Court Opinion

ID: 69617
Source: CourtListenerOpinion
Date Created: 2010-04-26 06:48:47+00
Date Added: 2024-06-11T17:20:06.663205
License: Public Domain

[DO NOT PUBLISH]

               IN THE UNITED STATES COURT OF APPEALS

                       FOR THE ELEVENTH CIRCUIT            FILED
                         ________________________ U.S. COURT OF APPEALS
                                                            ELEVENTH CIRCUIT
                                No. 09-11240                NOVEMBER 17, 2009
                            Non-Argument Calendar            THOMAS K. KAHN
                          ________________________               CLERK

                   D. C. Docket No. 08-00016-CV-FTM-SPC

NEREIDA VESY,

                                                             Plaintiff-Appellant,

                                     versus

MICHAEL J. ASTRUE,
Commissioner of Social Security,

                                                            Defendant-Appellee.

                          ________________________

                  Appeal from the United States District Court
                      for the Middle District of Florida
                       _________________________

                               (November 17, 2009)

Before TJOFLAT, MARCUS and WILSON, Circuit Judges.

PER CURIAM:

      Nereida Vesy appeals the district court’s order affirming the Commissioner

of Social Security’s denial of her application for disability insurance benefits,
pursuant to 42 U.S.C. § 405(g).         On appeal, Vesy argues that: (1) the

Administrative Law Judge’s (“ALJ”) assessment of her residual functional

capacity (“RFC”) is not supported by substantial evidence; (2) substantial evidence

does not support the ALJ’s decision not to credit her subjective testimony

concerning her symptoms; (3) the ALJ failed to adequately develop the

administrative record; and (4) the ALJ’s hypothetical questions to a vocational

expert (“VE”) failed to include all of her impairments. After careful review, we

affirm.

      In a social security case, we review the Commissioner’s factual findings to

determine whether they are supported by substantial evidence. Ingram v. Comm’r

of Soc. Sec. Admin., 496 F.3d 1253, 1260 (11th Cir. 2007). Substantial evidence

is defined as “such relevant evidence as a reasonable person would accept as

adequate to support a conclusion.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239

(11th Cir. 1983). We do not “decide the facts anew, reweigh the evidence, or

substitute our judgment for that of the [Commissioner].”           Id.     “If the

Commissioner’s decision is supported by substantial evidence we must affirm,

even if the proof preponderates against it.” Miles v. Chater, 84 F.3d 1397, 1400

(11th Cir. 1996).   We review the Commissioner’s legal conclusions de novo.

Ingram, 496 F.3d at 1260.

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                                         I.

      First, we disagree with Vesy’s argument that the ALJ’s RFC assessment is

not supported by substantial evidence. The Social Security regulations establish a

five-step sequential process for determining whether a claimant is disabled. 20

C.F.R. § 416.920. Under the first two steps, the ALJ must determine whether the

claimant is currently engaged in substantial gainful activity, and whether the

claimant has a severe impairment. Id. § 416.920(b) and (c). Under the third step,

the ALJ must decide whether the claimant’s impairments meet or medically equal a

listed impairment. Id. § 416.920(d). If the claimant has a severe impairment that

does not meet or equal a listed impairment, the ALJ must then determine whether

the claimant has the residual functional capacity to perform her past relevant work.

Id. § 416.920(e) and (f). “[R]esidual functional capacity is an assessment, based

upon all of the relevant evidence, of a claimant’s remaining ability to do work

despite his impairments.”    Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir.

1997); 20 C.F.R. § 404.1545. If the claimant cannot perform her past relevant

work, the ALJ must then determine whether the claimant may perform other work

that exists in the national economy. 20 C.F.R. § 416.920(g).

      Generally, the opinion of a treating physician “must be given substantial or

considerable weight unless ‘good cause’ is shown to the contrary.” Lewis, 125

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F.3d at 1440. “When electing to disregard the opinion of a treating physician, the

ALJ must clearly articulate [his] reasons.” Phillips v. Barnhart, 357 F.3d 1232,

1241 (11th Cir. 2004) (quotation omitted).       We have found good cause for

disregarding a treating physician’s opinion where: “(1) [the] treating physician’s

opinion was not bolstered by the evidence; (2) [the] evidence supported a contrary

finding; or (3) [the] treating physician’s opinion was conclusory or inconsistent

with the doctor’s own medical records.” Id.

      In this case, the ALJ conducted a review of all of the medical evidence in the

record, and his RFC assessment is supported by the medical evidence. As an initial

matter, in determining Vesy’s exertional impairments, the ALJ relied primarily on

the opinions of Drs. Johnson and Seo. Dr. Johnson reported that Vesy was limited

by fatigue and arthralgia, but could sit or stand for up to 6 hours in an 8-hour

workday, and could lift and carry up to 15 pounds. Similarly, Dr. Seo found that

Vesy could sit or stand for 30 minutes without interruption, was able to walk for a

few blocks, and could lift and carry up to 20 pounds. Because Dr. Johnson was a

long-term treating rheumatologist, the ALJ properly gave significant weight to her

opinion. See Lewis, 125 F.3d at 1440. Moreover, Dr. Johnson’s and Dr. Seo’s

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assessments were consistent with the medical evidence in the record, which

suggested that Vesy retained the ability to perform a limited range of light work.1

       We also find no support for Vesy’s argument that Dr. Pollack’s report --

which concluded that her examination of Vesy was “essentially unremarkable,”

and that Vesy did not have any exertional limitations -- failed to properly consider

her fibromyalgia and IBS symptoms, and, therefore, should not have been

considered by the ALJ. Indeed, Dr. Pollack did note that Vesy had a history of

IBS, Lyme Disease, and knee and back pain. She simply concluded that those

conditions did not cause any exertional impairments. And in any event, it does not

appear that the ALJ placed great reliance on Dr. Pollack’s assessment, as the ALJ

found that Vesy did, in fact, have exertional impairments that restricted her to a

limited range of light work.

       As for Vesy’s claim that the ALJ should not have relied upon the functional

capacity evaluation of Dr. Ilkay, the ALJ’s written opinion noted that Dr. Ilkay’s

       1
         As the record shows, in 1996, before the alleged disability onset date, Dr. Ekstrom
placed Vesy off of work for approximately three months due to her Irritable Bowel Syndrome
(“IBS”) symptoms, but he later allowed her to return to light duty work, with no excessive
bending or lifting. Drs. Bernstein, Dadrat, and Vogtland did not identify any functional
impairments caused by Vesy’s IBS. The state agency physician who reviewed Vesy’s
application concluded that she retained the capacity to perform light work. In 2001, Dr.
Fernando reported that Vesy’s fibromyalgia was “controlled,” and that Vesy was able to
occasionally exercise by walking or by riding a bike. Dr. Rodgers did not list any specific
limitations on Vesy’s ability to work in his treatment notes or medical evaluation forms.

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opinion was “obviously limited to a urological standpoint only.” Thus, it does not

appear that the ALJ gave significant weight to Dr. Ilkay’s opinion.

      Vesy also argues that the ALJ should have given more weight to the opinion

of Dr. Sell, a treating physician, who concluded that she: (1) could not sit or stand

for more than 1 hour in an 8-hour work day; (2) could occasionally or never lift or

carry items weighing less than ten pounds; (3) could not push or pull with either

arm; (4) could occasionally reach above shoulder level, but could never bend,

squat, kneel, or crawl. However, Dr. Sell’s assessment was inconsistent with the

opinions of Drs. Johnson and Seo. In addition, although Dr. Sell’s treatment notes

indicated that he treated Vesy for lower back pain, fibromyalgia, and IBS, they did

not suggest that Vesy was limited to the extent found by Dr. Sell in his functional

capacity evaluation.   Therefore, the ALJ was not required to give significant

weight to Dr. Sell’s opinion. See Phillips, 357 F.3d at 1241.

      Further, although Vesy argues that the ALJ’s RFC assessment should have

included non-exertional limitations, the medical evidence does not reveal any non-

exertional impairments that affected Vesy’s ability to work. Vesy testified that her

IBS caused diarrhea and vomiting, which required her to take frequent bathroom

breaks.   But Drs. Bernstein, Vogtland, and Sell reported that Vesy’s IBS was

controlled when she was taking FiberCon. And while Vesy suffered from pain,

                                          6
fatigue, and stiffness caused by arthralgia and fibromyalgia, Dr. Johnson concluded

that those symptoms did not affect her ability to perform light duty work. As a

result, the ALJ did not have to include any non-exertional symptoms in his RFC

assessment. For all of these reasons, the ALJ’s RFC assessment is supported by

substantial evidence.

                                          II.

      We likewise find no merit in Vesy’s claim that the ALJ erred by declining to

credit her subjective testimony concerning her symptoms.           In a case where a

claimant attempts to establish disability through his or her own testimony

concerning pain or other subjective systems, we apply a three-part “pain standard.”

Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991).           “The pain standard

requires (1) evidence of an underlying medical condition and either (2) objective

medical evidence that confirms the severity of the alleged pain arising from that

condition or (3) that the objectively determined medical condition is of such a

severity that it can be reasonably expected to give rise to the alleged pain.” Id.

      If the ALJ decides not to credit a claimant’s subjective testimony, “he must

articulate explicit and adequate reasons for doing so.” Id. If the ALJ fails to

articulate reasons for discrediting the claimant’s testimony, then that testimony

must be accepted as true. Id. In evaluating a claimant’s credibility, the ALJ may

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consider, among other things, the claimant’s daily activities and the “type, dosage,

effectiveness, and side effects” of any medication that the claimant uses to relieve

her symptoms. 20 C.F.R. § 404.1529(c)(3)(i), (iv).

      Here, the ALJ found that Vesy’s subjective testimony regarding the

frequency and intensity of her symptoms could not be fully credited because it was

inconsistent with Vesy’s daily activities and with the medical evidence. Thus, the

ALJ’s reasoning is consistent with the evidence in the record, and as a result, his

credibility determination is supported by substantial evidence. Further, because

Vesy’s subjective testimony was inconsistent with the record, the ALJ’s error in

noting that Vesy had not requested any bathroom breaks during the hearing when

she had in fact requested and received one break was harmless. See Diorio v.

Heckler, 721 F.2d 726, 728 (11th Cir. 1983) (holding that an ALJ’s factual error is

harmless if it does not affect the ALJ’s conclusion).

                                         III.

      Next, we reject Vesy’s argument that the ALJ failed to properly develop the

administrative record by ordering additional consultative examinations, re-

contacting Drs. Seo and Sell for clarification of their functional capacity

assessments, and making an inquiry into whether side effects from her medications

contributed to her disability. In a social security case, the ALJ has an affirmative

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duty to develop a full and fair record. Brown v. Shalala, 44 F.3d 931, 934 (11th

Cir. 1995).       This obligation applies regardless of whether the claimant is

represented by counsel, but it rises to the level of a special duty when the claimant

is unrepresented. Id. at 934-35. Nevertheless, the ALJ’s obligation to develop the

record does not relieve the claimant of the burden of proving that she is disabled.

Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003). Consequently, it is the

claimant’s responsibility to introduce evidence in support of her application for

benefits.   Id.    In determining whether it is necessary to remand a case for

development of the record, we consider “whether the record reveals evidentiary

gaps which result in unfairness of clear prejudice.”       Brown, 44 F.3d at 935

(quotations omitted).

      In Cowart v. Schweiker, the claimant, who was unrepresented at the hearing

but had not waived her right to counsel, testified that she was taking a number of

medications which caused her to be “kind of zonked most of the time.” 662 F.2d

731, 737 (11th Cir. 1981). Based on those facts, we held that the ALJ had a duty to

investigate the side effects of the claimant’s medications and to determine whether

those side effects had an impact on her ability to work. Id. Yet, we have also held

that the ALJ need not inquire into the side effects of a claimant’s medications

where the claimant was represented at the hearing, and did not assert that side

                                          9
effects from her medications contributed to her disability. Cherry v. Heckler, 760

F.2d 1186, 1191 n.7 (11th Cir. 1985).

      Under the Social Security regulations, the ALJ may order additional

consultative examinations if the medical evidence submitted by the claimant does

not provide enough information about an impairment to determine whether the

claimant is disabled. 20 C.F.R. § 416.917. But the ALJ is not required to order

additional examinations if the evidence in the record is sufficient to allow for an

informed decision. Ingram, 496 F.3d at 1269. In general, the ALJ should re-

contact a medical source when the evidence received from that source is

inadequate to determine whether the claimant is disabled. 20 C.F.R. § 416.912(e).

Under Social Security Ruling 96-5p, the ALJ must make “every reasonable effort”

to re-contact a medical source when the medical evidence does not support the

source’s opinion, and the ALJ cannot ascertain the basis for that opinion from the

case record. S.S.R. 96-5p (Cum. Ed. 1996).

      In this case, the ALJ developed a full and fair record. Although there was

some evidence that Vesy suffered from side effects caused by her medications, she

did not allege that those side effects contributed to her disability and notably, was

represented by counsel. As a result, the ALJ did not have a special duty to make a

further inquiry into the effects of Vesy’s medications. See Cherry, 760 F.2d at

                                         10
1191 n.7. Moreover, the ALJ was not required to re-contact Drs. Seo and Sell or to

order additional consultative examinations because the record already contained

sufficient evidence for the ALJ to made an informed decision regarding whether

Vesy was disabled. Ingram, 496 F.3d at 1269. Vesy therefore has not shown any

error with respect to the ALJ’s duty to develop the record.

                                         IV.

      Finally, we are unpersuaded by Vesy’s claim that the ALJ’s hypothetical

question to the VE failed to include her non-exertional impairments. As noted

above, under step five of the sequential evaluation process, the ALJ must

determine whether the claimant is able to perform other work that exists in the

national economy. 20 C.F.R. § 404.1520(g). If the ALJ finds that the claimant is

able to perform other work, he “must articulate specific jobs that the claimant is

able to perform, and this finding must be supported by substantial evidence, not

mere intuition or conjecture.” Wilson v. Barnhart, 284 F.3d 1219, 1227 (11th Cir.

2002). One way in which the ALJ may determine whether the claimant is able to

perform other jobs is by posing a hypothetical question to a VE. Id. “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.”

Id.   However, the ALJ’s hypothetical need not include a claimant’s asserted

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impairments that are not supported by the medical evidence, or that are controlled

or alleviated by medication. Ingram, 496 F.3d at 1270.

      As the record shows, the ALJ’s first hypothetical to the VE included all of

the impairments which the ALJ found to be supported by the record. Further, the

ALJ did not have to include any symptoms related to IBS because the medical

evidence indicated that Vesy’s IBS was being controlled through the use of

FiberCon.   Id.   Thus, the ALJ properly relied upon the VE’s testimony as

substantial evidence to support his conclusion that Vesy could perform other work

that existed in the national economy. See Wilson, 284 F.3d at 1227.

      AFFIRMED.

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