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Nelson v. Commissioner of Social Security

United States District Court, M.D. Florida, Orlando Division

May 29, 2018

AMY R. NELSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          REPORT AND RECOMMENDATION

          DANIEL C. IRICK UNITES STATES MAGISTRATE JUDGE

         Amy R. 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.

         I. Procedural History

         This 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.

         II. The ALJ's Decision

         The ALJ 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.[1] The ALJ determined that none of the foregoing impairments, individually or in combination, met or medically equaled any listed impairment. R. 29-30.

         Next, 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)[2] or light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b)[3] 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 crawling.

         R. 30. 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.

         III. Standard of Review

         The 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).

         IV. Analysis

         Claimant 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 in turn.

         A. Treatment Records

         Claimant 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.

         The 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. Id.

         The ALJ 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. 2012).[4]

         The ALJ 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.

         In 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.[5] 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.[6] Id. There is no evidence that Claimant treated at CFHM after November 2014.

         The ALJ 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.

         Claimant 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 ...


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