United States District Court, M.D. Florida, Orlando Division
AMY R. NELSON, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
REPORT AND RECOMMENDATION
C. IRICK UNITES STATES MAGISTRATE JUDGE
Nelson (Claimant) appeals the Commissioner of Social
Security's final decision denying her applications for
disability benefits. Doc. 1. Claimant raises several
arguments challenging the Commissioner's final decision
and requests that the case be reversed and remanded for an
award of benefits or, in the alternative, for further
proceedings. Doc. 20 at 9-16, 20-24, 27-29, 33. The
Commissioner argues that the ALJ committed no legal error and
that his decision is supported by substantial evidence, and,
as a result, his decision should be affirmed. Id. at
16-20, 24-27, 29-34. The undersigned
RECOMMENDS that the Commissioner's final
decision be AFFIRMED.
case stems from Claimant's applications for disability
insurance benefits and supplement security income. R. 205-14.
Claimant alleged that she became disabled on April 1, 2012.
R. 258. Claimant's applications were denied on initial
review and on reconsideration. The matter then proceeded
before an ALJ. On June 30, 2015, the ALJ held a hearing, at
which Claimant and her representative appeared. R. 46-75. On
July 10, 2015, the ALJ entered his decision denying
Claimant's applications for disability benefits. R.
26-39. On February 6, 2017, the Appeals Council denied
Claimant's request to review the ALJ's decision. R.
1-3. This appeal followed.
The ALJ's Decision
found that Claimant suffered from the following severe
impairments: Turner's syndrome; essential hypertension;
pulmonary hypertension; history of congestive heart failure;
asthma/bronchitis; disorders of the spine; hearing loss;
obesity; affective disorders; and history of polysubstance
abuse. R. 29. The ALJ determined that none of the
foregoing impairments, individually or in combination, met or
medically equaled any listed impairment. R. 29-30.
the ALJ found that Claimant had the residual functional
capacity (RFC) to perform sedentary work as defined in 20
C.F.R. §§ 404.1567(a) and 416.967(a) or light work as
defined in 20 C.F.R. §§ 404.1567(b) and
416.967(b) with the following specific limitations:
[A] sit/stand option (meaning the claimant is able to sit or
stand at her option to perform assigned tasks); she must
avoid ladders or unprotected heights; she must avoid
operation of heavy moving machinery; she must avoid
concentrated dust, fumes, or gases; she needs low stress (no
production line); she needs simple tasks; and she needs to
avoid high noise environments. The claimant can occasionally
bend, crouch, kneel, or stoop; but must avoid squatting or
In light of this RFC, the ALJ found that Claimant was able to
perform her past relevant work as a ticket taker and other
jobs in the national economy, such as house sitter, storage
facility rental clerk, and surveillance system monitor. R.
37-38. Thus, the ALJ concluded that Claimant was not disabled
between her alleged disability onset date, April 1, 2012,
through the date of the decision, July 10, 2015. R. 39.
Standard of Review
Court's review is limited to determining whether the
Commissioner applied the correct legal standards, and whether
the Commissioner's findings of fact are supported by
substantial evidence. Winschel v. Comm'r of Soc.
Sec., 631 F.3d 1176, 1178 (11th Cir. 2011). The
Commissioner's findings of fact are conclusive if they
are supported by substantial evidence, 42 U.S.C. §
405(g), which is defined as “more than a scintilla and
is such relevant evidence as a reasonable person would accept
as adequate to support a conclusion.” Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). The
Court must view the evidence as a whole, taking into account
evidence favorable as well as unfavorable to the
Commissioner's decision, when determining whether the
decision is supported by substantial evidence. Foote v.
Chater, 67 F.3d 1553, 1560 (11th Cir. 1995). The Court
may not decide facts anew, reweigh evidence, or substitute
its judgment for that of the Commissioner, and, even if the
evidence preponderates against the Commissioner's
decision, the reviewing court must affirm it if the decision
is supported by substantial evidence. Bloodsworth v.
Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983).
raises the following assignments of error: 1) the ALJ erred
by failing to weigh treatment records from Central Florida
Mental Health Associates, LLC (CFMH) and her Global
Assessment of Functioning (GAF) scores; 2) the ALJ erred by
relying on the Vocational Expert's (VE) response to a
hypothetical question that did not account for all of her
functional limitations; and 3) the ALJ erred by finding
Claimant's testimony concerning her pain and limitations
“not entirely credible.” Doc. 20 at 9-16, 20-24,
27-29. The undersigned will address each assignment of error
argues that the ALJ erred by failing to state the weight he
assigned to the treatment records from CFMH. Doc. 20 at 11,
14-5. Claimant also argues that the ALJ “totally
overlooked” the GAF scores contained in the treatment
records from CFMH and, as a result, failed to state the
weight he assigned those scores. Id. at 15-16.
Therefore, Claimant argues that the ALJ failed to apply the
proper legal standards in reaching his RFC determination,
and, as a result, his decision is not supported by
substantial evidence. Id. at 16.
Commissioner raises several arguments in response to
Claimant's first assignment of error. First, the
Commissioner argues that the treatment records from CFMH do
not contain any medical opinions, and, thus, the ALJ was not
required to weigh those records. Id. at 17-18.
Second, the Commissioner argues that even if the treatment
records from CFMH were interpreted as medical opinions,
Claimant has “failed to show that the
‘opinions' in any way undermine the ALJ's
assessment of [her] RFC.” Id. at 18-19. Third,
the Commissioner argues that the ALJ considered the treatment
records containing GAF scores, and expressly discussed one of
the GAF scores in his decision. Id. at 19 (citing R.
34). Finally, the Commissioner argues that while the ALJ did
not weigh the GAF scores his failure to do so does not
require reversal. See id. at 19-20 (citing
Cranford v. Comm'r of Soc. Sec., No.
6:13-cv-415-Orl-GJK, 2014 WL 1017972, at *6-7 (M.D. Fla. Mar.
17, 2014). Therefore, the Commissioner argues that the ALJ
applied the proper legal standards in considering the
treatment records from CFMH and the GAF scores, and his RFC
determination is supported by substantial evidence.
assesses the claimant's RFC and ability to perform past
relevant work at step four of the sequential evaluation
process. Phillips v. Barnhart, 357 F.3d 1232, 1238
(11th Cir. 2004). The RFC “is an assessment, based upon
all of the relevant evidence, of a claimant's remaining
ability to do work despite his impairments.”
Lewis, 125 F.3d at 1440. The ALJ is responsible for
determining the claimant's RFC. 20 C.F.R. §§
404.1546(c), 416.946(c). In doing so, the ALJ must consider
all relevant evidence, including the medical opinions of
treating, examining and non-examining medical sources.
See 20 C.F.R. §§ 404.1545(a)(3),
416.945(a)(3); see also Rosario v. Comm'r of Soc.
Sec., 490 Fed.Appx. 192, 194 (11th Cir.
must consider a number of factors in determining how much
weight to give each medical opinion, including: 1) whether
the physician has examined the claimant; 2) the length,
nature, and extent of the physician's relationship with
the claimant; 3) the medical evidence and explanation
supporting the physician's opinion; 4) how consistent the
physician's opinion is with the record as a whole; and 5)
the physician's specialization. 20 C.F.R. §§
404.1527(c), 416.927(c). The ALJ must state the weight
assigned to each medical opinion, and articulate the reasons
supporting the weight assigned to each opinion.
Winschel, 631 F.3d at 1179. The failure to state the
weight with particularity or articulate the reasons in
support of the weight prohibits the Court from determining
whether the ultimate decision is rational and supported by
substantial evidence. Id.
October 2013, Claimant began treating at CFMH. R. 578-83.
Specifically, Claimant treated with Autumn McBride, a
licensed marriage and family therapist. Id. Ms.
McBride initially assessed Claimant with depressive disorder
and a GAF score between 41 and 50. R. 583. Claimant treated
with Ms. McBride several times a month through March 2014. R.
584-634. Initially, Claimant routinely exhibited signs of
depression and anxiety. R. 584-607. After several months of
treatment, Claimant began exhibiting continued improvement in
her mood and affect. R. 611-22, 626-28, 632-34. In November
2014, Claimant returned to CFHM complaining of depression and
anxiety. R. 763. Claimant was assessed with depressive
disorder NOS and posttraumatic stress disorder, and she was
assigned a GAF score between 51 and 60. Id.
There is no evidence that Claimant treated at CFHM after
noted that Claimant “sought mental health treatment in
October 2013 and participated in generally weekly supportive
therapy sessions through at least March 2014.” R. 34
(citing R. 578-634). The ALJ also noted that the treatment
Claimant was receiving resulted in an improved GAF score
between 51 and 60, which indicates “moderate symptoms
or limitations in functioning.” Id. The ALJ,
however, did not assign any weight to the treatment records
from CFMH or the GAF scores contained in those records.
See R. 26-39.
argues that the treatment records from CFMH are
“extremely important” because they show that she
has “significant problems with depression and anxiety
resulting in a limited insight and impaired judgment.”
Doc. 20 at 14-15. Thus, Claimant argues that the ALJ should
have weighed these treatment records. Id. at 15.
“A medical provider's treatment notes may
constitute medical opinions if the content reflects judgment
about the nature and severity of the claimant's
impairments.” Lara v. Comm'r of Soc. Sec.,
705 Fed.Appx. 804, 811 (11th Cir. 2017) (citing
Winschel, 631 F.3d at 1179). The treatment records
at issue document Claimant's subjective statements,
mental status, and treatment. R. 584-634, 763-64. The
treatment records, however, do not reflect any statements or
judgments about the nature and severity of Claimant's
impairments, such as the severity of her depression, nor do