James E. Castle, Sr. v. Social Security Administration, Commissioner ( 2014 )

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[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 13-10007
Non-Argument Calendar
________________________
D.C. Docket No. 5:11-cv-03556-VEH
JAMES EARL CASTLE, SR.,
Plaintiff-Appellee,
versus
CAROLYN W. COLVIN,
ACTING COMMISSIONER
OF SOCIAL SECURITY
Defendant-Appellant.
___________________________
Appeal from the United States District Court
for the Northern District of Alabama
____________________________
(February 18, 2014)
Before TJOFLAT, PRYOR, and JORDAN, Circuit Judges.
PER CURIAM:
The Commissioner of Social Security appeals the district court’s order
reversing the Social Security Administration’s denial of disability insurance
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benefits to James E. Castle and remanding the case to the Administrative Law
Judge with instructions to obtain a consultative examination. We conclude that the
district court erred in ruling that substantial evidence did not support the ALJ’s
residual functional capacity (“RFC”) finding and in ordering a consultative
examination.1 Accordingly, we reverse and remand.
I
On October 26, 2009, Mr. Castle filed an application for a period of
disability and disability insurance benefits pursuant to Titles II and XVIII of the
Social Security Act, 42 U.S.C. §§ 401-433, 1395-1395kkk. Mr. Castle alleged a
disability onset date of January 1, 2008, and was last insured through March 31,
2009. The medical evidence submitted by Mr. Castle in support of his claim
revealed that he had a knee arthroscopy in October of 1998. Dr. Troy Layton, the
doctor who performed the surgery, ultimately released Mr. Castle back to work
without restrictions in April of 2000. Following Dr. Layton’s release, Mr. Castle
did not visit any physician regarding knee trouble or knee pain between 2001 and
2009.
In 2007, Mr. Castle saw a primary care physician for a cough, earache, sinus
pressure, and a sore throat. The doctor's notes indicated that Mr. Castle had a
1
Mr. Castle contends that we do not have jurisdiction, but he is mistaken. The district court
entered an order reversing the decision of the ALJ and remanding the matter pursuant to sentence
four of 42 U.S.C. § 405(g). As such, the district court’s order is final and appealable, and we
have jurisdiction over this appeal. See Newsome v. Shalala, 8 F.3d 775, 778 (11th Cir. 1993) (“If
the district court enters a “sentence four” remand order, that judgment is appealable.”).
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history of lumbar disc disease that had improved and a normal gait and station. At
this 2007 visit, Mr. Castle denied any significant musculoskeletal symptoms. Mr.
Castle visited the same doctor again in May of 2008 for a cough and ear infection.
At this visit, the doctor noted that Mr. Castle's lumbar condition was stable, Mr.
Castle again denied musculoskeletal symptoms, and the doctor observed that Mr.
Castle had a normal gait and station.
In was only in June of 2009—three months after his date last insured and
nine years after his knee arthroscopy—that Mr. Castle visited a chiropractor for
knee pain. Several visits with doctors ensued, and in February of 2010 Mr. Castle
had a knee arthroplasty. In March of 2011—two years after Mr. Castle’s date last
insured—Dr. Saadat Ansari, a doctor whom Mr. Castle had frequently visited since
October of 2009, completed a physical RFC assessment. Dr. Ansari opined that
Mr. Castle’s pain frequently interfered with his attention and concentration and
that even working a low stress job would be problematic. Dr. Ansari noted,
however, that his assessment was primarily based on subjective findings.
Mr. Castle’s application for disability and disability insurance benefits was
ultimately denied on December 21, 2009, and he subsequently requested a hearing
before an ALJ. The ALJ conducted a hearing on April 19, 2011. The ALJ found
that Mr. Castle had not established that he was disabled by his date last insured—
March 31, 2009—and that the records after that date were immaterial. The ALJ did
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find that Mr. Castle had severe impairments of obesity and knee arthritis. But
because neither impairment nor combination of impairments met or equaled a
listed impairment, the ALJ had to make a determination of Mr. Castle’s RFC. The
ALJ determined that Mr. Castle's RFC was less than the full range of medium
work, and that Mr. Castle could (1) frequently lift 25 pounds; (2) occasionally lift
50 pounds; (3) stand, walk, and sit for 6 hours; (4) frequently push and pull with
his lower extremities, as well as balance, stoop, and crouch; and (5) occasionally
climb, kneel, and crawl.
The ALJ noted that Mr. Castle's impairments reasonably could be expected
to cause the alleged symptoms, but that Mr. Castle's statements concerning the
intensity, persistence, and limited effects were not credible to the extent they were
inconsistent with the RFC. The ALJ cited to a function report completed in
November of 2009, where Mr. Castle himself noted that he shopped, prepared
meals, drove, mowed his lawn, attended church, walked, and did laundry. The ALJ
further noted that Mr. Castle also failed to seek medical treatment for his knee
from the alleged onset date through the date last insured, which suggested that his
knee problems were not severely limiting during that time. The ALJ determined
that the limitations Mr. Castle listed in the November 2009 function report were
inconsistent with the activities of daily living that Mr. Castle reported in the same
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function report and were inconsistent with the lack of medical treatment prior to
the date last insured.
The ALJ also afforded little weight to Dr. Ansari's opinions from March
2011, as they were based on subjective findings and information obtained after the
March 2009 date last insured. The ALJ noted that Mr. Castle had not sought
medical treatment for his knees between 2001 and October of 2009, denied
significant musculoskeletal symptoms in 2007 and 2008, had a normal gait and
station in 2007 and 2008, and participated in significant activities of daily living.
The ALJ determined that, although Mr. Castle could not perform his past relevant
work, there were other existing jobs that he could perform. Thus, the ALJ found
that he was not disabled. Mr. Castle appealed the ALJ' s determination, but the
Appeals Council denied his appeal.
In October 2011, Mr. Castle filed a complaint in the district court. The
district court determined that the ALJ did not err in affording little weight to Dr.
Ansari' s RFC assessment, as it was completed two years after the date last insured.
The district court also ruled, however, that the ALJ’s RFC finding was not
supported by substantial evidence. The court found that the ALJ discounted the
only physician assessment regarding Mr. Castle's ability to work, so the record did
not contain any medical opinion regarding his ability to work with his physical
limitations. The court noted that the ALJ was not a trained medical professional,
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and found that the ALJ "play[ed] doctor" by interpreting the lack of medical data.
The court noted that the ALJ had a duty to develop a full and fair record and ruled
that it was error for the ALJ to fail to order a consultative examination when one
was necessary to make an informed decision. The court remanded the case with
instructions for the ALJ to order a consultative examination of Mr. Castle. This
appeal by the Commissioner timely followed.
II
We review "de novo the district court's decision on whether substantial
evidence supports the ALJ's decision." Wilson v. Barnhart, 284 F.3d 1219, 1221
(11th Cir. 2002). Thus, "the question is not whether substantial evidence supports a
finding made by the district court but whether substantial evidence supports a
finding made by the [ALJ]." Graham v. Bowen, 790 F.2d 1572, 1575 (11th Cir.
1986). Substantial evidence is defined as "more than a scintilla and is such relevant
evidence as a reasonable person would accept as adequate to support a conclusion."
Crawford v. Comm'r of Soc. Sec. Admin., 363 F.3d 1155, 1158 (11th Cir. 2004)
(internal quotation marks omitted). Even if we find that the evidence preponderates
against the ALJ's decision, we must affirm the ALJ's decision if the decision is
supported by substantial evidence. See id. at 1158-59. See also Ellison v. Barnhart,
355 F.3d 1272, 1275 (11th Cir. 2003).
III
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The district court erred in concluding that the ALJ’s RFC finding was not
supported by substantial evidence. On the contrary, the record was fully and fairly
developed, and a consultative examination was unnecessary.
Pursuant to 20 C.F.R. § 404.1520, an ALJ must follow a five-step,
sequential evaluation process for determining disability. During the first three
steps, the claimant bears the burden of proving that (1) he “has not engaged in
substantial gainful activity,” (2) he “has a severe impairment or combination of
impairments, and (3) his “impairment or combination of impairments meets or
equals a listed impairment.” Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999).
If the claimant “cannot prevail at the third step, [he] must proceed to the fourth
step where [he] must prove that [he] is unable to perform [his] past relevant work.”
Id.
At this fourth step, the ALJ must make an assessment of the claimant’s RFC.
See Phillips v. Barnhart, 357 F.3d 1232, 1238 (11th Cir. 2004). The RFC is an
assessment, based on all relevant medical and other evidence, of a claimant’s
remaining ability to work despite his impairment. See Lewis v. Callahan, 125 F.3d
1436, 1440 (11th Cir. 1997). The claimant is responsible for providing medical
evidence demonstrating an impairment and how severe the impairment is during
the relevant time period. See 20 C.F.R. § 404.1512(c). A claimant who is seeking
to establish a disability based on subjective testimony of pain and other symptoms
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“must satisfy two parts of a three-part test showing: (1) evidence of an underlying
medical condition; and (2) either (a) objective medical evidence confirming the
severity of the alleged pain; or (b) that the objectively determined medical
condition can reasonably be expected to give rise to the claimed pain.” Wilson v.
Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002). See also Dyer v. Barnhart, 395
F.3d 1206, 1210 (11th Cir. 2005). If a claimant satisfies step four, the burden at
step five shifts to the Commissioner to demonstrate there is other work available in
the national economy that the claimant can perform. See Jones, 190 F.3d at 1228.
If the Commissioner demonstrates that jobs are available, the claimant must show
that he is unable to perform those jobs in order to be found disabled. Id.
Here, the ALJ’s RFC finding is sufficiently supported by the record. During
the relevant time period between January of 2008 and March of 2009, Mr. Castle
did not once visit a physician for his alleged knee pain. When Mr. Castle did visit
his primary care physician during the relevant time period, he denied
musculoskeletal problems and the doctor noted that he had a normal gait and
station. Moreover, Mr. Castle testified at his hearing before the ALJ that he did
not seek treatment for his knees until several months after his date last insured.
Mr. Castle also admitted, in the function report he completed in November of
2009, that he regularly prepared meals taking up to one and a half hours, mowed
the yard for up to four hours, did the laundry, attended church, cared for doves,
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grocery shopped, and went out to eat. Finally, Dr. Troy Layton, who operated on
Mr. Castle’s knee in 1998, released Mr. Castle with no work restrictions as of April
of 2000. We conclude that such evidence was sufficient to support the ALJ’s RFC
finding.
With regards to Mr. Castle’s subjective testimony of pain and other
symptoms, it is true that Mr. Castle may have suffered from knee problems and
obesity, but the record is devoid of any objective medical evidence confirming the
severity of the alleged pain. The ALJ noted that although it was possible that Mr.
Castle’s alleged pain could reasonably be expected to arise from his impairments,
Mr. Castle's statements concerning the intensity, persistence, and limited effects
were not credible to the extent they were inconsistent with the RFC assessment.
See Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005) (“The ALJ discredited
[claimant’s subjective complaints of pain] by explaining that this pain had not
require[d] routine or consistent treatment, and [the claimant] often went for months
or years between complaining of this pain to his physicians.”).
IV
Because we conclude that the record was fully and fairly developed, a
consultative examination was not necessary for the ALJ to make an informed
decision. “[A] hearing before an ALJ is not an adversary proceeding,” and “the
ALJ has a basic obligation to develop a full and fair record.” Graham v. Apfel, 129
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F.3d 1420, 1422 (11th Cir. 1997). At this hearing, the burden was on Mr. Castle to
prove that he was disabled before his date last insured and, therefore, entitled to
receive Social Security benefits. See Doughty v. Apfel, 245 F.3d 1274, 1278 (11th
Cir. 2001); 20 C.F.R. § 404.1512. The ALJ “has a duty to develop the record
where appropriate but is not required to order a consultative examination as long as
the record contains sufficient evidence for the [ALJ] to make an informed
decision.” Ingram v. Comm’r of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir.
2007). In this case, the record contains sufficient evidence supporting the ALJ’s
RFC finding: (1) Mr. Castle’s lack of treatment for his knee problems; (2) his
denial of musculoskeletal issues; (3) his weekly regiment; (4) and Dr. Layton’s
release without work restrictions.
Contrary to the district court's reasoning, the ALJ did not "play doctor" in
assessing Mr. Castle’s RFC, but instead properly carried out his regulatory role as
an adjudicator responsible for assessing Mr. Castle’s RFC. See 20 C.F.R. §
404.1545(a)(3) ("We will assess your residual functional capacity based on all of
the relevant medical and other evidence."). Indeed, the pertinent regulations state
that the ALJ has the responsibility for determining a claimant’s RFC. 20 C.F.R. §
404.1546(c). An ALJ must give a treating physician’s opinion substantial weight,
unless good cause is shown. See Phillips v. Barnhardt, 357 F.3d 1232, 1240 (11th
Cir. 2004). Good cause exists when the “(1) treating physician's opinion was not
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bolstered by the evidence; (2) evidence supported a contrary finding; or (3) treating
physician's opinion was conclusory or inconsistent with the doctor's own medical
records.” Id. at 1241. The district court correctly noted that the ALJ should have
afforded Dr. Ansari’s 2011 opinion less weight. First, Dr. Ansari completed his
assessment two years after Mr. Castle’s date last insured. Second, other evidence in
the record supports a contrary finding: the lack of medical treatment during the
relevant time period; Mr. Castle’s own testimony; his self-reported activities; and
Dr. Layton’s opinion following Mr. Castle’s knee arthroscopy.
In ordering a consultative examination, the district court relied on Manso-
Pizarro v. Sec'y of Health & Human Servs., 76 F.3d 15, 17 (1st Cir. 1996), and
ruled that an ALJ is not qualified to interpret raw data in a medical record. That
reliance, in our view, was misplaced. In Manso-Pizarro, the claimant’s medical
record, involving a serious heart condition and multiple stays at the hospital, was
far more complicated than Mr. Castle’s. See id. at 18 (“During the claimant’s 12-
day hospital stay, seven electrocardiograms combined conclusively to show sinus
tachycardia. Two chest x-rays revealed an enlarged heart. No fewer than five
physicians were asked to consult.”). Furthermore, medical tests revealed
“ventricular tachycardia [ ], frequent PVCs, premature arterial contractions, and
some evidence of paroxysmal atrial [ ].” Id. The First Circuit found that “those
reports otherwise unambiguously indicate the existence of medical conditions and
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symptomatology that do not appear, at least without further evaluation by an
expert, to be so mild as to make it obvious to a layperson that the claimant's ability
to perform her particular past work as a cook's helper was unaffected.” Id. at 18-19
Mr. Castle’s case is unlike the claimant’s case in Manso-Pizarro and falls
within the exception articulated by the First Circuit. See id. at 17 ("[W]here the
medical evidence shows relatively little physical impairment, an ALJ permissibly
can render a commonsense judgment about functional capacity even without a
physician's assessment.”). Mr. Castle’s lack of medical treatment for his knees
during the relevant period does not demand review by a medical professional.
V
The ALJ appropriately considered all of the evidence Mr. Castle proffered in
support of his claim of disability. The district court erred in concluding that
substantial evidence did not support the ALJ’s RFC finding, that the ALJ’s
findings should have been underpinned by a medical source opinion, and that the
ALJ was not qualified to interpret Mr. Castle’s straightforward medical record.
Because the ALJ=s RFC finding is supported by substantial evidence and the ALJ
properly carried out his regulatory role, we reverse and remand for proceedings
consistent with this opinion.
REVERSED AND REMANDED.
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