the expiration of the date last insured

in order to obtain DIB. See 42 U.S.C. §§ 416(i)(3), 423(a) and (c); 20 C.F.R. 

§§ 404.101, 404.130, 404.131; see also Moore v. Barnhart, 405 F.3d 1208, 1211 

(11th Cir. 2005). 

Pursuant to 20 C.F.R. § 404.1520(a)(4), the Commissioner analyzes a 

disability claim in five steps. 4 “Throughout the process, the burden is on the 

claimant to introduce evidence in support of her application for benefits.” Adams, 

586 F. App’x at 533. The five steps are as follows: 

1. If the claimant is performing substantial gainful activity, she is not 

disabled.

2. If the claimant is not performing substantial gainful activity, her

impairments must be severe before she can be found disabled.

3. If the claimant is not performing substantial gainful activity and she has 

severe impairments that have lasted or are expected to last for a continuous period 

of at least twelve months, and if her impairments meet or medically equal the criteria 

4 In general, the legal standards applied are the same whether a claimant seeks DIB or SSI, but 

separate, parallel statutes and regulations exist for DIB and SSI claims (see 20 C.F.R. §§ 404, 

416). Therefore, citations in this Memorandum Decision and Order should be considered to 

incorporate the appropriate parallel provisions. The same applies to citations of statutes or 

regulations found in quoted court decisions.

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of any impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, the claimant 

is presumed disabled without further inquiry.

4. If the claimant’s impairments do not prevent her from performing past 

relevant work, she is not disabled.5

5. Even if the claimant’s impairments prevent her from performing past 

relevant work, if other work exists in significant numbers in the national economy 

that accommodates the claimant’s RFC and vocational factors, she is not disabled.6

At step five (or step four in cases in which the ALJ decides a claimant can 

perform past work), the ALJ formulates RFC through interpretation of the medical 

evidence and the claimant’s subjective complaints, based on the impairments 

identified at step two. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). 

“[R]esidual functional capacity is the most [a claimant] can still do despite [the 

claimant’s] limitations. 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). The ALJ 

relies on RFC to make the ultimate vocational determination required by step five.

5 As set forth above, the claimant bears the burden of establishing a severe impairment that keeps 

her from performing past relevant work. 20 C.F.R. § 404.1512; Chester v. Bowen, 792 F.2d 129, 

131 (11th Cir. 1986). 

6 If the claimant meets her burden at step four, the burden shifts to the Commissioner at step five 

to show the existence of other jobs in the national economy which, given the claimant=s 

impairments, the claimant can perform. MacGregor v. Bowen, 786 F.2d 1050, 1052 (11th Cir. 

1986). 

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FACT BACKGROUND

Plaintiff was 54 years old on the alleged onset date (tr. 77, 91). She has a 

high school education and work experience as a criminal justice technician and field 

service technician for a sheriff’s office (id. at 40–42, 287–88). Plaintiff alleges

disability due to neck, back, hand, and wrist impairments, as well as depression and 

anxiety (id. at 77–78, 91–92). 

Plaintiff testified at the hearing as to her impairments and the alleged effects 

thereof. Plaintiff explained she had four surgeries on her neck and two fusions of 

her lumbar spine (id. at 59–60). She said she needed additional imaging of her neck

but was unable to afford it (id. at 60–61). She also said Dr. Stevenson wanted to 

give additional injections for pain and that if that did not work, he would “probably 

have to go in and take care of some more discs” (id. at 61). Plaintiff said her left 

arm was fractured (id. at 46–47). She also said she had severe depression and 

anxiety and suffered from panic attacks (id. at 48). 

Plaintiff testified she could sit for about fifteen minutes and stand for 

approximately ten minutes at a time (id. at 49). She could walk “real slow” for 

about half an hour and used a walker when she had a pinched nerve (id. at 49–50). 

She said her biggest problem was her neck (id. at 50). 

Plaintiff said she could lift approximately six pounds (id.). She also said she

could pick up a gallon of milk but had to use two hands (id. at 50–51). She could 

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climb approximately five steps before getting dizzy and cramping up with pain down 

her buttocks (id.). She said she was unable to reach up to get something off a high 

shelf (id. at 52). Plaintiff testified her left hand was weaker than her right and that 

she wore a brace on her right hand, which was going to require surgery (id. at 54). 

She could use her fingers to pick up small objects but was “not accurate” (id. at 54–

55). She could not squat or stoop due to pain in her lower back (id. at 55).

When asked about her daily activities, Plaintiff said she dressed and bathed

herself (id.). She cooked, washed dishes, did laundry, and cleaned, although 

vacuuming was “a little difficult” (id.). She explained she had to vacuum for ten 

minutes at a time and then rest for about half an hour before resuming (id. at 55–56). 

She could drive but did not use the computer or read because she could not keep her 

head down without her arms going numb (id. at 56–58). She said she watched

television all day—from eleven o’clock in the morning until two o’clock the 

following morning—and did not attend church because she could not sit in the pews 

for any length of time (id. at 57–58). 

A vocational expert, Jackson C. McKay, also testified at the hearing (id. at 38, 

66–75). Mr. McKay classified Plaintiff’s past work as that of a sheriff’s deputy, 

explaining that even though “she wasn’t making arrests, . . . she was observing and 

assisting the public” (id. at 67). Mr. McKay testified Plaintiff performed the 

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position at the heavy exertional level (id. at 67–68). Mr. McKay also testified 

Plaintiff would have acquired transferable skills through her position as a sheriff’s 

deputy, including “knowledge of the criminal justice system, specific knowledge of 

emergency radio communications, and recordkeeping,” which would transfer to the 

job of emergency dispatcher (id. at 70–71). According to Mr. McKay, a person of 

Plaintiff’s age, education, and work experience, with the RFC the ALJ assigned,

could perform the job of emergency dispatcher (id. at 72–73). If the individual 

required breaks throughout the day such that she was off task for twenty percent or 

more of the workday, however, she could not perform that or any other position, as 

all work would be eliminated (id. at 73). The same would be true if the individual 

was absent four or more times per month or limited to the performance of simple 

and routine tasks (id. at 74–75). 

DISCUSSION

I. Mental Limitations 

As indicated above, Plaintiff argues the ALJ erred in failing to include mental 

limitations in the RFC and in a hypothetical question posed to the vocational expert. 

The Eleventh Circuit has held that “where a claimant has presented a colorable claim 

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

PRTF [Psychiatric Review Technique Form] and append it to the decision, or 

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incorporate its mode into his findings and conclusions.” Moore, 405 F.3d at 1214; 

see Mills v. Comm’r of Soc. Sec., 659 F. Appx 541, 542–43 (11th Cir. 2016) (citing 

Moore). This technique requires rating the claimant’s degree of functional 

limitation in four broad areas—ability to understand, remember, or apply 

information; ability to interact with others; ability to concentrate, persist, or maintain 

pace; and ability to adapt or manage oneself. 20 C.F.R §§ 404.1520a(c)(3) and 

416.920a(c)(3); see Moore, 405 F.3d at 1213–14. These functional areas can be 

rated none, mild, moderate, marked, or extreme. 20 C.F.R §§ 404.1520a(c)(4); 

416.920(c)(4). If the ALJ finds a mental limitation, even if non-severe, the ALJ 

must consider the limitation when determining RFC and document the findings and 

conclusions in that regard in the written decision. 20 C.F.R. §§ 404.1520a(d)(3), 

416.920a(d)(3), 404.1520a(e)(4), 416.920a(e)(4). The ALJ also must incorporate 

the limitation into a hypothetical question posed to the vocational expert. Winschel 

v. Comm’r Soc. Sec., 631 F.3d 1176, 1180–81 (11th Cir. 2011); 20 C.F.R. 

§§ 404.1523, 416.923, 404.1545(a)(2), 416.945(a)(2) (requiring adjudicators to 

consider the functional effects of even non-severe impairments when formulating 

RFC); SSR 96-8p, 1996 WL 374184, at *5 (“In assessing RFC, the adjudicator must 

consider limitations and restrictions imposed by all of an individual’s impairments, 

even those that are not ‘severe.’”). Only if the limitation is included can the 

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vocational expert’s testimony constitute substantial evidence in support of the ALJ’s 

decision. Winschel, 631 F.3d at 1180–81; Lanier v. Comm’r. of Soc. Sec., 252 F.

App’x 311, 315 (11th Cir. 2007) (“In order for a [vocational expert’s] testimony to 

constitute substantial evidence, the ALJ must pose a hypothetical question which 

comprises all of the claimant’s impairments[,] . . . [b]ut the hypothetical need only 

include limitations supported by the record.”). Failure to incorporate the limitation 

in the hypothetical necessitates remand. Moore, 405 F.3d at 1214. 

In his decision, the ALJ found Plaintiff had medically determinable 

impairments of affective disorders, personality disorders, and substance addiction 

disorders (tr. 18). He further found that the impairments “do not cause more than 

minimal limitation in Plaintiff’s ability to perform basic mental work activities,” 

when considered singly and in combination, and thus are non-severe (id.). The ALJ

discussed evidence in the record pertaining to the disorders, including treatment 

records, and stated it “appear[ed] that the bulk of complaints [were] situational 

(related to job loss and loss of income)” and that “[t]he bulk of mental status exams 

following [the] alleged onset date [were] generally unremarkable . . . except for mild 

labile effect and dysphoric mood . . . and anxious mood/affect” (id.). The ALJ noted 

Plaintiff’s memory was considered intact on multiple occasions, and her attention 

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and concentration were adequate (id.). He also observed that Plaintiff’s treatment 

“consisted primarily of medication management with some therapy” (id.). 

The ALJ gave great weight to the opinions of Department of Disability 

Services mental health specialists, who opined Plaintiff’s mental impairments did 

not cause more than mild functional limitation, finding they were supported by the 

overall record (id.). The ALJ then explicitly addressed the four broad areas of 

mental functioning, finding mild limitation in each and setting forth the evidence of 

record upon which he relied in making such findings (id. at 18–19). 

The ALJ explained that mental limitations do not constitute an RFC 

assessment but, instead, are used to rate the severity of mental impairments at steps 

two and three and that “[t]he mental RFC assessment used at steps four and five of 

the sequential evaluation process requires a more detailed assessment by itemizing 

various functions contained in the broad categories found in paragraph B of the adult 

mental disorders listings in 12.00 of the Listing of Impairments” (id. at 19). The 

ALJ concluded by stating the RFC assessment set forth in the decision “reflects the 

degree of limitation [he] found in the ‘paragraph B’ mental function analysis” (id.). 

Based on the above, the undersigned rejects Plaintiff’s contention that the ALJ 

did not consider her mental limitations when formulating RFC—he plainly did. 

The undersigned agrees, however, that despite finding limitations in all four 

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functional areas, which the ALJ acknowledged may have caused some limitation in 

Plaintiff’s ability to perform basic mental work activities, the ALJ did not include 

any such limitations in a hypothetical question posed to the vocational expert or 

otherwise account for them, relying instead only on the assigned RFC which 

incorporated no mental limitations. The ALJ erred in that regard. Accordingly, 

the undersigned finds this case should be remanded so the ALJ can incorporate

Plaintiff’s mental limitations into a hypothetical question posed to the vocational 

expert and render a decision that accounts for the vocational expert’s response to the 

question posed. See, e.g., Winschel, 631 F.3d at 1181 (reversing and remanding 

because the ALJ determined at step two that claimant’s mental impairments caused 

a moderate limitation in maintaining concentration, persistence, and pace but did not 

indicate such impairment did not affect claimant’s ability to work or otherwise 

implicitly account for the limitation in the hypothetical, holding “the ALJ should 

have explicitly included the limitation in the hypothetical question to the vocational 

expert”).

7

7 Plaintiff also argues the record supports the contention that she has mental limitations that impact 

her ability to engage in sustained work activity (ECF No. 13 at 32–33). Given the undersigned’s 

finding that the ALJ erred in failing to include mental limitations in a hypothetical question posed 

to the vocational expert, the undersigned need not address whether the record, in fact, supports 

such assertion. 

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II. Dr. Stevenson’s Opinions

Plaintiff also argues the ALJ erred in giving little weight to the opinions of 

Dr. Stevenson, a treating physician. In evaluating medical opinions, an ALJ 

considers a number of factors, including whether the doctor examined or treated the 

claimant, the evidence the doctor presents to support his or her opinion, and whether 

the opinion is consistent with the record as a whole. See 20 C.F.R. §§ 404.1527(c), 

416.927(c). “[T]he ALJ must state with particularity the weight given to different 

medical opinions and the reasons therefor.” Denomme v. Comm’r, Soc. Sec. 

Admin., 518 F. App’x. 875, 877 (11th Cir. 2013). An ALJ may choose to accept 

some conclusions––or restrictions––within an opinion while rejecting others. If 

such a choice is made, in addition to explaining the overall weight given a particular 

medical opinion, the ALJ must explain “‘with at least some measure of clarity the 

grounds for [a] decision’” to adopt particular aspects of a medical opinion. 

Winschel, 631 F.3d at 1179 (quoting Owens v. Heckler, 748 F.2d 1511, 1516 (11th 

Cir. 1984)). Failure to explain the rationale for crediting only certain aspects of an 

opinion will result in a reviewing court “declin[ing] to affirm ‘simply because some 

rationale might have supported the ALJ’s conclusion.’” Id.

A treating source’s opinion generally is entitled to more weight, and an ALJ 

must give good reason for discounting such an opinion. See 20 C.F.R. 

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§§ 404.1527(c)(2); 416.927(c)(2); Winschel, 631 F.3d at 1179.8 The opinion of a 

non-treating physician, however, is not entitled to any deference or special 

consideration. See 20 C.F.R. §§ 404.1502; 404.1527(c)(1), (c)(2); 416.902, 

416.927(c)(1), (c)(2); Denomme, 518 F. App’x at 877–78; Crawford v. Comm’r of 

Soc. Sec., 363 F.3d 1155, 1160 (11th Cir. 2004). Moreover, opinions on certain 

issues, such as a claimant’s RFC and whether a claimant is disabled, “are not medical 

opinions, . . . but are, instead, opinions on issues reserved to the Commissioner 

because they are administrative findings that are dispositive of a case; i.e., that would 

direct the determination or decision of disability.” 20 C.F.R. §§ 404.1527(d), 

416.927(d); see SSR 96-5p. Opinions reserved to the Commissioner, even when 

offered by a treating physician, are not entitled to controlling weight or special 

significance. See SSR 96-5p. Indeed, “[g]iving controlling weight to such 

opinions . . . would be an abdication of the Commissioner’s statutory responsibility 

to determine whether an individual is disabled.” Id. Therefore, although a 

physician’s opinions about what a claimant can still do or the claimant’s restrictions 

may be relevant, such opinions are not determinative because the ALJ is responsible 

8 On January 18, 2017, the Social Security Administration adopted new rules which, for claims 

filed after March 27, 2017, modify the rule of primacy for treating physicians’ opinions. 82 F.R. 

5844, 5869. Because this claim was filed on June 23, 2016 (tr. 77–78, 91–92), the new rules do 

not apply. 82 F.R. 5869.

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for assessing the claimant’s RFC. See 20 C.F.R. §§ 404.1527(d), 416.927(d), 

416.945(a)(3), 416.946(c); SSR 96-5p. 

On October 8, 2014, before the alleged onset date, Dr. Stevenson completed 

a Physical Assessment form in which he opined Plaintiff’s symptoms were severe 

enough to constantly interfere with the attention and concentration required to 

perform simple work-related tasks (tr. 359, 1416). Dr. Stevenson indicated

Plaintiff’s medications caused drowsiness and that she would need to recline or lie 

down during an eight-hour workday in excess of normal breaks (id.). Dr. Stevenson 

opined Plaintiff could walk only half a block before needing rest or experiencing 

significant pain and could sit and stand/walk a total of only two hours each in an 

eight-hour workday (id.). He said Plaintiff would need to take unscheduled breaks 

every thirty minutes, which would last five minutes (id.). Finally, Dr. Stevenson

indicated Plaintiff could frequently lift less than ten pounds but never lift more than 

ten pounds and would be absent from work four or more days per month (id. at 359–

60). 

Dr. Stevenson completed another Physical Assessment form on November 2, 

2016 (id. at 1584). Dr. Stevenson noted he treated Plaintiff for failed cervical and 

lumbar surgeries (id.). He again indicated Plaintiff’s medications caused 

drowsiness (id.). He reiterated that Plaintiff’s symptoms were severe enough to

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constantly interfere with the attention and concentration required to perform simple 

work-related tasks and that Plaintiff would need to recline or lie down during an 

eight-hour workday in excess of normal breaks (id.). This time, Dr. Stevenson said 

Plaintiff could not walk any distance without experiencing pain and could sit and 

stand/walk a total of only one hour each in an eight-hour workday (id.). He imposed 

the same lifting/carrying restrictions as in the first assessment and again opined 

Plaintiff would be absent from work four or more days per month (id. at 1584–85). 

Dr. Stevenson completed a third Physical Assessment form on May 10, 2017

(id. at 1738, 1741). He stated Plaintiff’s medications caused drowsiness, dizziness, 

upset stomach, balance issues, and an inability to think clearly (id. at 1738). He 

once again said Plaintiff would need to recline or lie down during an eight-hour 

workday in excess of normal breaks, could not walk any distance without 

experiencing pain, and could sit and stand/walk a total of only one hour each in an 

eight-hour day (id.). He indicated Plaintiff would need to take unscheduled breaks 

every fifteen minutes, lasting up to five minutes at a time, and could frequently 

lift/carry up to ten pounds but never more (id.). Dr. Stevenson opined Plaintiff 

could use her hands, fingers, and arms only five percent of the day and would be 

absent from work four or more days per month (id. at 1738–39). 

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The ALJ gave the opinions Dr. Stevenson expressed in the Physical 

Assessment forms little weight, finding as follows: 

As for the [first Physical Assessment form], the undersigned gives this 

little weight as it was given back in 2014 (prior to the alleged onset 

date). As for the [subsequent assessments], the undersigned gives 

them little weight. Although these limitations were given by a treating 

provider, they were actually not supported or consistent with treatment 

notes that have revealed she has been managed with medications. 

With regard to limitations given back in October 2016 . . . , those were 

not consistent with postoperative records indicating that [Plaintiff] was 

doing well (with regard to h[er] lumbar spine) postoperatively . . . . 

The evidence shows minimal follow up for her alleged lumbar 

complaints leading up to the [October 2016 assessment]. As for the

[May 2017 assessment], the undersigned does not finds [sic] that this is 

supported by treatment notes (in light of rather limited treatment notes 

other than some injections and surgery) but limited follow up to support 

such severe limitations. Moreover, it was noted that she was not able to 

think clearly but this is simply not documented in the treatment records 

as well. 

(id. at 25).

In arguing the ALJ erred in discounting Dr. Stevenson’s opinions, Plaintiff 

points out that Dr. Stevenson had “the most longitudinal treating relationship of any 

provider in the record,” having treated Plaintiff for twelve years (ECF No. 13 at 24). 

Plaintiff contends the ALJ’s conclusion that Dr. Stevenson’s opinions were 

unsupported or inconsistent with treatment notes that reveal she was managed with 

medications “is belied by any common sense reading of the medical evidence and . 

. . a blatant mischaracterization of the evidence” (id.). Plaintiff says she was not 

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managed by medication alone, as evidenced by the fact that she had six surgeries on 

her cervical and lumbar spine and three surgeries related to wrist and hand 

impairments over the course of seven years. Plaintiff characterizes the ALJ’s 

statement that the bulk of her treatment was conservative as “blatantly absurd given 

the extent of Plaintiff’s spinal deformities and hand/wrist impairments” (id. at 28). 

Plaintiff references her treatment records, including Dr. Stevenson’s notes indicating 

she had failed conservative treatment and even surgeries. Plaintiff argues that in 

giving little weight to Dr. Stevenson’s opinions, the ALJ mischaracterized the 

medical record and substituted his opinion for that of Dr. Stevenson, warranting 

remand. 

Given the fact that this matter is being remanded due to the ALJ’s failure to 

incorporate Plaintiff’s mental limitations into a hypothetical question posed to the 

vocational expert, the undersigned need not determine whether the ALJ also erred 

in giving little weight to Dr. Stevenson’s opinions. It bears noting, however, that 

many of the ALJ’s reasons for discounting Dr. Stevenson’s opinions are supported 

by the record. For example, the opinions expressed in the 2014 Physical 

Assessment form are of limited relevance because Dr. Stevenson completed the form 

nearly two years before Plaintiff’s alleged onset date. See Carmickle v. Comm’r, 

Soc. Sec. Admin., 533 F.3d 1155, 1165 (9th Cir. 2008) (noting “[m]edical opinions 

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that predate the alleged onset of disability are of limited relevance”) (cited in Jones 

v. Saul, No. 1:19cv123/CAS, 2020 WL 1704411, at *16 (N.D. Fla. Apr. 6, 2020)); 

see also Goff ex rel. Goff v. Comm’r of Soc. Sec. Admin., 253 F. App’x 918, 922 

(11th Cir. 2007) (distinguishing between medical opinions offered during the 

relevant time period and those that related back several years). The 2014 opinions

also are inconsistent with Plaintiff’s work as a criminal justice technician through 

June 2016, in which capacity Plaintiff—according to her own testimony—lifted 

boxes and bags weighing sixty to seventy pounds, and did so up to ten to twenty 

times per day (tr. 40–41, 286, 300). Moreover, many of the opinions expressed in 

the 2016 and 2017 forms are inconsistent with Dr. Stevenson’s treatment notes (see, 

e.g., tr. 22–26, 960, 962, 1018, 1302, 1584, 1707, 1713, 1738, 1810, 1818, 1827). 

Considering Plaintiff’s medical history, however, particularly the numerous neck 

and back surgeries, the undersigned recommends that, upon remand, the ALJ revisit 

the issue of Plaintiff’s physical RFC and the weight assigned to Dr. Stevenson’s 

opinions.

9

 

9 Plaintiff also contends the ALJ impermissibly substituted his judgment for that of Dr. Stevenson. 

The undersigned rejects Plaintiff’s argument in that regard. Although an ALJ may not arbitrarily 

substitute his judgment for that of a medical professional, as Plaintiff asserts, an ALJ does not do 

so simply by discounting the weight given a physician’s opinion. See, e.g., Beegle v. Soc. Sec. 

Admin., Comm’r, 482 F. App’x 483, 488 (11th Cir. 2012) (ALJ did not substitute her opinion for 

that of a doctor where she gave the opinion little weight based on its inconsistency with other 

evidence in the record); Wind v. Barnhart, 133 F. App’x 684, 691 (11th Cir. 2005) (finding ALJ 

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CONCLUSION

For the foregoing reasons, the undersigned finds the ALJ erred in failing to 

incorporate mental limitations in a hypothetical question posed to the vocational 

expert and that the ALJ’s decision therefore should be reversed and the matter 

remanded with instructions that the ALJ pose a hypothetical question to a vocational 

expert that accounts for the mental limitations he found and render a decision that 

takes into consideration the vocational expert’s response to the question posed.

10 42 

U.S.C. § 405(g); Lewis, 125 F. 3d at 1439; Foote v. Chater, 67 F.3d 1553, 1560 (11th 

Cir. 1995). The undersigned also recommends that, upon remand, the ALJ revisit 

the issue of Plaintiff’s physical RFC and the weight assigned to Dr. Stevenson’s 

opinions. 

Accordingly, it is hereby ORDERED:

1. Pursuant to sentence four of 42 U.S.C. § 405(g), the decision of the

Commissioner is REVERSED.

did not substitute his opinion for, and properly discounted, doctor’s opinion based in part on 

claimant’s statements of daily activities, noting that “[c]hoosing between conflicting evidence is a 

task particularly suited to the fact finder”).

10 The court notes that, to the extent it reviewed the legal principles upon which the ALJ’s decision 

is based, it conducted a de novo review. See Moore, 405 F.3d at 1208. 

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2. The Commissioner is directed to remand this case to the ALJ for the 

purpose of the ALJ posing a hypothetical question to a vocational expert that 

accounts for the mental limitations he found and rendering a decision that accounts 

for the vocational expert’s response to the question posed. The undersigned also 

recommends that, upon remand, the ALJ revisit the issue of Plaintiff’s physical RFC

and the weight assigned to Dr. Stevenson’s opinions.

3. The clerk of court is directed to enter judgment accordingly and close 

the file.

DONE AND ORDERED this 18th day of March 2021.

/s/ Elizabeth M. Timothy 

ELIZABETH M. TIMOTHY

CHIEF UNITED STATES MAGISTRATE JUDGE

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