United States District Court, M.D. Florida, Tampa Division
KATHY D. PATTON, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
D. WHITTEMORE JUDGE
THE COURT is the Report and Recommendation of the
Magistrate Judge recommending that the Commissioner's
decision denying Plaintiffs claims for aperiod of disability,
disability insurance benefits, and supplemental security
income be affirmed. (Dkt. 23). Plaintiff filed objections,
(Dkt. 24), to which the Commissioner responded, (Dkt. 25). A
district court may accept, reject, or modify a magistrate
judge's report and recommendation. 28 U.S.C. §
636(b)(1). Those portions of the report and recommendation to
which objection is made are accorded de novo review.
Id.; Fed.R.Civ.P. 72(b)(3).
de novo review of the findings to which objections
are made, and a review of the findings to which objection is
not made for plain error, I find that the Commissioner's
decision must be reversed and the case remanded based on the
Administrative Law Judge's ("ALJ") failure to
clearly articulate the reasons for affording little weight to
the opinion of Plaintiff s treating physician.
sole objection to the Report and Recommendation is that the
ALJ rejected an opinion of Dr. Jay Azneer, Plaintiffs
treating physician, without good cause. (Dkt. 24).
ALJ's decision is reviewed to determine whether the
correct legal standards were applied, Graham v.
Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997) (per
curiam), and if the decision as a whole is supported by
substantial evidence, Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Substantial evidence is
"more than a scintilla and is such relevant evidence as
a reasonable person would accept as adequate to support a
conclusion." Winschel v. Commissioner of Soc.
Sec, 631 F.3d 1176, 1178 (11th Cir. 2011) (internal
quotation marks and citations omitted). The court "may
not decide the facts anew, reweigh the evidence, or
substitute [its] judgment for that of the
[Commissioner]." Id. (internal quotation marks
and citations omitted). Legal conclusions of the ALJ,
however, are reviewed de novo. Ingram v. Commissioner of
Soc. Sec, 496 F.3d 1253, 1260 (11th Cir. 2007).
is a five-step, sequential evaluation process to determine
whether a claimant is disabled. Winschel, 631 F.3dat
1178 (citing Phillips v. Barnhart, 357 F.3d 1232,
1237-39 (11thCir. 2004)). The first three steps evaluate
whether (1) the claimant is currently engaged in substantial
gainful activity, (2) the claimant has a severe impairment or
combination of impairments, and (3) the impairment meets or
equals the severity of the specified impairments in the
Listing of Impairments. Id. The fourth step asks
whether, based on the claimant's residual functional
capacity ("RFC") assessment, the claimant can
perform any of her past relevant work despite the limitations
caused by her impairments. Id. At the fourth step,
the ALJ considers "all the relevant medical and other
evidence" in the case record to determine the
claimant's RFC. Phillips, 357 F.3d at 1238
(quoting 20 C.F.R. § 404.1520(e)). The final step
evaluates whether there are significant numbers of jobs in
the national economy the claimant can perform, given her RFC,
age, education, and work experience. Winschel, 631
F.3d at 1178.
found, as to steps one and two, that Plaintiff had not been
engaged in substantial gainful activity and she had severe
impairments including "idiopathic polyneuropathy
involving the right foot; left shoulder supraspinatus
capsulitis with tendinopathy from an impingement;
questionable chronic fatigue syndrome without specific tender
points; chronic obstructive pulmonary disease (COPD); chronic
pain syndrome; and depression, anxiety/posttraumatic stress
disorder (PTSD), and panic disorder without
agoraphobia." (Decision, Dkt 13-2 at pp. 22-23).
Plaintiff has no objections relating to the findings and
analysis at the first or second steps. (Objections, Dkt. 24).
Rather, Plaintiff objects to the sections of the Magistrate
Judge's report addressing the ALJ's determination, at
steps three and four, that her impairments do not meet or
medically equal the severity of listed impairments and that
she had the RFC to perform light work with some specific
restrictions. (Decision, Dkt. 13-2 at pp. 23-30; Objections,
Dkt. 24). As noted, Plaintiff objects on the ground that the
ALJ rejected without good cause Dr. Azneer's opinion
regarding her physical and mental impairments. (Dkt. 24).
Dr. Azneer 's History of Treatment of
Azneer, D.O., of M.D. D.O. Associates was Plaintiffs primary
care physician from 2011 to 2014. (Treatment Records, Dkt.
13-9 at pp. 346-89); see also (October 23, 2014
Treatment Records of Pinellas Medical Associates, Dkt. 13-9
at p. 335) (identifying Dr. Azneer as Plaintiffs primary care
physician). His earliest medical records for Plaintiff
indicate that her conditions included anxiety disorder,
depressive disorder, chronic pain syndrome, osteoarthritis,
myalgia, and myositis, among others. (Treatment Records, Dkt.
13-9 at p. 384). His muscoloskeletal examination indicated
normal tone; normal motor strength; no contractures,
malalignment, tenderness, or abnormalities of the bones,
joints or muscles; normal movement of all extremities; back
pain; arthralgias/joint pain; muscle aches; no swelling in
the extremities; no muscle weakness; and no cyanosis, edema,
varicosities, or palpable cord in the extremities.
(Id. at pp. 385-86). His neurological examination
indicated she had normal gait and station; grossly intact
cranial nerves; numbness in her right leg; reflexes: DTRs 2
bilaterally throughout; and no tremors, weakness, numbness,
seizures, dizziness, headaches, or loss of consciousness.
(Id.). His psychiatric examination indicated good
judgment; normal mood and affect; active; alert; orientation
to time, place, and person; normal recent memory; normal
remote memory; depression; no sleep disturbances; and no
alcohol abuse. (Id.). His assessment / plan
indicates he prescribed her medication for depressive
disorder. (Id. at 386).
Dr. Azneer's findings and assessments for Plaintiff
remained substantially the same throughout his treatment of
her, with some exceptions. (Id. at pp. 346-83). The
greatest changes occurred to her psychiatric diagnoses.
(Id.). Treatment records for an appointment on
December 27, 2012 indicate for the first time in the
assessment / plan that Plaintiff had an anxiety disorder that
would "remain managed" by diazepam that had already
been prescribed to her for other reasons. (Id. at p.
374). Treatment records for a April 8, 2013 appointment
indicate for the first time muscoloskeletal findings of
malalignment, tenderness, and limited range of motion
throughout her thorax. (Id. at p. 3 62). Treatment
records for a June 10, 2013 appointment indicate for the
first time that Plaintiff suffered from panic disorder
without agoraphobia, she reported restless sleep, and Dr.
prescribed her xanax to replace the diazepam. (Id.
at pp. 358-59). Appointment records for August 12, 2014
indicate that her anxiety medication had been changed to
xanax, that her panic disorder without agoraphobia diagnosis
included her complaints of "difficulty leaving her
house, " that her depressive disorder was being treated
with sertaline, and that she was not to receive separate
treatment for her agoraphobia. (Id. at pp. 355-56).
last records of Plaintiff s appointments with Dr. Azneer are
for appointments on October 13, 2014 and November 7, 2014.
(Id. at pp. 346-53). His discussion notes for both
of these appointments indicate that "[Plaintiffs]
ability to cope has decreased markedly-she is at the limit of
her endurance just to be in the office with me."
(Id. at pp. 349, 353). The October 13, 2014 records
indicate for the first time that Plaintiffs panic disorder
without agoraphobia was "severe" and that she was
under the care of psychiatrist Dr. Aaron Brooks for her
depressive disorder. (Id. at pp. 352-53). The
November 7, 2014 records indicate ...