Perez v. Commissioner of Social Security

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF FLORIDA

ORLANDO DIVISION

NITZA ANGELA PEREZ,

Plaintiff,

v. Case No: 6:20-cv-1470-LRH

COMMISSIONER OF SOCIAL

SECURITY

Defendant.

MEMORANDUM OF DECISION1

Nitza Angela Perez (“Claimant”) appeals the final decision of the

Commissioner of Social Security (“the Commissioner”) denying her applications for

Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”).

Claimant raises one argument challenging the Commissioner’s final decision, and,

based on that argument, requests that the matter be reversed and remanded for

further administrative proceedings. (Doc. 27, at 12, 39). The Commissioner

asserts that the decision of the Administrative Law Judge (“ALJ”) is supported by

substantial evidence and should be affirmed. (Id., at 39). For the reasons

1 The parties have consented to the exercise of jurisdiction by a United States Magistrate

Judge. See Docs. 26, 30-31.

discussed herein, the Commissioner’s final decision is REVERSED and

REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. §

405(g).

I. PROCEDURAL HISTORY.

On January 16, 2018, Claimant filed applications for DIB and SSI, alleging that

she became disabled on April 11, 2017. (R. 204, 211, 217).2 Her claims were

denied initially and on reconsideration, and she requested a hearing before an ALJ.

(R. 122-27; 128-29; 130-41). A hearing was held before the ALJ on August 5, 2019,

at which Claimant was represented by an attorney. (R. 35-57). Claimant and a

vocational expert (“VE”) testified at the hearing. (Id.). Following the hearing, the

ALJ issued an unfavorable decision finding that Claimant was not disabled. (R.

14–34). Claimant sought review of the ALJ’s decision by the Appeals Council. See

R. 4-5. On June 10, 2020, the Appeals Council denied the request for review. (R.

1–5). Claimant now seeks review of the final decision of the Commissioner by this

Court. (Doc. 1).

2 The Joint Memorandum and the ALJ’s decision state that Claimant filed her applications

for benefits on January 25, 2018. See Doc. 27, at 1, 13; R. 17. However, the applications themselves

are dated January 16, 2018. (R. 211, 217).

II. THE ALJ’S DECISION.3

After considering the entire record, the ALJ performed the five-step

evaluation process as set forth in 20 C.F.R. §§ 404.1520(a), 416.920(a). (R. 19-28).4

The ALJ first found that Claimant meets the insured status requirements of the

Social Security Act through December 31, 2022. (R. 19). The ALJ concluded that

Claimant had not engaged in substantial gainful activity since April 11, 2017, her

alleged onset date. (Id.).

The ALJ then found that Claimant suffered from the following severe

impairments: degenerative disc disease, carpal tunnel syndrome, chronic

obstructive pulmonary disease (“COPD”), obesity, fibromyalgia, cervical dystonia,

depression, and anxiety. (Id.). The ALJ also found that Claimant has

gastroesophageal reflux disease (“GERD”), but that it is a non-severe impairment.

(R. 19-20). The ALJ concluded that Claimant did not have an impairment or

3 Upon a review of the record, the Court finds that counsel for the parties have adequately

stated the pertinent facts of record in the Joint Memorandum. (Doc. 27). Accordingly, the Court

adopts those facts included in the body of the Joint Memorandum by reference and only restates

them herein as relevant to considering the issues raised by Claimant.

4 An individual claiming Social Security disability benefits must prove that he or she is

disabled. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005) (citing Jones v. Apfel, 190 F.3d 1224,

1228 (11th Cir. 1999)). The five steps in a disability determination include: (1) whether the

claimant is performing substantial, gainful activity; (2) whether the claimant’s impairments are

severe; (3) whether the severe impairments meet or equal an impairment listed in 20 C.F.R. Part

404, Subpart P, Appendix 1; (4) whether the claimant can return to his or her past relevant work;

and (5) based on the claimant’s age, education, and work experience, whether he or she could

perform other work that exists in the national economy. See generally Phillips v. Barnhart, 357 F.3d

1232, 1237 (11th Cir. 2004) (citing 20 C.F.R. § 404.1520).

combination of impairments that met or equaled a listed impairment in 20 C.F.R.

Part 404, Subpart P, Appendix 1. (R. 20).

After careful consideration of the entire record, the ALJ determined that

Claimant had the residual functional capacity (“RFC”) to perform sedentary work

as defined in the Social Security regulations,5 except:

frequently reaching in all directions bilaterally. [Claimant] can

frequently handle and finger bilaterally. The claimant can climb

ramps and stairs frequently, climb ladders and ropes, or scaffolds

occasionally. The claimant can frequently balance, stoop, kneel,

crouch, and crawl. The claimant can work at unprotected heights

occasionally, moving mechanical parts occasionally, in extreme cold

occasionally, in extreme heat occasionally, in vibration occasionally.

The claimant is able to perform simple, routine tasks, and she [is] able

to perform simple work-related decisions. The claimant is able to

interact with supervisors and co-workers frequently and she can

interact with the public occasionally.

(R. 22).

Based on this assessment, the ALJ concluded that Claimant was not capable

of performing past relevant work, which included work as a mail clerk, dental

5 The social security regulations define sedentary work to include:

lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like

docket files, ledgers, and small tools. Although a sedentary job is defined as one which

involves sitting, a certain amount of walking and standing is often necessary in carrying

out job duties. Jobs are sedentary if walking and standing are required occasionally and

other sedentary criteria are met.

20 C.F.R. §§ 404.1567(a), 416.967(a). The ALJ referenced in his decision §§ 404.1567(b) and

416.967(b), both of which define “light work.” (R. 22). The Court believes this to be a scrivener’s

error, as both the ALJ and the parties repeatedly reference and consider only sedentary work. See,

e.g., R. 26-28; Doc. 27, at 12.

assistant, receptionist, and file clerk. (R. 26). However, the ALJ found that,

considering Claimant’s age, education, work experience, and residual functional

capacity, as well as the testimony of the VE, Claimant is capable of making a

successful adjustment to other work that exists in significant numbers in the

national economy. (R. 27). Specifically, the ALJ found that Claimant would be

able to perform the requirements of representative occupations such as: telephone

clerk, doc preparer, and call out operator. (R. 27-28). Accordingly, the ALJ

concluded that Claimant was not under a disability, as defined by the Social

Security Act, from her alleged disability onset date through the date of decision.

(R. 28).

III. STANDARD OF REVIEW.

Because Claimant has exhausted her administrative remedies, the Court has

jurisdiction to review the decision of the Commissioner pursuant to 42 U.S.C. §

405(g), as adopted by reference in 42 U.S.C. § 1383(c)(3). The scope of 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 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 if the decision

is supported by substantial evidence. Bloodsworth v. Heckler, 703 F.2d 1233, 1239

(11th Cir. 1983).

IV. ANALYSIS.

In the Joint Memorandum, which the Court has reviewed, Claimant raises

only one assignment of error: that the ALJ erred in his consideration of the joint

opinion of Claimant’s treating psychiatric providers, Dr. Naomi Jones, Ph.D.,

Christine Forge, APRN, and Dr. Ramon O. Martinez, M.D. (Doc. 27, at 12-24).

Accordingly, this is the only issue the Court will address.

The ALJ is tasked with assessing a claimant’s RFC and ability to perform past

relevant work. 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. In

determining a claimant’s RFC, the ALJ must consider all relevant evidence,

including the opinions of medical and non-medical sources. 20 C.F.R. §§

404.1545(a)(3), 416.945(a)(3).

Claimant filed her applications for DIB and SSI on January 16, 2018. (R. 211,

217). Effective March 27, 2017, the Social Security Administration implemented

new regulations related to the evaluation of medical opinions, which provide, in

pertinent part, as follows:

(a) How we consider medical opinions and prior administrative

medical findings. We will not defer or give any specific evidentiary

weight, including controlling weight, to any medical opinion(s) or

prior administrative medical finding(s), including those from your

medical sources. When a medical source provides one or more

medical opinions or prior administrative medical findings, we will

consider those medical opinions or prior administrative medical

findings from that medical source together using the factors listed in

paragraphs (c)(1) through (c)(5) of this section, as appropriate. The

most important factors we consider when we evaluate the

persuasiveness of medical opinions and prior administrative medical

findings are supportability (paragraph (c)(1) of this section) and

consistency (paragraph (c)(2) of this section). We will articulate how

we considered the medical opinions and prior administrative medical

findings in your claim according to paragraph (b) of this section.

20 C.F.R. §§ 404.1520c(a), 416.920c(a). Subparagraph (c) provides that the factors

to be considered include: (1) supportability; (2) consistency; (3) relationship with

the claimant (which includes consideration of the length of treatment relationship;

frequency of examination; purpose of treatment relationship; extent of treatment

relationship; and examining relationship); (4) specialization; and (5) other factors

that tend to support or contradict a medical opinion or prior administrative medical

finding. Id. §§ 404.1520c(c), 416.920c(c).

Pursuant to the new regulations, the Commissioner is not required to

articulate how she “considered each medical opinion or prior administrative

medical finding from one medical source individually.” Id. §§ 404.1520c(b)(1),

416.920c(b)(1). Rather, under the regulations, the most important factors the

Commissioner will consider when determining the persuasiveness of medical

opinions are supportability and consistency. Id. §§ 404.1520c(b)(2), 416.920c(b)(2).

The regulations state that the Commissioner will explain how she considered the

supportability and consistency factors in the determination or decision. Id. Thus,

“[o]ther than articulating [her] consideration of the supportability and consistency

factors, the Commissioner is not required to discuss or explain how [she]

considered any other factor in determining persuasiveness.” Freyhagen v. Comm’r

of Soc. Sec. Admin., No. 3:18-cv-1108-J-MCR, 2019 WL 4686800, at *2 (M.D. Fla. Sept.

26, 2019) (quoting Mudge v. Saul, No. 4:18CV693CDP, 2019 WL 3412616, at *4 (E.D.

Mo. July 29, 2019)). See also Bolton v. Comm’r of Soc. Sec. Admin., No. 6:20-cv-1900-

DNF, 2021 WL 5231760, at *7 (M.D. Fla. Nov. 10, 2021) (finding no error where ALJ

did not address in the decision any factors other than supportability and

consistency) (citing Torres v. Comm'r of Soc. Sec., No. 6:19-cv-1662-ORL-PDB, 2020

WL 5810273, at *2 (M.D. Fla. Sept. 30, 2020))).

On July 22, 2019, Claimant’s treating psychiatric providers, Dr. Naomi Jones,

Ph.D., Christine Forge, APRN, and Dr. Ramon O. Martinez, M.D. (“the treating

providers”) jointly completed and signed a “Mental Impairment Questionnaire” on

behalf of Claimant. (R. 776-79). The questionnaire instructed the treating

providers to answer a series of questions intended to “determine [the] individual’s

ability to do work-related activities on a day-to-day basis in a regular work setting.”

(R. 776) (emphasis in original removed). The treating providers assessed

Claimant’s functional limitations in numerous categories, and in particular opined

that she had “extreme” limitations in her abilities to: maintain attention and

concentration for extended periods; work in coordination with or in proximity to

others without being distracted by them; complete a normal workday or workweek

without interruptions from psychologically based symptoms; interact

appropriately with the general public; accept instructions and respond

appropriately to criticism from supervisors; get along with coworkers or peers

without distracting them or exhibiting behavioral extremes; respond appropriately

to changes in the work setting; and travel in unfamiliar places or use public

transportation. (R. 776-78).

Throughout the questionnaire, the treating providers also noted Claimant’s

severe anxiety, explaining, for example, that Claimant “is unable to go out into

public due to severe anxiety. She stays home and her husband does tasks such as

grocery shopping. The tremors she experiences cause[] social anxiety and

prevent[] [Claimant] from attending functions where there are people she does not

know.” (R. 777). The treating providers indicated that Claimant has had the

limitations and restrictions outlined in the questionnaire since January 16, 2019 –

the date they began treating her. (R. 779). They opined that Claimant would

likely have four or more absences from work in an average month. (R. 777). The

entirety of the ALJ’s analysis of the questionnaire is as follows:

I find that the mental health impairment questionnaire completed by

Dr. Jones Ph.D., Dr. Ramon Martines [sic], and Christine Forfe [sic]

APRN, is not persuasive because it is inconsistent with the mental

health records. (Ex. 24F). Status examinations largely show normal

functions on insight, decision, she is see [sic] appropriately groomed,

and she has no suicidal or homicidal issues. Further, the claimant has

never been hospitalized for mental issues-voluntarily or involuntarily.

She even has reported to improvement with medication and she has

not identified issues with regard to getting along with others. (Ex.

7E).

(R. 25-26).

In sum, the ALJ provided three reasons for discounting the treating

providers’ opinion: (1) Claimant’s mental status examinations were largely normal,

(2) Claimant has never been voluntarily or involuntarily hospitalized for mental

issues, and (3) Claimant has reported improvement with medication and has not

identified issues with regard to getting along with others.

Claimant concedes that the new regulations apply to her claims, and that the

two most important factors to consider are consistency and supportability. (Doc.

27, at 13-14). Nonetheless, Claimant argues generally that the ALJ did not comply

with the new regulations because he did not explain why the treating providers’

opinion was not consistent with existing medical records or how the opinions were

not supported by the records. (Id.). And while Claimant’s argument is not a

model of clarity, she appears to challenge the ALJ’s evaluation of the treating

providers’ opinion on four specific grounds: (1) the ALJ failed to specify which

records and findings he relied on to support his conclusion that the opinion was

inconsistent with mental health records, or explain the purported inconsistency, (2)

the ALJ’s rationale that Claimant reported improvement in her symptoms with

medication is misplaced, (3) the ALJ erroneously found that Claimant has not

identified issues in getting along with others, and (4) the ALJ’s reliance on the lack

of mental health hospitalizations is improper. (Id., at 14-24). The Court will

address each of these arguments in turn.6

6 In the Joint Memorandum, Claimant raises an additional argument with respect to the

ALJ’s statement that Claimant had a neat appearance and engaged in certain daily activities, and

contends that this was an improper rationale for rejecting the opinion of the treating providers.

(Doc. 27, at 18; citing R. 25-26). While the ALJ mentions that Claimant appeared before her

treating providers “appropriately groomed,” in the context of summarizing examination records,

the discussion of Claimant’s personal hygiene and daily activities was made in reference to

Claimant’s subjective testimony. See R. 26. Claimant has not challenged the ALJ’s analysis of her

subjective testimony, thus to the extent Claimant seeks to raise that here, such issues have been

waived. See Persichilli v. Comm'r of Soc. Sec. Admin., 246 F. App'x 613, 615 (11th Cir. 2007) (issues

not raised before the district court are waived).

First, Claimant argues that the ALJ erred by failing to specify which records

and findings he relied on to support his conclusion that the opinion was

“inconsistent with the mental health records” or to explain the alleged

inconsistencies. (Id., at 14; citing R. 25). Claimant argues that while the ALJ did

reference status examinations which “largely show normal functions on insight,

decision” and show that she was appropriately groomed and displayed no suicidal

or homicidal ideation, the ALJ never discussed how this evidence was inconsistent

with the treating providers’ opinion. (Id.).

The Court agrees with Claimant’s first argument. The ALJ stated, in

conclusory fashion, that the treating providers’ opinion is inconsistent with the

mental health records, but he provided little in the way of support for this

conclusion. Rather, the ALJ stated generally that “[s]tatus examinations largely

show normal functions on insight, decision, she is see[n] appropriately groomed,

and she has no suicidal or homicidal issues.” (Id.). Elsewhere in the decision,

the ALJ references a mental status examination from Claimant’s treating providers

indicating that Claimant’s thought process was clear and her insight and judgment

were intact, and primary care notes stating that Claimant appeared well-groomed.

(R. 24-25). However, because the ALJ did not discuss these records in relation to

the treating providers’ opinion or explain how they demonstrate an inconsistency

between the opinion and the evidence of record, the ALJ “failed to build the

requisite ‘accurate and logical bridge from the evidence to [his]

conclusion.’” Pierson v. Comm'r of Soc. Sec., No. 6:19-cv-01515-RBD-DCI, 2020 WL

1957597, at *4 (M.D. Fla. Apr. 8, 2020), report and recommendation adopted, 2020 WL

1955341 (M.D. Fla. Apr. 23, 2020) (quoting Flentroy-Tennant v. Astrue, 2008 WL

876961, at *8 (M.D. Fla. Mar. 27, 2008)).7

And the ALJ’s statement that Claimant has no suicidal or homicidal issues is

similarly problematic. Claimant argues that the ALJ failed to explain how her lack

of suicidal or homicidal ideations translates into an ability to sustain concentration,

persistence or pace, to adapt to changes, or to interact appropriately with others in

a work setting, particularly where the treating providers opined that Claimant has,

at times, extreme limitations in social interaction stemming from her anxiety in

being around others. (Id., at 19; see R. 776-79). The Court agrees. The ALJ

provided no rationale for his finding that Claimant’s lack of homicidal or suicidal

issues is inconsistent with the treating providers’ opinion, and thus the ALJ has

erred. See also Castro v. Acting Comm’r of Soc. Sec., 783 F. App'x 948, 956 (11th Cir.

7 Further, the Eleventh Circuit has recognized that it is not inconsistent that a person

suffering from certain mental health conditions may be capable of demonstrating normal judgment

and insight in the controlled setting of a medical clinic. See Simon v. Comm'r, Soc. Sec. Admin., 7

F.4th 1094, 1107 (11th Cir. 2021); see also Castro v. Acting Comm'r of Soc. Sec., 783 F. App'x 948, 956

(11th Cir. 2019) (“Without more, we cannot say that [psychiatrist’s] observations of Castro's

judgment, insight, thought process, and thought content in a treatment environment absent work

stressors were inconsistent with his assessments about the limitations she would face in a day-to-

day work environment.”).

2019) (noting that “‘the work environment is completely different from home or a

mental health clinic’”) (quoting Morales v. Apfel, 225 F.3d 310, 319 (3d Cir. 2000))).8

Absent an explanation from the ALJ, the Court cannot say that the ALJ’s

determination that the opinion is inconsistent with the mental health records is

supported by substantial evidence. See Pierson, 2020 WL 1957597, at *4 (holding,

under both the new and old regulations, that “[c]onclusory statements by the ALJ

that an examining physician's opinion is inconsistent with the medical record are

insufficient to show an ALJ's decision is supported by substantial evidence unless

the ALJ articulates factual support for such a conclusion. Otherwise, the Court is

left to guess at which particular records the ALJ asserts support the ALJ's decision

and, in doing so, impermissibly reweigh the evidence.”) (internal quotations and

citations omitted); Hanna v. Astrue, 395 F. App'x 634, 636 (11th Cir. 2010) (“The ALJ

must state the grounds for his decision with clarity to enable us to conduct

meaningful review.”). See also Brown v. Comm'r of Soc. Sec., No. 6:20-CV-840-GJK,

2021 WL 2917562, at *4 (M.D. Fla. July 12, 2021) (noting that when evaluating

medical opinions under the new regulations, the ALJ must “explain his decision,

particularly with respect to supportability and consistency”) (emphasis in original)

(citing Pierson, 2020 WL 1957597, at *6)).

8 Unpublished opinions of the Eleventh Circuit are cited as persuasive authority. See 11th

Cir. R. 36–2.

Second, Claimant takes issue with the ALJ’s rationale that Claimant reported

improvement in her symptoms with medication. (Doc. 27, at 17-18). Claimant

argues that the ALJ’s rationale is misplaced and points to evidence in the record

indicating that she continued to struggle with mental health issues despite being

treated with medication. (Id., at 17; citing R. 746, 749, 750, 752, 753). Specifically,

Claimant notes that during several mental status examinations, Claimant reported

some improvement in mood stabilization with medication but nonetheless reported

being “overly emotional,” “weepy at times,” and at times continuing to experience

panic attacks. (Id.). Claimant argues that, at best, these mental status

examinations indicate that “some days…were better than others,” but that the ALJ’s

reliance on Claimant’s “good days” as a basis for discrediting the treating

providers’ opinion was improper. (Id., at 17-18).

While the ALJ did not provide a citation to the record in support of his finding

in the section of the decision where he discusses the opinion of the treating

providers, elsewhere in the decision the ALJ cited to an April 10, 2019 treatment

note in which Claimant reported improvement in her mood, depression, and

anxiety with medication. (R. 25; citing R. 750). However, as explained above, it

is not the role of the Court to assume that the ALJ intended to cite this record as

support for his conclusion that the treating providers’ opinion is inconsistent with

the record evidence. See, e.g., Pierson, 2020 WL 1957597, at *4 (“Even if the Court

waded through the ALJ's entire discussion of the medical record in this case (which

is contained in a separate section of the decision) and managed to identify those

records that both fall within the relevant time period and (in the Court's opinion)

appear inconsistent with Dr. Perdomo's ‘limited residual functional capacity,’ the

ALJ never discussed any such records in relation to Dr. Perdomo's opinion.”).

Accordingly, the Court cannot say that the ALJ’s finding on this point is supported

by substantial evidence, because to do so would require impermissibly reweighing

the evidence. See Bloodsworth, 703 F.2d at 1239. Moreover, as the Eleventh Circuit

has noted, occasional references to a claimant with mental health issues as being

“stable on medication” are not necessarily inconsistent with a finding of debilitating

mental illness, as many mental disorders “are characterized by the unpredictable

fluctuation of their symptoms.” Simon, 7 F.4th at 1106. Given this, the ALJ’s failure

to explain how Claimant’s reported improvement on medication contradicts the

treating providers’ opinion is especially problematic. Thus, the Court finds this

argument persuasive.

Next, Claimant challenges the ALJ’s statement that Claimant “has not

identified issues with regard to getting along to others.” (Doc. 27, at 19-20; citing

R. 26). In support of this statement, the ALJ cites to a Function Report completed

by Claimant. (R. 26; citing R. 280-87). Claimant argues that the ALJ erred in

failing to explain how her ability to get along with others translates into an ability

to control her emotions and function in a work setting. (Doc. 27, at 19-20).

Moreover, Claimant points to evidence in the record, including the Function Report

itself, indicating that Claimant has reported difficulty in getting along with others.

(Id.).

The Court agrees with Claimant that the ALJ’s finding on this point is not

supported by substantial evidence. As Claimant points out, in the Function Report

cited by the ALJ, Claimant checked the box for “yes” in answering the question “Do

you have any problems getting along with family, friends, neighbors, or others?”

and thereafter explained that she sometimes does not get along with friends and

family because they “sometimes don’t understand my frustration.” (R. 285). And

in fact, elsewhere in the decision the ALJ contradictorily states that “the claimant

reported to difficulty remembering, completing tasks, concentrating,

understanding, and getting along with others” – citing, in part, the Function Report.

(R. 22-23). Thus, as the ALJ himself has noted, Claimant in fact has reported

difficulty in getting along with others. See R. 285. The Court therefore cannot say

that the ALJ’s finding is supported by substantial evidence because to attempt to

guess at which records the ALJ may have intended to cite to support this rationale

would require the Court to impermissibly reweigh the evidence. See Pierson v.

2020 WL 1957597, at *4; Bloodsworth, 703 F.2d at 1239.

Last, Claimant argues that the ALJ’s reasoning that Claimant has never been

hospitalized for mental health issue is erroneous. (R. 25). Claimant argues

generally that the ALJ erred by failing to provide an explanation as to how

Claimant’s lack of hospitalization for mental health issues is relevant to his

determination that Claimant can sustain work activity or how her lack of

hospitalization contradicts the opinion of the treating providers. (Id., at 20-21).

Claimant thereafter points to evidence in the record which she contends is

consistent with the treating providers’ assessment of Claimant’s mental health

issues, including evidence that in August of 2018, Claimant’s anxiety led her to the

emergency room with chest pains, fearing that she was having a heart attack. (Id.,

at 21-23; citing R. 547).

On review, the Court agrees that the ALJ erred. Again, the ALJ has not

provided an explanation as to how Claimant’s lack of voluntary or involuntary

hospitalization for her mental health issues is inconsistent with the treating

providers’ opinions. See R. 25-26. Further confusing this matter is the record cited

by Claimant, which does in fact indicate that Claimant was admitted to the

emergency room in part due to anxiety and received a primary discharge diagnosis

which included a panic attack. (R. 547, 553).9 Thus, the Court agrees that the ALJ

9 Additionally, the ALJ elsewhere in the decision cited to a record from January 2019 in

which Claimant presented to the emergency room with shortness of breath, back pain, and anxiety.

(R. 23; citing R. 604).

erred by failing to provide an explanation for this rationale, especially in light of

evidence in the record that is potentially contrary to his statement.

It could be that the ALJ intended to indicate that Claimant has never been

hospitalized at a mental health facility, but it is not the role of this Court to guess at

the ALJ’s rationale. See Bloodsworth, 703 F.2d at 1239 (“[The Court] may not…

reweigh the evidence, or substitute [its] judgment for that of the

[Commissioner]…”). Accordingly, the Court cannot say whether the ALJ’s

reasoning on this point is supported by substantial evidence. See Hanna v. Astrue,

395 F. App'x at 636 (11th Cir. 2010); Pierson, 2020 WL 1957597, at *6.

In sum, the Court agrees with Claimant’s arguments and finds that the ALJ’s

stated reasons for finding the treating providers’ opinion unpersuasive are not

supported by substantial evidence, and therefore, the Court will reverse and

remand the final decision of the Commissioner.10

10 The Court has not discussed in any detail the arguments raised by the Commissioner in

the Joint Memorandum, and this lack of discussion was deliberate. Over the 14 pages of argument

the Commissioner makes, 12.5 pages are expended discussing the new SSA regulations, and

whether prior precedent still applies. (Doc. 27, at 24-37). The remaining 1.5 pages is a cursory

discussion of the ALJ’s analysis of the mental health questionnaire, followed by the

Commissioner’s conclusion that the ALJ satisfied the new regulations’ supportability and

consistency factors. (Id., at 37-38). Because the Court addresses these factors in detail within this

Report, there is no need to address the Commissioner’s arguments further.

Vv. CONCLUSION.

Based on the foregoing, it is ORDERED that:

1. The Commissioner’s final decision is REVERSED and REMANDED for

further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).

2. The Clerk of Court is DIRECTED to enter judgment in favor of Claimant

and against the Commissioner, and thereafter, to CLOSE the case.

DONE and ORDERED in Orlando, Florida on January 21, 2022.

LESLIE R. HOFFMAN □

UNITED STATES MAGISTRATE JUDGE

Copies furnished to:

Counsel of Record

Ay.