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Williams v. Saul

United States District Court, N.D. Florida, Panama City Division

September 9, 2019

ANDREW M. SAUL,[1] Defendant.


          Michael J. Frank United States Magistrate Judge

         Plaintiff Gloria J. Williams brings this action under 42 U.S.C. § 405(g) and seeks review of a final adverse decision of the Commissioner of the Social Security Administration. The Commissioner denied her applications for a period of disability, Disability Insurance Benefits (DIB), and Supplemental Security Income (SSI). Plaintiff timely pursued and exhausted her administrative remedies. After careful consideration of the entire record, the decision of the Commissioner is affirmed.[2]

         I. Procedural History

         On July 17, 2015, Plaintiff protectively filed: (1) a Title II application for a period of disability and disability insurance benefits; and (2) an application for supplemental security income. (Tr. 10). In her applications, Plaintiff alleged that her disability began March 14, 2014. (Id.). Her claims were initially denied on August 27, 2015, and upon reconsideration on October 29, 2015. Thereafter Plaintiff requested a hearing before an administrative law judge (“ALJ”). (Id.). On May 12, 2017, Plaintiff, represented by counsel, appeared before the assigned ALJ at a video hearing. (Id.). On August 16, 2017, the ALJ issued a decision in which she found Plaintiff was not under a disability. (Tr. 10-22). Plaintiff appealed to the Appeals Council, and, on May 9, 2018, the Appeals Council denied Plaintiff's request for review. (Tr. 1-6). Thus, the decision of the ALJ stands as the final decision of the Commissioner, subject to review in this court. Ingram v. Comm'r of Soc. Sec. Admin., 496 F.3d 1253, 1262 (11th Cir. 2007). This appeal followed.

         II. Findings of the ALJ

          In denying Plaintiff's claims, the ALJ made the following findings relevant to the issues raised in this appeal:

(1) Plaintiff met the insured status requirement of the Social Security Act through March 31, 2019.
(2) Plaintiff had not engaged in substantial gainful activity since March 14, 2014, the alleged onset date.
(3) The claimant had the following severe impairments: depression, anxiety, borderline intellectual functioning, personality disorder not otherwise specified, degenerative disc disease of the cervical spine, and obesity. The ALJ found that Plaintiff's hypertension, dyslipidemia, pre-diabetes, uterine hypoechaic masses, low potassium, and gastroesophageal reflux disease were non-severe impairments. The ALJ found that fibromyalgia and joint disease other than the cervical spine were not medically determinable impairments.
(4) Plaintiff did not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.
(5) Plaintiff had a residual functional capacity (RFC) to perform medium work, as defined in 20 C.F.R. Part 404.1567(c) and 416.967(c), except:
a. she can frequently balance, stoop, crawl, and climb ramps and stairs;
b. she can never climb ladders, ropes, or scaffolds or work at unprotected heights;
c. she is limited to performing simple, routine tasks and making simple work-related decisions; and
d. she can frequently interact with co-workers and can have occasional contact with the public.
(6) Plaintiff was “capable of performing past relevant work as a cleaner, housekeeping.”
(7) The claimant had not been under a disability, as defined by the Social Security Act, from March 14, 2014, through the date of the ALJ's decision.

         III. Standard of Review

          Review of the Commissioner's final decision is limited to determining whether the decision is supported by substantial evidence from the record and was a result of the application of proper legal standards. Carnes v. Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991) (“[T]his Court may reverse the decision of the [Commissioner] only when convinced that it is not supported by substantial evidence or that proper legal standards were not applied.”); see also Lewis v. Callahan, 125 F.3d 1436, 1439 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987). “A determination that is supported by substantial evidence may be meaningless . . . if it is coupled with or derived from faulty legal principles.” Boyd v. Heckler, 704 F.2d 1207, 1209 (11th Cir. 1983), superseded by statute on other grounds as stated in Elam v. R.R. Ret. Bd., 921 F.2d 1210, 1214 (11th Cir. 1991). As long as proper legal standards were applied, the Commissioner's decision will not be disturbed if, in light of the record as a whole, the decision appears to be supported by substantial evidence. 42 U.S.C. § 405(g); Falge v. Apfel, 150 F.3d 1320, 1322 (11th Cir. 1998); Lewis, 125 F.3d at 1439; Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995).

         Substantial evidence is more than a scintilla, but not a preponderance; it is “such relevant evidence as a reasonable mind would accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427 (1971) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 217 (1938)); Lewis, 125 F.3d at 1439. The reviewing court may not decide the facts anew, reweigh the evidence, or substitute its judgment for that of the Commissioner. Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990) (citations omitted). Even if the evidence preponderates against the Commissioner's decision, the decision must be affirmed if supported by substantial evidence. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir. 1986). A court “‘must scrutinize the record as a whole to determine if the decision reached is reasonable and supported by substantial evidence.'” Schink v. Comm'r of Soc. Sec., __ F.3d __, 2019 WL 4023639, at *6 (11th Cir. Aug. 27, 2019) (citing MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986)).

         The Act defines a disability as an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To qualify as a disability the physical or mental impairment must be so severe that the claimant is not only unable to do her previous work, “but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.” Id. § 423(d)(2)(A). Pursuant to 20 C.F.R. § 404.1520(a)-(g), [3] the Commissioner analyzes a disability claim in five steps:

1. If the claimant is performing substantial gainful activity, she is not disabled.
2. If the claimant is not performing substantial gainful activity, her impairments must be severe before she can be found disabled.
3. If the claimant is not performing substantial gainful activity and she has severe impairments that have lasted or are expected to last for a continuous period of at least twelve months, and if her impairments meet or medically equal the criteria of any impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, the claimant is presumed disabled without further inquiry.
4. If the claimant's impairments do not prevent her from doing her past relevant work, she is not disabled.
5. Even if the claimant's impairments prevent her from performing her past relevant work, if other work exists in significant numbers in the national economy that accommodates her RFC and vocational factors, she is not disabled.

         The claimant bears the burden of establishing that she suffers from a severe impairment that keeps her from performing her past work. 20 C.F.R. § 404.1512. If the claimant establishes such an impairment, the burden shifts to the Commissioner at step five to show the existence of other jobs in the national economy which, given the claimant's impairments, the claimant can perform. MacGregor, 786 F.2d at 1052. If the Commissioner carries this burden, the claimant must then prove she cannot perform the work suggested by the Commissioner. Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987).

         IV. Plaintiff's Medical History and Employment History

         A. Medical History

         Results from a July 2006 Magnetic Resonance Imaging (“MRI”) scan showed “mild disc degeneration at ¶ 5-6 with a small posterior disc protrusion extending beyond smaller spurs that was very close to cord with no displacement or complication.” (Tr. 17, 550). It also showed a smaller posterior disc bulge or minor protrusion at ¶ 6-7, causing mild deformity of the thecal sac, but not contacting the cord. (Id.). There were also subtle disc bulges at ¶ 4-5 and C7-T1. (Id.). The scan also indicated that there was a minimal bulge at ¶ 3-4. (Id.). Plaintiff has not received medical treatment for this impairment. (Id., Tr. 48).

         In February 2014, Plaintiff presented to the Bay County Health Department for blood pressure medication refills. Plaintiff reported a history that included a back and a left knee injury, but she denied any numbness, tingling, depression, or difficulty with sleeping. (Tr. 618). She also did not report any neck pain. Plaintiff was not prescribed anything for pain. (Tr. 618-23). In May 2014, Plaintiff denied any muscle or joint problems, pain, swelling, tingling, or numbness. (Tr. 614-15). These records reflect that she had no joint abnormalities or swelling. She had full range of motion and full strength. (Tr. 616). In July 2014, she reported swelling in her fingers and feet; however, she denied muscle or joint problems, muscle pain, numbness, or tingling. (Tr. 611). She also had no gross motor dysfunction and a normal mental status. (Tr. 612). These records also indicate that she had no joint abnormalities or swelling and that she had full range of motion and full strength. (Id.). In November 2014, she similarly denied any musculoskeletal or psychiatric problems. (Tr. 608). Plaintiff's additional exam results remained normal. (Tr. 606-08).

         In January 2015, Plaintiff received care from St. Andrew Community Medical Center. She reported occasional numbness and tingling in her hands and feet, but she did not report any neck pain. (Tr. 565-67). She denied muscle weakness, instability, or swelling. (Tr. 566). She denied any anxiety or depression. (Tr. 567). Upon exam, Plaintiff had a full range of motion, full strength in her upper and lower extremities, and intact hand grasp. (Tr. 567). In subsequent appointments in 2015 and 2016, Plaintiff continued to have normal exams. (Tr. 558-59, 561-63, 664-65). Plaintiff took only Tylenol for chronic pain. (Tr. 558, 664, 671, 678, 681, 684, 686, 688). In June 2016, Plaintiff was prescribed Vistaril for sleep. (Tr. 678). The ALJ noted that the records reflect that at her June 2016 appointment, Plaintiff's assessments included anxiety and depression for the first time. (Tr. 679). She was prescribed Celexa for depression and anxiety.[4] (Tr. 678, 681, 684, 686, 688). In November 2016, Plaintiff reported that she was doing well and had no new issues. She reported some depression but indicated that it was being managed by the Celexa. (Tr. 671). She stated that she should talk to someone about how to deal with life stressors including the death of her mother. (Id.).

         In July 2015, Dr. Brian Boehman, Ph.D., conducted a psychological evaluation of Plaintiff as part of her vocational rehabilitation. During the mental status exam, Plaintiff could perform simple arithmetic, simple subtraction, multiplication, and division. (Tr. 589). She did not struggle with immediate recall and was successful in delayed recall. (Id.). She was able to recall 2 of 3 words after a five-minute delay. She also correctly listed 6 digits forward and four digits backwards. (Id.). Plaintiff's mood was noted to be calm and friendly, but she exhibited signs of elevated anxiety through the evaluation. (Id.). Plaintiff's conversation was normal and appropriate, and she did not exhibit any confusion in her thought process. (Id.).

         Dr. Boehman also administered the Wechsler Adult Intelligence Scale-Fourth Edition and the Woodcock John II Test of Achievement. (Tr. 589-92). On the Wechsler test, Plaintiff obtained a verbal comprehension score of 80 (low average); a perceptual reasoning score of 73 (borderline); a working memory score of 86 (low average); a processing speed score of 68 (extremely low); and a full-scale IQ score of 72 (borderline). (Tr. 590). On the Woodcock Test, Plaintiff obtained a score in the average range in broad reading and broad written language. (Tr. 592). She scored in the low average range in broad mathematics. (Id.). When compared to others at her age level, Plaintiff's overall level of achievement was average. (Id.).

         Dr. Boehman also administered the Woodcock Johnson III Test of Cognitive Abilities to assess Plaintiff's executive processing ability. (Tr. 590, 592-93). Plaintiff scored in the low range in long-term retrieval and process speed; the low average range in verbal ability, cognitive efficiency, comprehension-knowledge, and auditory process; and the average range in short-term memory. (Tr. 592). Dr. Boehman administered the Wechsler Memory Scale-Fourth Edition. (Tr. 590, 593-94). Plaintiff scored in the extremely low range in auditory and immediate memory; the borderline range in visual memory and delayed memory; and the low average range in visual working memory. (Tr. 593).

         Plaintiff also took the Million Clinical Multiaxial Inventory-Third Edition test. (Tr. 590, 594). Dr. Boehman noted that Plaintiff's response style may indicate a tendency to magnify illness, an inclination to complain, or feelings of extreme vulnerability associated with a current episode of turmoil. (Tr. 594). He indicated that her scaled scores may be somewhat exaggerated. (Id.). Plaintiff's profile indicated that she was markedly dependent, anxious, and depressed. (Tr. 594). Plaintiff also took the Beck Anxiety Inventory and the Beck Depression Inventory and expressed a severe level of anxiety and a moderate level of depression. (Tr. 590, 595).

         Dr. Boehman diagnosed Plaintiff with major depressive disorder, recurrent, severe, without psychotic features; generalized anxiety disorder; and unspecified personality disorder. (Tr. 595). Dr. Boehman stated that Plaintiff's psychological functioning may impact her functioning in social and occupational environments. He stated that given Plaintiff's age and physical issues, a less physically challenging position would better fit her job needs. (Tr. 596). He noted that if Plaintiff was under stress, she may claim that simple responsibilities are too demanding for her. (Id.). Dr. Boehman noted that confidence in Plaintiff's ability to assume self-care may be fostered through a supportive attitude and a time-limited focus with explicit and constructive instruction to engage in behavioral changes. (Id.). He encouraged Plaintiff to seek counseling for her depression and anxiety.

         Plaintiff also was seen by three State Agency consultants. In October 2015, State Agency medical consultant Dr. Suzanne Johnson, D.O., completed a “Physical Residual Functional Capacity Assessment.” (Tr. 169-71). Dr. Johnson opined that Plaintiff could lift and/or carry 50 pounds occasionally and 25 pounds frequently; stand and/or walk for about 6 hours in an 8-hour workday and sit for about 6 hours in an 8-hour workday; frequently balance, stoop and crawl; and climb ramps, stairs, ladders, ropes, and scaffolds. (Tr. 169-71).

         In August 2015, State Agency psychological consultant Dr. Maurice Rudmann, Ph.D., completed a “Psychiatric Review Technique Form.” (Tr. 134-36). Dr. Rudmann opined that Plaintiff had mild restrictions on activities of daily living; moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no repeated episodes of decompensation. (Tr. 134). Dr. Rudmann also completed a “Mental Residual Functional Capacity Assessment.” (Tr. 137-39). Dr. Rudmann indicated that Plaintiff was moderately limited in her ability to: understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; complete a normal workday and work week without interruptions from psychologically based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods; interact appropriately with the general public; and respond appropriately to changes in the work setting. (Id.).

         In October 2015, State Agency psychological consultant Dr. Keith Bauer, Ph.D., also completed a “Psychiatric Review Technique Form” and a “Mental Residual Functional Capacity Assessment, ” Dr. Bauer concurred with Dr. Rudmann's findings. (Tr. 167-68, 171-73).

         B. Employment History

         The ALJ found that Plaintiff had past relevant work as a cleaner, housekeeping. The Vocational Expert (VE) testified that this job required light exertion with a specific vocational preparation of 2. (Tr. 21, 81).

         C. Relevant Hearing Testimony

         At Plaintiff's hearing, held on May 12, 2017, Plaintiff testified that she had tried to obtain a GED, but she did not pass. (Tr. 51). She had completed the eleventh grade. (Tr. 50). Plaintiff also testified that she has difficulty with math but she is capable of doing simple math. Plaintiff stated she could make change and manage her money jointly with her husband. (Tr. 51-52). Plaintiff testified that she could read pretty well, but later opined that she was “not the best reader.” (Tr. 52, 54). She stated that she has some trouble with words in a newspaper. (Tr. 55).

         As for her physical impairments, Plaintiff testified that she had swelling and tingling, muscle spasms, and pain in her hands. (Tr. 50). Plaintiff stated that she did not have trouble picking up and holding onto objects, however. (Id.). She had pain from head to toe, including: spasms and pain in her neck that radiated to her shoulders and arms. (Tr. 63-64). She has swelling in her knees and pain in her knees and hips. (Tr. 66). Plaintiff testified that she had bone spurs that caused pain in her foot. When her foot bothers her, Plaintiff uses a cane. (Tr. 72). Although Plaintiff could not recall how often she used the cane, she indicated that she last used the cane one month prior to the hearing. (Tr. 72). Plaintiff has custom orthotics made for her shoes. (Tr. 72-73). Plaintiff also testified that she has chest pains all of the time. (Tr. 74).

         Plaintiff stated that she did not have problems sitting, but she could sit in a chair for 10-15 minutes before she had to stand up and move around. (Tr. 71). She estimated she could stand in one place for 10-15 minutes before sitting down. (Tr. 69). She testified that she could walk for approximately 10 minutes. (Tr. 70).

         As for her psychological symptoms, Plaintiff testified that she suffered from depression, anxiety, panic attacks, paranoia, and has trouble sleeping. (Tr. 74). Plaintiff testified she could not handle heights, as heights caused anxiety and panic attacks. (Tr. 62, 74-75). Plaintiff testified that her panic attacks have worsened over the years. She stated that these panic attacks last as long as the problem that makes her anxious. (Tr. 365).

         A Vocational Expert (VE) also testified at the hearing. As noted above, the VE testified that Plaintiff's previous job of “cleaner, housekeeping” required light exertion with an SVP of 2. (Tr. 21, 81). The ALJ asked the VE to consider whether an individual could perform Plaintiff's past work if the person:

(1) was the same age, had the same education, and past work experience as Plaintiff;
(2) was limited to medium work;
(3) could climb ramps and stairs frequently;
(4) never climb ladders, ropes, or scaffolds;
(5) balance, stoop, and crawl frequently;
(6) could never work at unprotected heights;
(7) limited to performing simple, routine tasks;
(8) could have frequent contact with coworkers, but can have only occasional contact with the public; and
(9) is limited to simple, work-related decisions.

(Tr. 81-82, 83).[5] The VE testified that such a person would be able to perform Plaintiff's past work. (Tr. 82, 84-85). The VE testified that there were other jobs in the national economy that would accommodate such limitations, including: (1) packager, hand (medium with SVP of 2); (2) packer, agricultural (medium with SVP 2); and (3) cook helper (Medium with SVP 2). The ALJ then asked the VE to consider a person with the same limitations as the previous hypothetical except that the individual is limited to light work. The VE testified that there were jobs that would accommodate these ...

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