Court Opinion

ID: 4503355
Source: CourtListenerOpinion
Date Created: 2020-01-31 15:00:27.731589+00
Date Added: 2024-06-11T12:49:29.543610
License: Public Domain

Case: 19-11495   Date Filed: 01/31/2020   Page: 1 of 10

                                                     [DO NOT PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                   FOR THE ELEVENTH CIRCUIT
                     ________________________

                            No. 19-11495
                        Non-Argument Calendar
                      ________________________

                  D.C. Docket No. 6:17-cv-01841-DCI

JAMES DEWEY BAILEY,

                                                     Plaintiff-Appellant,

                                  versus

COMMISSIONER OF SOCIAL SECURITY,

                                                     Defendant-Appellee.

                      ________________________

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

                           (January 31, 2020)

Before MARTIN, ROSENBAUM, and EDMONDSON, Circuit Judges.
               Case: 19-11495   Date Filed: 01/31/2020    Page: 2 of 10

PER CURIAM:

      James Bailey appeals the district court’s order affirming the Social Security

Commissioner’s denial of Bailey’s application for disability insurance benefits

(“DIB”), 42 U.S.C. § 405(g). Reversible error has been shown; we affirm in part

and reverse in part the district court’s order; we remand with instructions to vacate

the Commissioner’s decision and to remand to the Commissioner for further

proceedings.

      Our review of the Commissioner’s decision is limited to whether substantial

evidence supports the decision and whether the correct legal standards were

applied. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011).

“Substantial evidence is more than a scintilla and is such relevant evidence as a

reasonable person would accept as adequate to support a conclusion.” Id. “If the

Commissioner’s decision is supported by substantial evidence, this Court must

affirm, even if the proof preponderates against it.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Under this limited standard of review, we may not

make fact-findings, re-weigh the evidence, or substitute our judgment for that of

the Administrative Law Judge (“ALJ”). Moore v. Barnhart, 405 F.3d 1208, 1211

(11th Cir. 2005). We review de novo the district court’s determination about

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whether substantial evidence supports the ALJ’s decision. Wilson v. Barnhart, 284
F.3d 1219, 1221 (11th Cir. 2002).

       A person who applies for Social Security DIB must first prove that he is

disabled.* See 20 C.F.R. § 404.1512(a). The Social Security Regulations outline a

five-step sequential evaluation process for determining whether a claimant is

disabled. 20 C.F.R. § 404.1520(a)(4). The ALJ must evaluate (1) whether the

claimant engaged in substantial gainful work; (2) whether the claimant has a severe

impairment; (3) whether the severe impairment meets or equals an impairment in

the Listings of Impairments; (4) whether the claimant has the residual functional

capacity (“RFC”) to perform his past relevant work; and (5) whether, in the light of

the claimant’s RFC, age, education, and work experience, there exist other jobs in

the national economy the claimant can perform. Id.

       Appling the five-step evaluation process, the ALJ first determined that

Bailey had engaged in no substantial gainful activity since his application date.

The ALJ then determined that Bailey had the following severe impairments:

disorders of the spine, cervical radiculitis, mild carpal tunnel syndrome, left cubital

tunnel syndrome, hypertension, psoriasis, Guillain-Barre Syndrome (“GBS”),

*
 Disability is the “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).
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chronic inflammatory demyelinating polyneuritis, polyneuropathy, history of

diverticulitis, history of muscle weakness, and history of benign prostatic

hyperplasia.

      The ALJ next determined that Bailey had the RFC to perform light work

with limitations. Among other limitations, the ALJ determined that Bailey could

sit, stand or walk for up to 6 hours each within an 8-hour workday, and could lift

and carry up to 20 pounds occasionally and 10 pounds frequently. In the light of

Bailey’s RFC, the ALJ concluded that Bailey was capable of performing his past

relevant work as a dispatcher and, thus, was not disabled. The district court

affirmed.

      On appeal, Bailey argues that the ALJ failed to apply the correct legal

standard to the medical opinions of treating physicians Dr. Yee and Dr. Garewal.

Bailey says the ALJ erred in giving only “partial weight” to Dr. Yee’s opinion.

Bailey also contends that the ALJ failed to consider adequately and to specify the

weight given to the medical opinion of Dr. Garewal.

      In determining a claimant’s RFC, the ALJ must consider all medical

opinions in the claimant’s case record together with other pertinent evidence. 20

C.F.R. § 404.1520(e). In deciding how much weight to give a medical opinion, the

ALJ considers, among other things, (1) the examining relationship; (2) the

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treatment relationship; (3) the extent to which the opinion is supported by medical

evidence and explanations; and (4) whether the opinion is consistent with the

record as a whole. 20 C.F.R. § 404.1527(c). Absent “good cause” to the contrary,

the ALJ must give substantial weight to the opinion, diagnosis, and medical

evidence of a treating physician. Crawford v. Comm’r of Soc. Sec., 363 F.3d
1155, 1159 (11th Cir. 2004). Good cause may exist under these circumstances: (1)

the treating physician’s opinion was not bolstered by evidence; (2) evidence

supported a contrary finding; or (3) the treating physician’s opinion was

conclusory or inconsistent with the doctor’s own medical records. Lewis v.

Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).

      “[T]he ALJ must state with particularity the weight given to different

medical opinions and the reasons therefor.” Winschel, 631 F.3d at 1179. We will

not affirm a decision “when the ALJ fails to state with at least some measure of

clarity the grounds for his decision.” Id. (quotations omitted).

Dr. Yee

      Dr. Yee is Bailey’s primary care physician. On 10 March 2014, Bailey

presented to Dr. Yee with weakness, tingling in his arms, and fatigue. Dr. Yee sent

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Bailey to the hospital emergency room, where Bailey was later diagnosed with

GBS. On 4 April 2014, Bailey saw Dr. Yee for a follow-up appointment. Dr. Yee

reported that Bailey was fatigued and weak, with a motor strength of 3/5 in the

upper and lower extremities, a weak gait, and an “unremarkable” non-focal

neurological exam. Dr. Yee prescribed medication for GBS and referred Bailey to

a neurologist for further evaluation. Bailey visited Dr. Yee again on 7 November

2014, complaining of weakness and muscle spasms. Dr. Yee’s physical exam

revealed largely the same physical conditions as on 4 April. Dr. Yee prescribed

additional medications for GBS and recommended “light home exercise” of at least

30 minutes of cardiovascular exercise 3 times per week.

      On 12 December 2014, Dr. Yee completed a pre-printed form titled

“Medical Assessment of Ability to do Work-Related Activities (Physical).” On the

form, Dr. Yee opined that Bailey could sit for 1-2 hours at a time for a total of 6-7

hours a day; could stand for 20 minutes at a time for a total of 4 hours a day; and

could walk for 5-10 minutes at a time for a total of 2-3 hours a day. Dr. Yee also

opined that Bailey could lift or carry less than five pounds, needed both hands to

carry things, and had poor hand dexterity and grip. Dr. Yee said that Bailey’s

prognosis was “fair/chronic” given his GBS and neuropathy.

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      The ALJ assigned only “partial weight” to Dr. Yee’s opinion from the

Medical Assessment form, to the extent Dr. Yee’s opinion was consistent with the

ALJ’s RFC assessment. Substantial evidence supports the ALJ’s decision. The

ALJ explained that Dr. Yee’s opinion about Bailey’s physical limitations was

inconsistent with the objective medical evidence in the record, which the ALJ

found showed an overall improvement in Bailey’s neurological symptoms and

medical condition over the course of his treatment by all providers. Dr. Yee’s

assessment was also inconsistent with Dr. Yee’s own treatment records, which

prescribed a “generally conservative/conventional treatment” plan, including

medication management and an at-home exercise routine. Dr. Yee’s opinion was

also contradicted by Bailey’s own testimony that he was able to work part-time as

a delivery driver, had no problems sitting, could lift and carry up to ten pounds,

and could perform (with some difficulty) several activities of daily living,

including cooking, grocery shopping, driving, and mowing the lawn with a riding

mower.

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Dr. Garewal

      Dr. Garewal (a treating neurologist) first saw Bailey on 15 April 2014. Dr.

Garewal reported that Bailey had normal motor strength, reduced sensation in a

stocking-glove distribution, slow fine finger movements, and a good stride. Dr.

Garewal assessed Bailey with idiopathic progressive polyneuropathy, disturbance

of skin sensation, and chronic inflammatory demyelinating polyneuritis. After

conducting EMG/NCV testing, Dr. Garewal noted abnormal study findings with

proximal polyradiculopathy as seen in GBS, mild carpal tunnel syndrome, and left

cubital tunnel syndrome. Dr. Garewal prescribed medications, diagnostic imaging,

and a social work consult.

      At a follow-up appointment on 15 May 2014, Bailey presented with largely

the same physical conditions as on 15 April, except Dr. Garewal reported that

Bailey had “mild weakness in distal hands with grip/pad/dabpsoaritic changes in

hands.” Dr. Garewal continued Bailey’s medications.

      Also on 15 May, Dr. Garewal signed a handwritten “To Whom It May

Concern” note that said, “I am treating [Bailey] for progressive neuropathy which

is resulting in weakness, pain, and sensory deficits. I don’t presently think he can

work.”

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      On appeal, Bailey contends that the ALJ committed reversible error by

failing to mention or to assign weight to Dr. Garewal’s 15 May handwritten note.

We agree. Although an ALJ may decide to disregard the opinion of a treating

physician upon a finding of “good cause,” the ALJ must articulate clearly his

reasons for doing so. Winschel, 631 F.3d at 1179. Here, where the ALJ made no

mention of Dr. Garewal’s opinion that Bailey was unable to work and failed to

specify the weight given to that opinion, we cannot “determine whether the

ultimate decision on the merits of the claim is rational and supported by substantial

evidence.” See id.

      We acknowledge the Commissioner’s contention that the first sentence of

Dr. Garewal’s 15 May note was duplicative of information already considered

expressly by the ALJ. We also recognize that the final determination about

whether a claimant is “unable to work” is one that is reserved to the

Commissioner: a physician’s opinion that a person is “unable to work” is thus not

determinative and is entitled to no “special significance.” See 20 C.F.R. §

404.1527(d). We stress, however, that the ALJ must consider all the claimed

expert, medical opinions in the record and must specify the weight -- including no

weight, if applicable -- given to each purported medical opinion and the reasons

therefor. See id. at §§ 404.1520(e), 404.1527(c); Winschel, 631 F.3d at 1179; see

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also Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997) (“[T]he ALJ has a

basic obligation to develop a full and fair record.”). We have said that failure to

articulate clearly the reasons for giving less weight to the opinion of a treating

physician constitutes reversible error. MacGregor v. Bowen, 786 F.2d 1050, 1053

(11th Cir. 1986).

      The judgment of the district court is affirmed in part and reversed in part,

and this case is remanded to the district court with instructions to vacate the

Commissioner’s decision and to remand to the Commissioner for further

proceedings.

      AFFIRMED IN PART, REVERSED IN PART, AND REMANDED.

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