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Stebbins v. Berryhill

United States District Court, N.D. Florida, Gainesville Division

February 15, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff appeals to this Court from a final decision of the Acting Commissioner of Social Security (the “Commissioner”) denying Plaintiff's application for Period of Disability and Disability Insurance Benefits pursuant to Title II of the Social Security Act (“the Act”) and for Supplemental Security Income pursuant to Title XVI of the Act. (ECF No. 1.) The Commissioner has answered, ECF No. 8, and both parties have filed briefs outlining their respective positions. (ECF Nos. 19, 22.) For the reasons discussed below, it is recommended that the Commissioner's decision be affirmed.


         Plaintiff filed her Title II and Title XVI applications on May 16, 2013, alleging a disability onset date of August 12, 2012. (R. 20, 63, 71, 158-69.) Plaintiff alleged that she could no longer work due to lupus, depression, and hypertension. (R. 63, 71, 105, 111.) Her applications were denied initially and upon reconsideration. (R. 63-78, 81-102, 105-17, 123-34.) On July 2, 2015, an administrative law judge (“ALJ”) issued a decision unfavorable to Plaintiff. (R. 20-30.) The Appeals Council denied Plaintiff's request for review on December 22, 2016. (R. 1-4.) Plaintiff then filed the instant appeal. (ECF No. 1.)


         The Commissioner's findings of fact are conclusive if supported by substantial evidence. See 42 U.S.C. § 405(g) (2000). Substantial evidence is more than a scintilla, i.e., the evidence must do more than merely create a suspicion of the existence of a fact, and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982); Richardson v. Perales, 402 U.S. 389, 401 (1971)); accord Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991).

         Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. Edwards, 937 F.2d at 584 n.3; Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560. However, the district court will reverse the Commissioner's decision on plenary review if the decision applies incorrect law, or if the decision fails to provide the district court with sufficient reasoning to determine that the Commissioner properly applied the law. Keeton v. Dep't Health & Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).

         The law defines disability as the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. §§ 416(I), 423(d)(1); 20 C.F.R. § 404.1505 (2005).[2] The impairment must be severe, making Plaintiff unable to do his previous work, or any other substantial gainful activity which exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511.

         The ALJ must follow five steps in evaluating a claim of disability. 20 C.F.R. §§ 404.1520, 416.920. The claimant has the burden of proving the existence of a disability as defined by the Social Security Act. Carnes v. Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). First, if a claimant is working at a substantial gainful activity, he is not disabled. 20 C.F.R. § 404.1520(b). Second, if a claimant does not have any impairment or combination of impairments which significantly limit his physical or mental ability to do basic work activities, then he does not have a severe impairment and is not disabled. 20 C.F.R. § 404.1520(c). Third, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, he is disabled. 20 C.F.R. § 404.1520(d). Fourth, if a claimant's impairments do not prevent him from doing past relevant work, he is not disabled. 20 C.F.R. § 404.1520(e). Fifth, if a claimant's impairments (considering his residual functional capacity (“RFC”), age, education, and past work) prevent him from doing other work that exists in the national economy, then he is disabled. 20 C.F.R. § 404.1520(f).


         Plaintiff's medical records cover the time period from 2011 to 2015 and are from Gainesville Family Physicians, North Florida Regional Medical Center, Shands Hospital, Alachua County Health Department, Meridian Behavioral Healthcare, and Vascular Interventional Physicians. Because the issue on appeal relates to Plaintiff's credibility, the relevant portions of the medical record, the opinion evidence, the hearing testimony, and the ALJ's findings are summarized below.

         A. Medical Evidence

         In 2011 and 2012 Plaintiff visited Dr. Jackson at Gainesville Family Physicians. Her lab results revealed diagnoses of Vitamin B deficiency, lupus erythematosus, and hypertension. Other diagnoses included migraines, tension headaches, lumbago, neck pain, rash, abdominal pain, right upper quadrant pain, and chest pain. Her physical examinations, however, revealed overall normal findings other than some moderate tenderness and aching in the cervical area and legs at times and some occasional limited range of motion at the hip and neck. Imaging in 2011 revealed transitional lumbsacral segment with partial lumbarization of S1-S2, and a hip exam showed degenerative changes without acute fracture. But Plaintiff's other tests and exams were normal. Plaintiff was prescribed various medications and referred to physical therapy to decrease pain and improve range of motion. (R. 254-92, 360-75, 797-857.)

         Plaintiff visited North Florida Regional Medical Center in August 2012 where her discharge diagnoses included severe headache and severe back and neck pain. Her physical exam findings during her stay were normal, aside from mild tenderness in the cervical spine, upper right abdomen, and neck as well as appearing in pain. An MRI of the cervical spine revealed a nonspecific chronic-appearing lesion at C2, but it did not require any treatment. The chest x-rays and head CT were normal. The impression was acute headache, and Plaintiff was given medication and told to avoid exertional activities for only a week. (R. 296-354, 734-92.)

         Plaintiff returned to North Florida Regional Medical Center in 2013 regarding right upper quadrant abdominal pain. Her physical exam findings were normal other than distress and tenderness from pain in that area, and her abdomen CT and chest exams were unremarkable. She experienced relief from medications and was discharged. (R. 388-402.)

         Plaintiff also visited Shands at the University of Florida in 2012 and 2013. In October 2012 her discharge diagnoses included chest pain that was likely musculoskeletal, SLE, and hypertension, and her discharge physical exam was normal. Her other testing revealed no acute cardiopulmonary disease. Notably, an SLE flare up was thought to be unlikely, and her lupus was noted as stable. She returned in November 2012, complaining of leg pain. Her physical exam findings were normal apart from tenderness and swelling in the right thigh. The clinical impression was a muscle strain. (R. 407-27, 459-526, 1050-52.)

         In January 2013 Plaintiff again complained of chest pain. Her physical exam findings were normal as were her chest x-rays. Her diagnosis included nonspecific chest pain, but it was noted that she had a normal myocardial heart test and normal cardiac enzymes. Then in April 2013 Plaintiff complained of pain on her right side and was diagnosed with acute right flank pain. Her physical exam findings were normal other than tenderness in the right upper quadrant, and her CT scan of the abdomen and pelvis did not contain findings to explain the right-sided flank pain. (R. 527-91, 1040-44.)

         In May 2013, however, Plaintiff again presented with chest pain, among other things, but her discharge diagnosis was viral gastroenteritis causing dehydration and syncope. She had a normal EKG and CT scan of her head. Additionally, a lupus flare was ruled out by blood test. Then Plaintiff returned at the end of May, complaining of headache, fever, and swollen neck. Her physical exam findings were normal, and she was diagnosed with a headache and viral illness. (R. 527-632.)

         Plaintiff returned in July 2013, complaining of abdominal pain, and she was diagnosed with right upper quadrant pain. Yet other than tenderness in that area, her physical exam findings were normal. Her chest x-ray revealed underinflated lungs without acute cardiopulmonary abnormality, and she had no acute abdominal abnormality. (R. 697-716.)

         Her clinical visits from the Alachua County Health Department in 2012 and 2013 revealed overall normal physical exam findings. Her diagnoses varied throughout her visits, and they included benign essential hypertension, unspecified chest pain, unspecified back ache, right upper quadrant abdominal pain, lump or mass in breast, bronchitis, probable phlebitis and thromophlebitis of deep veins of lower extremities, unspecified hyperlipidemia, and situational depression. (R. 428-53, 636-67, 681-91.)

         With regard to Plaintiff's mental health, Plaintiff also underwent mental health screening in May 2013 at the Alachua County Health Department. She was diagnosed with depressive affective disorder, single episode, severe, without mention of psychotic behavior. She complained of worsening depression in August, but her mood and affect were appropriate during her mental status examination. (R. 634-35, 684.)

         Plaintiff also visited Meridian Behavioral Healthcare at the Crisis Stabilization Unit from July 29, 2013, to August 1, 2013, voluntarily due to depression. She was diagnosed with ...

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