Court Opinion

ID: 6499201
Source: CourtListenerOpinion
Date Created: 2022-07-11 21:00:32.142821+00
Date Added: 2024-06-11T09:11:56.107410
License: Public Domain

USCA11 Case: 21-13324     Date Filed: 07/11/2022    Page: 1 of 12

                                           [DO NOT PUBLISH]
                            In the
         United States Court of Appeals
                 For the Eleventh Circuit

                   ____________________

                         No. 21-13324
                   Non-Argument Calendar
                   ____________________

LISA JENSEN,
                                              Plaintiff-Appellant,
versus
COMMISSIONER OF SOCIAL SECURITY,

                                            Defendant-Appellee.

                   ____________________

          Appeal from the United States District Court
              for the Southern District of Florida
             D.C. Docket No. 0:20-cv-60987-RAR
                   ____________________
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2                       Opinion of the Court                  21-13324

Before JORDAN, ROSENBAUM, AND NEWSOM, Circuit Judges.
PER CURIAM:
        Lisa Jensen appeals the district court’s order affirming the
decision of the Commissioner of the Social Security Administration
(“Commissioner”) to deny her application for a period of disability
and disability insurance benefits (collectively, “disability benefits”).
On appeal, she contends that the administrative law judge failed to
adequately explain his decision not to include a sit-stand option,
failed to consider her need to recline and lie down during the day,
and selectively credited examination findings to fit the unfavorable
decision. She also contends that substantial evidence does not sup-
port the ALJ’s conclusion that her subjective complaints of disa-
bling symptoms were not entirely consistent with the medical and
other evidence of record.
                                   I.
        Jensen applied for disability benefits in June 2015, alleging
that she became disabled on June 1, 2014, when she was 59 years
old, due mainly to right hip and lower back impairments. After a
hearing, an ALJ issued an unfavorable decision in March 2018, con-
cluding that Jensen was not disabled from the onset date to the date
last insured of December 13, 2017.
       Jensen requested review of the ALJ’s decision and submitted
additional medical records. The new evidence included MRIs of
Jensen’s right hip and lower back, which were taken in March 2018.
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21-13324               Opinion of the Court                        3

The MRI of her right hip indicated moderate to severe right hip
osteoarthritis, ganglion and synovial cysts in her joint, a degenera-
tive hip labral tear with paralabral cyst, and a cam deformity sug-
gesting femoral acetabular impingement. These results were con-
sistent with earlier x-rays showing moderate to severe osteoarthri-
tis of the right hip, which had been found in physical examinations
to significantly restrict Jensen’s range of motion. The MRI report
of her lumbar spine indicated moderate to severe left foramina ste-
nosis and compression of the L4 nerve root, moderate bilateral fo-
ramina stenosis and mild compression of the L4 and L5 nerve roots,
and central disc herniation at L5 to S1 compressing the thecal sac.
       In January 2019, the Appeals Council granted review, va-
cated the ALJ’s decision, and remanded the case to consider the
new medical evidence, obtain additional evidence concerning Jen-
sen’s musculoskeletal impairments, and further consider her maxi-
mum residual functional capacity (“RFC”) and provide appropriate
rationale for the assessed limitations.
       On remand, the ALJ arranged for an examination by a con-
sulting physician, Roland Kaplan, D.O. In his May 2019 examina-
tion, Dr. Kaplan found that Jensen walked with an “antalgic gait
favoring the right lower extremity” and had significant restriction
of range of motion in her right hip. He also noted that x-rays
showed a “high moderate amount of osteophytic changes in the
right hip”—bone spurs, in other words—consistent with her symp-
tomatology and degenerative changes at multiple levels in the lum-
bar spine. He assessed her with lumbar herniated disc, lumbar
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4                          Opinion of the Court                      21-13324

spinal stenosis, and osteoarthritis of the right hip. In addition, Dr.
Kaplan prepared a medical source statement, opining in part that,
in an eight-hour workday, Jenson could sit for a total of four hours
and for one hour at a time, stand for a total of two hours and thirty
minutes at a time, and walk for a total of two hours and thirty
minutes at a time.
        Then, in October 2019, Jensen appeared with counsel and
testified at the remand hearing before the same ALJ. A vocational
expert also testified at the hearing. In November 2019, the ALJ is-
sued a second unfavorable decision, concluding that Jensen had the
RFC to perform sedentary work1 with certain additional limita-
tions not relevant here, and could perform past relevant work as a
legal secretary or mortgage clerk.
       In explaining his decision, the ALJ found that Jensen had sev-
eral severe impairments, including “osteoarthritis of the hips more
so on the right,” generalized osteoarthritis, and “degenerative disc
disease lumbar spine with stenosis.” Although the ALJ found that
these impairments could reasonably be expected to cause the al-
leged symptoms, he found that her statements about the severity

1 According to the relevant regulation, “Sedentary work involves lifting no
more than 10 pounds at a time and occasionally lifting or carrying articles like
docket files, ledgers, and small tools. Although a sedentary job is defined as
one which involves sitting, a certain amount of walking and standing is often
necessary in carrying out job duties. Jobs are sedentary if walking and standing
are required occasionally and other sedentary criteria are met.” 20 C.F.R.
§ 404.1567(a).
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21-13324               Opinion of the Court                        5

of her symptoms were not entirely consistent with the record as a
whole.
       After summarizing most of Jensen’s medical records, the
ALJ turned to Dr. Kaplan’s opinion, stating that it was “largely con-
sistent” with the ALJ’s RFC. But the ALJ explained that he found
it “more appropriate[] to limit the claimant to sedentary work
given the standing and walking involved.” As a result, in the ALJ’s
view, Jensen “would not need further limitations.” The ALJ stated
that, “[i]n the most recent medical evidence, the claimant had no
spine tenderness along with a normal gait,” and that, “[e]arlier in
the evidence it was noted the claimant [had] normal range of mo-
tion and her gait and station were unremarkable.” The ALJ also
cited Jensen’s testimony that she left her last job—in May 2012—
because she was laid off and not due to physical problems, “which
would support the finding that she could perform sedentary work.”
       The ALJ also gave “partial weight” to the opinions of the
state agency physicians who initially reviewed Jensen’s applica-
tions. He disagreed with these physicians that Jensen could per-
form light work, but he again noted that examination findings of
“having unremarkable gait and station” and a “normal gait with no
spine tenderness” supported the assessed RFC.
      The ALJ concluded,
      While the MRIs and x-rays showed the claimant to
      have osteoarthritis of the hip along with nerve root
      impingement and herniation and disc protrusion in
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6                      Opinion of the Court               21-13324

      the lumbar, the physical examination note[d] the
      claimant had an unremarkable gait and station and
      [was] later found to have a normal gait. I [therefore]
      conclude[] the claimant’s subjective complaints and
      alleged limitations are not fully persuasive and that
      she retains the capacity to perform work activities
      with the limitations as set forth above.
        This time, the Appeals Council denied review of the ALJ’s
decision. Jensen then sought judicial review in federal district
court. See 42 U.S.C. § 405(g). Based on a magistrate judge’s report
and recommendation, to which Jensen timely submitted objec-
tions, the district court affirmed the agency’s decision. Jensen now
appeals to this Court.
                                II.
       “In Social Security appeals, we must determine whether the
Commissioner’s decision is supported by substantial evidence and
based on proper legal standards.” Winschel v. Comm'r of Soc. Sec.,
631 F.3d 1176, 1178 (11th Cir. 2011) (quotation marks omitted).
“Substantial evidence is more than a scintilla and is such relevant
evidence as a reasonable person would accept as adequate to sup-
port a conclusion.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th
Cir. 1997). We must affirm a decision that is supported by substan-
tial evidence even if the evidence preponderates against the
agency’s findings. Ingram v. Comm'r of Soc. Sec., 496 F.3d 1253,
1260 (11th Cir. 2007). And we may not reweigh the evidence,
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21-13324               Opinion of the Court                         7

decide the facts anew, or substitute our judgment for that of the
ALJ. Winschel, 631 F.3d at 1178.
        But deference does not mean abdication. We have an obli-
gation to “scrutinize the record as a whole to determine if the de-
cision reached is reasonable and supported by substantial evi-
dence.” MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986).
A decision is not supported by substantial evidence if the ALJ
“reached the result that [he] did by focusing upon one aspect of the
evidence and ignoring other parts of the record.” McCruter v.
Bowen, 791 F.2d 1544, 1548 (11th Cir. 1986) (“It is not enough to
discover a piece of evidence which supports that decision, but to
disregard other contrary evidence.”). The ALJ also must state with
at least some measure of clarity the grounds for his decision, which
guides our review, and we will not affirm “simply because some
rationale might have supported the ALJ’s conclusions.” Winschel,
631 F.3d at 1179.
        Under the Social Security Act, a person is disabled if she is
unable “to engage in any substantial gainful activity by reason of
any medically determinable physical or mental impairment.” 42
U.S.C. § 423(d)(1)(A). Regulations outline a five-step, sequential
evaluation process ALJs must use to determine whether a claimant
is disabled: (1) whether she is currently engaged in substantial gain-
ful activity; (2) whether she has a severe impairment or combina-
tion of impairments; (3) whether the impairment meets or equals
the severity of a specified impairment in the Listing of Impair-
ments; (4) whether she can perform her past relevant work despite
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8                      Opinion of the Court                 21-13324

her impairments; and (5) whether, if past relevant work is pre-
cluded by her impairments, she can perform other work found in
the national economy. Winschel, 631 F.3d at 1178; see 20 C.F.R.
§§ 404.1520(a)(4)(i)–(v), 416.920(a)(4)(i)–(v).
       At step four of the sequential analysis, the ALJ must deter-
mine a claimant’s RFC by considering all relevant medical and
other evidence. Phillips v. Barnhart, 357 F.3d 1232, 1238 (11th Cir.
2004). The RFC is an assessment of a claimant’s ability to do work
despite her impairments. Lewis, 125 F.3d at 1440. Relevant evi-
dence includes a claimant’s medical history, medical signs, labora-
tory findings, and statements about how the symptoms affect the
claimant. 20 C.F.R. §§ 404.1545(a)(3), 416.945(a)(3).
                                 III.
       We conclude that the ALJ’s decision is not supported by sub-
stantial evidence. The ALJ’s rationale reflects a selective reading of
the record and does not adequately support his ultimate conclu-
sions. To the extent the Commissioner offers a viable rationale to
uphold the ALJ’s decision, we cannot affirm “simply because some
rationale might have supported the ALJ’s conclusions.” Winschel,
631 F.3d at 1179.
       Key to the ALJ’s adverse November 2019 decision were
treatment notes reflecting Jensen’s normal gait and station and lack
of spine tenderness. See ALJ Decision at 22 (“In the most recent
medical evidence, the claimant had no spine tenderness along with
a normal gait.”; “Earlier in the evidence it was noted the claimant
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21-13324               Opinion of the Court                       9

to have normal range of motion and her gait and station were un-
remarkable.”; “[T]he claimant’s physical examination of having un-
remarkable gait and station and later having a normal gait with no
spine tenderness would support the findings.”; “[T]he physical ex-
amination note[d] the claimant had an unremarkable gait and sta-
tion and later found to have a normal gait.”). Yet the ALJ failed to
reconcile these observations—which largely occurred in the con-
text of visits unrelated to her back or hip impairments—with other
contrary evidence, or even to address some of that evidence.
       For starters, it’s not accurate to say that the “most recent
medical evidence” shows a normal gait. The record shows that Dr.
Kaplan conducted a physical examination in May 2019 and found
that Jensen walked with an “antalgic gait favoring the right lower
extremity” and had significant restriction of range of motion in her
right hip. This examination post-dated the examinations cited by
the ALJ, and it is consistent with earlier findings that Jensen had
decreased range of motion with pain in her right hip.
       What’s more, the ALJ did not explain why Jensen’s normal
gait and station indicated that her hip and back impairments were
not as severe as she asserted or undermined Dr. Kaplan’s opinions.
Treatment notes from a visit to the Orthopaedic Center of South
Florida on June 22, 2015, which are notably absent from the ALJ’s
discussion of the medical evidence, reflect that Jensen had a “nor-
mal” gait and standing alignment and no tenderness. Still, accord-
ing to the doctor who prepared the notes, Jensen had “arthroplasty
level symptoms” “consistent with end-stage degenerative arthrosis
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10                     Opinion of the Court                 21-13324

of the joint,” which had caused “significant functional limitations”
that had not improved despite “numerous nonoperative interven-
tions.” As a result, total hip replacement surgery was recom-
mended—though ultimately not performed, as far as the record
shows.
       As we stated in McCruter, “[i]t is not enough to discover a
piece of evidence which supports th[e] decision”—here, the evi-
dence of Jensen’s normal gait and station—“but to disregard other
contrary evidence.” 791 F.2d at 1548. While the ALJ noted that
imaging results since that time have confirmed that Jensen suffers
from moderate to severe osteoarthritis of the right hip with nerve
root impingement, it failed to explain the significance it attached to
her “normal” gait or how it related to the pain Jensen allegedly ex-
perienced during prolonged periods of sitting. See id. (“The review
must take into account and evaluate the record as a whole.”).
        Nor do we agree with the ALJ’s statement that limiting Jen-
sen to sedentary work adequately accounted for Dr. Kaplan’s opin-
ions. While the ALJ’s RFC appears to be more restrictive than Dr.
Kaplan’s opinions with regard to the total length of time Jensen
could stand or walk in a workday, it did not incorporate his views
as to the total length of time Jensen could sit or the length of time
she could sit, stand, or walk at any one time. Dr. Kaplan opined
that Jensen could sit for no more than four hours in an eight-hour
workday. Limiting her to sedentary work, which largely “involves
sitting,” seems to contradict that assessment. The ALJ also did not
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21-13324                   Opinion of the Court                              11

include the type of “sit/stand” option 2 he had adopted in the orig-
inal adverse decision, which would have been broadly consistent
with Dr. Kaplan’s views as to Jensen’s inability to remain in a con-
stant position for any length of time. Likewise, Jensen’s testimony
reflects that, due to severe and persistent pain, she was unable to
sit for long without getting up and walking around, sitting in a re-
cliner with an ice pack for between twenty minutes and an hour,
or lying in bed. 3 We do not express or imply any view that the ALJ
was required to credit Dr. Kaplan’s opinions regarding Jensen’s
functional limitations. But on the current record, we cannot rec-
oncile the ALJ’s generally favorable statements regarding Dr.
Kaplan’s evaluation with the limitations imposed.
       Finally, we cannot say Jensen’s testimony about the circum-
stances of leaving her last job reasonably supports the ALJ’s deci-
sion. The ALJ found that Jensen’s testimony that she did not leave
her last job for physical problems, but rather was laid off to make
room for a returning employee, “would support the finding that
she could perform sedentary work.” But Jensen testified that she
was let go from her position in May 2012, more than two years

2 In the original unfavorable decision, the ALJ included a “sit stand option de-
fined as a brief positional change from sitting to standing and vice versa with
no more than one change in position every 20 minutes and without leaving
the workstation so as not to diminish pace or production.”
3 The vocational expert indicated that that there would be no jobs for a person
who required three additional breaks, up to 15 minutes, during a typical work-
day, or for a person who had to recline 80 percent of the day.
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12                      Opinion of the Court                 21-13324

before the alleged onset of disability. That Jensen could work be-
fore she allegedly became disabled is hardly surprising, and it says
little if anything, at least without further elaboration, about the pe-
riod in question. We also note that Jensen testified she attempted
to look for work after being laid off but “the pain got so bad that
[she] couldn’t even sit in front of a computer while [she] was . . .
searching and applying for jobs.”
       Having carefully reviewed the record as a whole and the ra-
tionale provided by the ALJ, we conclude that substantial evidence
does not support the ALJ’s decision based on the rationale pro-
vided. See Winschel, 631 F.3d at 1179. We therefore vacate the
judgment of the district court and remand with instructions to re-
mand this case to the Commissioner for further proceedings re-
garding Jensen’s eligibility for disability benefits.
       VACATED AND REMANDED, with instructions.