Court Opinion

ID: 9948225
Source: CourtListenerOpinion
Date Created: 2024-03-06 18:01:54.775979+00
Date Added: 2024-06-11T14:29:20.476708
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USCA11 Case: 23-10157    Document: 21-1      Date Filed: 03/06/2024   Page: 1 of 13

                                                    [DO NOT PUBLISH]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

                           ____________________

                                 No. 23-10157
                           Non-Argument Calendar
                           ____________________

        CRAIG A. SMITH, II,
                                                       Plaintiﬀ-Appellant,
        versus
        COMMISSIONER OF SOCIAL SECURITY,

                                                     Defendant-Appellee.

                           ____________________

                  Appeal from the United States District Court
                       for the Middle District of Florida
                     D.C. Docket No. 5:21-cv-00551-PRL
                           ____________________
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        2                      Opinion of the Court                  23-10157

        Before ROSENBAUM, LAGOA, and BRASHER, Circuit Judges.
        PER CURIAM:
               Craig Smith appeals the judgment affirming the decision of
        the Commissioner of the Social Security Administration (“Com-
        missioner”) to deny his application for a period of disability and dis-
        ability insurance benefits (collectively, “disability benefits”). He
        contends that the ALJ failed to apply proper legal standards and
        made findings not supported by substantial evidence. After careful
        review, we vacate and remand for further proceedings.
                                          I.
               Smith is a veteran who applied for disability benefits in De-
        cember 2019, alleging that he became disabled in September 2018
        due to a combination of diabetes, sleep apnea, high cholesterol,
        narcolepsy, and insomnia. He indicated that his narcolepsy made
        him feel completely drained daily and that he could not work due
        to excessive sleepiness and the need for scheduled naps. After the
        agency denied his applications initially and on reconsideration,
        Smith requested a hearing before an administrative law judge.
                                          A.
               During the telephonic hearing, Smith testified about his nar-
        colepsy condition. He was diagnosed with “narcolepsy with re-
        verse REM sleep with sleep hypnosis” while in the military. He
        experienced narcolepsy episodes two or three times a day, every
        day, lasting from minutes to hours, which caused an inconsistent
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        23-10157                 Opinion of the Court                             3

        sleep schedule and “heavy sleep deprivation,” making it difficult to
        concentrate when awake. Smith would fall asleep at random times
        and wake up feeling paralyzed and disoriented. He took medica-
        tion, which helped some but not much. He also reported that em-
        ployers had been unwilling to work with his narcolepsy by offering
        nap breaks during the day.
               The record shows that Smith sought treatment for his nar-
        colepsy from the sleep clinic at the Orlando Veterans Affairs Medi-
        cal Center. Over two visits in August 2018, Smith reported wors-
        ening symptoms, including sleep paralysis, hypnagogic 1 hallucina-
        tions, hypersomnia (excessive tiredness), and naps that were “hard
        to come out of.” The treatment notes reflect a diagnostic impres-
        sion of “narcolepsy uncontrolled,” and a sleep clinic physician, Dr.
        Sherwin Mina, started Smith on the stimulant medication
        modafinil.
               Smith returned to the sleep clinic in September 2018, report-
        ing no improvement from modafinil, as well as symptoms includ-
        ing sleep attacks, sleep paralysis, hypnagogic hallucinations, and
        cataplexy (muscle weakness). The treatment notes reflect a diag-
        nostic impression of “narcolepsy on [m]odafinil without improve-
        ment of his symptoms,” and Dr. Mina increased his dosage.
              Follow-up visits in October and November 2018 were simi-
        lar. On October 24, 2018, Smith complained of worsening sleep, as

        1 The term “hypnagogic” refers to the transitional state between wakefulness

        and sleep.
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        4                     Opinion of the Court                23-10157

        well as symptoms including sleep paralysis, hypnagogic hallucina-
        tions, and cataplexy. The clinic diagnosed sleep deprivation and
        narcolepsy, which was “not well controlled,” and Dr. Mina in-
        creased the morning dose of modafinil. On November 26, 2018,
        Smith reported continuing to experience “sleep attacks daily where
        he sleeps for 1–3 hours” and wakes up confused and dazed. Dr.
        Mina increased the afternoon dose of modafinil.
               Smith returned to the sleep clinic on February 25, 2019, re-
        porting no improvement since increasing his medication. Smith
        also reported that his sleep pattern was “all over” because he was
        taking care of a young baby as a full-time dad. The physician, Dr.
        Vanthanh Ly, noted that Smith’s narcolepsy was “not well con-
        trolled due to psychosocial stress factors,” and continued the same
        dosage of modafinil.
               Smith visited Dr. Mina at the sleep clinic on May 28, 2019,
        reporting that he continued to have “sleep attacks” but was “man-
        aging” with modafinil and marijuana. Dr. Mina noted a diagnostic
        impression of “narcolepsy without cataplexy” that was “stable at
        this time,” and he prescribed the same dosage of modafinil. At a
        follow-up visit with Dr. Mina on August 28, 2019, Smith reported
        that modafinil was “helpful,” but he was having difficulty with in-
        somnia and staying asleep. Dr. Mina noted that Smith’s narcolepsy
        was “stable on modafinil,” although his insomnia was “not well
        controlled.”
              Meanwhile, on December 13, 2018, Dr. Felix Mejias-Carta-
        gena, a physiatrist, conducted an in-person examination of Smith,
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        23-10157                   Opinion of the Court                                 5

        reviewed his VA records, and completed a Narcolepsy Disability
        Benefits Questionnaire for a separate VA disability evaluation.2
        Based on Smith’s narcolepsy diagnosis and medications, as well as
        his complaints of excessive daytime sleepiness, sleep attacks, cata-
        plexy, sleep paralysis, and hypnagogic hallucinations, Dr. Mejias-
        Cartagena concluded that Smith’s narcolepsy would impact his
        ability to work. Nearly one year later, on December 6, 2019, Dr.
        Chad Masters completed a similar questionnaire based on a review
        of Smith’s VA file, likewise concluding that Smith’s narcolepsy
        would affect his ability to work. Dr. Masters explained, “Extreme
        daytime fatigue and lack of concentration along with ability to ran-
        domly fall asleep during the day—all of these lead to issues with
        veteran completing tasks at work.” Both evaluations noted that
        Smith had undergone a polysomnogram in 2015, which was unre-
        markable.
               On June 27, 2020, Smith was seen for an in-person Social Se-
        curity consultative examination performed by Dr. Benyam Yoseph.
        Dr. Yoseph found that, while Smith had no physical limitations, his
        narcolepsy and insomnia affected his ability to “focus or concen-
        trate.” State agency medical consultants who reviewed Smith’s
        medical records, however, opined that his impairments were not
        severe enough to qualify for disability benefits.

        2 As a result, the VA raised its disability rating for Smith’s narcolepsy from 10%

        to 80%.
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        6                     Opinion of the Court                23-10157

                                        B.
               After the hearing, the ALJ issued a written decision conclud-
        ing that Smith was not disabled. The ALJ found that Smith had the
        medically determinable impairments of narcolepsy, obesity, de-
        pression, and anxiety. But, in the ALJ’s view, Smith did not have a
        “severe impairment”—that is, an impairment or combination of
        impairments that significantly limited his ability to perform basic
        work-related activities.
               The ALJ explained that she found persuasive the opinions of
        the state agency medical consultants, which were “consistent with
        the medical record that reveals that the narcolepsy was stable on
        [m]odafinil.” In contrast, the ALJ stated, Dr. Yoseph’s “opinion
        that the claimant [was] unable to focus or concentrate [was] not
        persuasive” because it was inconsistent with Dr. Yoseph’s “normal
        mental status examination findings.” The ALJ also found unper-
        suasive the opinions of the doctors who evaluated Smith’s narco-
        lepsy for the VA, stating that they were “not persuasive as they
        [we]re not consistent with observable clinical signs of record and
        other opinion evidence and are based on symptoms.” In support
        of that conclusion, the ALJ cited treatment notes indicating that
        Smith was “managing” or “stable” on his medication and the nor-
        mal examination conducted by Dr. Yoseph.
              The Appeals Council denied Smith’s request for review of
        the ALJ’s decision, and the district court affirmed. Smith appeals.
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        23-10157               Opinion of the Court                        7

                                         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 substantial
        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, decide the facts
        anew, or substitute our judgment for that of the ALJ. Winschel, 631
        F.3d at 1178.
               Nevertheless, we will not “merely rubber-stamp a decision.”
        Schink v. Comm’r of Soc. Sec., 935 F.3d 1245, 1257 (11th Cir. 2019).
        “We must scrutinize the record as a whole to determine if the de-
        cision reached is reasonable and supported by substantial evi-
        dence.” Id. (quotation marks omitted). A decision is not supported
        by substantial evidence if the ALJ “reached the result that [she] 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 some measure of clarity the grounds
        for her decision, and we will not affirm “simply because some
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        8                       Opinion of the Court                  23-10157

        rationale might have supported the ALJ’s conclusions.” Winschel,
        631 F.3d at 1179.
               A claimant is entitled to disability benefits if he is unable “to
        engage in any substantial gainful activity by reason of any medi-
        cally determinable physical or mental impairment” that is expected
        to last for at least twelve continuous months. 42 U.S.C.
        § 423(d)(1)(A). Regulations outline a five-step, sequential evalua-
        tion process ALJs must use to determine whether a claimant is dis-
        abled. Winschel, 631 F.3d at 1178; see 20 C.F.R. §§ 404.1520(a)(4)(i)–
        (v), 416.920(a)(4)(i)–(v).
                At the second step, “the ALJ must determine if the claimant
        has any severe impairment.” Jamison v. Bowen, 814 F.2d 585, 588
        (11th Cir. 1987). A “severe impairment” is defined by regulations
        as “any impairment or combination of impairments which signifi-
        cantly limits [a claimant’s] physical or mental ability to do basic
        work activities,” regardless of age, education, or work experience.
        20 C.F.R. §§ 404.1520(c), 416.920(c). “This step acts as a filter; if no
        severe impairment is shown the claim is denied,” but if a severe
        impairment is present, the ALJ proceeds to consider whether the
        claimant can still reasonably be expected to work. Jamison, 814 F.2d
        at 588.
               “A claimant’s burden to establish a severe impairment at
        step two is only mild.” Schink, 935 F.3d at 1265 (quotation marks
        omitted). We have described step two as merely a “threshold in-
        quiry” that “allows only claims based on the most trivial impair-
        ments to be rejected.” McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th
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        23-10157               Opinion of the Court                         9

        Cir. 1986). And “[w]e have recognized that an impairment is not
        severe only if the abnormality is so slight and its effect so minimal
        that it would clearly not be expected to interfere with the individ-
        ual’s ability to work.” Schink, 935 F.3d at 1265 (quotation marks
        omitted).
                Based on these standards, substantial evidence does not sup-
        port the ALJ’s conclusion that Smith lacked a severe impairment.
        Rather, the record compels the conclusion that Smith’s narcolepsy
        and related symptoms “cannot be considered only ‘slight’ or ‘triv-
        ial’ abnormalities.” Id.
               Smith has a longstanding diagnosis of narcolepsy, and he
        sought treatment for worsening symptoms at a sleep clinic begin-
        ning in August 2018. Over several visits in the following months,
        he reported experiencing daily symptoms to include excessive day-
        time tiredness, sleep attacks, sleep paralysis, hypnagogic hallucina-
        tions, and cataplexy. The clinic repeatedly diagnosed sleep depri-
        vation and narcolepsy, which it described as “uncontrolled” or “not
        well controlled,” and prescribed medication, increasing the dosage
        several times over successive visits.
                It does not appear the ALJ disputes that, in its uncontrolled
        state, Smith’s narcolepsy could have a substantial effect on his abil-
        ity to work. As both Dr. Mejias-Cartagena and Dr. Masters indi-
        cated, excessive fatigue and random sleep attacks during the day
        could be expected to interfere with an individual’s ability to work,
        whether through lack of concentration or falling asleep on the job.
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        10                      Opinion of the Court                  23-10157

               Rather, the ALJ reasoned that Smith’s “impairments were
        controlled with medication,” repeatedly citing Dr. Mina’s treat-
        ment notes in May 2019 and August 2019 that Smith’s narcolepsy
        was “stable” on modafinil. Whether a condition is “stable,” how-
        ever, says little on its own about whether the condition is disabling.
        See Kohler v. Astrue, 546 F.3d 260, 268 (2d Cir. 2008) (stating that the
        term “stable” “could mean only that [a claimant’s] condition has
        not changed, and she could be stable at a low functional level”).
        And nothing in the treatment notes suggests that Smith’s pre-
        scribed medication, which he admits helps his condition, rendered
        his narcolepsy symptoms “only ‘slight’ or ‘trivial’ abnormalities.”
        Schink, 935 F.3d at 1265.
               In May 2019, Smith reported that, while he was “managing”
        with modafinil, he still suffered daytime “sleep attacks,” which, as
        we’ve mentioned above, could interfere with his ability to work.
        And in August 2019, Dr. Mina noted that, while Smith’s narcolepsy
        was “stable on modafinil,” which he had reported was “helpful,”
        his insomnia was “not well controlled.” Insomnia can be a symp-
        tom of narcolepsy 3, as well as a side effect of the stimulant
        modafinil, according to the treatment notes, and could reasonably
        be expected to contribute to daytime fatigue. So it should have
        been, but apparently was not, considered by the ALJ when as-
        sessing the effects of Smith’s narcolepsy. See Cowart v. Schweiker,

        3 National Institutes of Health, Narcolepsy, NAT’L INST. OF NEUROLOGICAL

        DISORDERS & STROKE, https://www.ninds.nih.gov/health-information/dis-
        orders/narcolepsy (last visited Nov. 6, 2023).
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        23-10157               Opinion of the Court                       11

        662 F.2d 731, 737 (11th Cir. 1981) (noting that “side effects of med-
        ication could render a claimant disabled or at least contribute to a
        disability”). Thus, it appears the ALJ “reached the result that [she]
        did by focusing upon one aspect of the evidence and ignoring other
        parts of the record.” McCruter, 791 F.2d at 1548.
                The ALJ’s other cited reasons do not provide reasonable
        grounds for finding Smith’s narcolepsy non-severe. For starters,
        whether Smith’s narcolepsy was stable or controlled by mid-2019
        is not inconsistent with Dr. Mejias-Cartagena’s opinion from De-
        cember 2018, when the condition was not well controlled. The
        treatment notes reflect that Smith’s narcolepsy was “uncontrolled”
        or “not well controlled” from September 2018, when disability on-
        set allegedly occurred, through at least May 2019, when Dr. Mina
        first noted that the condition was “stable.” And the ALJ did not
        make any findings about Smith’s narcolepsy in its uncontrolled
        state, which covered a period relevant to his claim. While the ALJ
        cited treatment notes from February 2019, she inaccurately stated
        that Dr. Ly had “noted this impairment was well controlled,” in-
        stead of “not well controlled.”
               Nor do we see any inconsistency between Smith’s disability
        claim and Dr. Yoseph’s “unremarkable” examination in July 2020.
        Smith’s claim is based primarily on narcolepsy symptoms, includ-
        ing excessive daytime fatigue and random sleep attacks, along with
        the immediate confusion that arises upon waking from these sleep
        attacks—not any other physical inability to perform. And the mere
        fact that Smith was “alert” and “oriented” during a one-time
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        12                     Opinion of the Court                 23-10157

        mental-status examination hardly supports a conclusion that he
        could remain alert and on task in a work setting on a sustained ba-
        sis. See Schink, 935 F.3d at 1266 (“[T]he ability to complete tasks in
        settings that are less demanding than a typical work setting does
        not necessarily demonstrate an applicant’s ability to complete tasks
        in the context of regular employment during a normal workday or
        work week.”). Likewise, that Smith may have been able to struc-
        ture his life while not working to manage his condition—such as
        timing medication and taking naps—tells us very little “about his
        ability to function in a stressful work setting” on a sustained basis.
        Id. Indeed, the treatment notes reflect that stress exacerbates the
        symptoms of Smith’s narcolepsy.
               Finally, the mere fact that Smith declined an alternative
        medication, with its own potential benefits and risks, is not enough,
        on this record, to show that his condition was not severe. The rec-
        ord shows that Smith actively pursued treatment for his narcolepsy
        and took prescribed medication, which after several increases in
        dosage helped him manage the condition to some degree.
        Whether or not Smith’s impairments, when treated, would be
        compatible with employment—the question reserved for steps
        four and five of the sequential analysis—the effects of treatment on
        Smith, and his choice not to pursue an alternative medication while
        actively seeking appropriate treatment, are not substantial evi-
        dence that his narcolepsy was non-severe.
               For these reasons, the ALJ’s conclusion at step two of the
        analysis that Smith did not have any severe impairment is not
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        23-10157               Opinion of the Court                         13

        supported by substantial evidence. The record shows that, regard-
        less of whether his impairments could be compatible with employ-
        ment, the symptoms of his narcolepsy cannot be considered “only
        ‘slight’ or ‘trivial’ abnormalities.” Schink, 935 F.3d at 1265. Because
        the ALJ stopped at step two and did not consider the remaining
        steps in the sequential analysis, we vacate the judgment and re-
        mand with instructions to remand this case to the Commissioner
        for further proceedings on Smith’s disability claim.
               VACATED AND REMANDED.