# Rice v. Saul (CONSENT)

> District Court, M.D. Alabama · March 26, 2021

URL: https://www.frixlaw.com/law-library/cases/9987257

## Case

- **Court:** District Court, M.D. Alabama
- **Decided:** March 26, 2021
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/9987257

## How later opinions describe it (automated extraction)

- finding doctor did not constitute a treating source “because he did only one examination of [plaintiff] and did not have an ongoing treatment relationship with her”
- finding physician who examined plaintiff on only one occasion was not a “treating physician” and, therefore, her opinion was not entitled to great weight
- finding duty to recontact did not arise where substantial evidence supported the ALJ’s determination that claimant was not disabled
- noting that doctor who examined claimant on only one occasion was not a treating physician

## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF ALABAMA
SOUTHERN DIVISION

JENNIFER M. RICE, )
)
Plaintiff, )
)
v. ) CASE NO. 1:19-CV-791-KFP
)
ANDREW SAUL, )
Commissioner of Social Security, )
)
Defendant. )

MEMORANDUM OPINION AND ORDER

On August 29, 2016, Plaintiff Jennifer M. Rice filed applications for a period of
disability, Disability Insurance Benefits, and Supplemental Security Income based on
various physical and mental impairments, alleging an onset date of April 1, 2016.1 T. 21.
On December 19, 2018, after appropriate proceedings, the Administrative Law Judge
issued an unfavorable decision, finding Plaintiff was not disabled. T. 18-35. Plaintiff seeks
judicial review of that decision (see Doc. 1), and judicial review now proceeds under 42
U.S.C. §§ 405(g) and 1383(c)(3). Upon careful consideration of the parties’ briefs (Docs.
14, 15) and the transcript (Doc. 16), the undersigned AFFIRMS the Commissioner’s
decision for the reasons set forth below.

1 The parties and the ALJ all agree to this timeline. See Doc. 14 at 1; Doc. 15 at 2; T. 21. However, the
parties cite to portions of the record indicating that Plaintiff completed her applications for Disability
Insurance Benefits and Supplemental Security Income on September 16, 2016 (T. 195, 199), alleging an
onset date of April 1, 2016 as to the benefits (T. 195) and August 29, 2016 as to the income (T. 199).
Because the parties agree and because Plaintiff’s exact filing and onset dates are immaterial to the issue
presented in this Order, the Court will accept the parties’ agreed upon timeline as correct.
I. STANDARD OF REVIEW

The Court’s review of the Commissioner’s decision is a limited one. The Court’s
sole function is to determine whether the ALJ’s opinion is supported by substantial
evidence and whether the proper legal standards were applied. See Jones v. Apfel, 190 F.3d
1224, 1228 (11th Cir. 1999); Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir.
1983). “The Social Security Act mandates that ‘findings of the Secretary as to any fact, if
supported by substantial evidence, shall be conclusive.’” Foote v. Chater, 67 F.3d 1553,
1560 (11th Cir. 1995) (quoting 42 U.S.C. §405(g)). Thus, this Court must find the

Commissioner’s decision conclusive if it is supported by substantial evidence. Graham v.
Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). Substantial evidence is more than a scintilla—
i.e., the evidence must do more than merely create a suspicion of the existence of a fact
and must include such relevant evidence as a reasonable person would accept as adequate
to support the conclusion. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (citing

Richardson v. Perales, 402 U.S. 389 (1971)); Foote, 67 F.3d at 1560 (citing Walden v.
Schweiker, 672 F.2d 835, 838 (11th Cir. 1982)).
If the Commissioner’s decision is supported by substantial evidence, the Court will
affirm, even if the Court would have reached a contrary result as finder of fact and even if
the evidence preponderates against the Commissioner’s findings. Ellison v. Barnhart, 355

F.3d 1272, 1275 (11th Cir. 2003); Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir.
1991) (quoting MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986)). The Court
must view the evidence as a whole, taking into account evidence that is favorable as well
as unfavorable to the decision. Foote, 67 F.3d at 1560 (citing Chester v. Bowen, 792 F.2d
129, 131 (11th Cir. 1986). The Court “may not decide facts anew, reweigh the evidence,
or substitute [its] judgment for that of the [Commissioner]”; instead, it “must defer to the

Commissioner’s decision if it is supported by substantial evidence.” Miles v. Chater, 84
F.3d 1397, 1400 (11th Cir. 1997) (quoting Bloodsworth, 703 F.2d at 1239).
The Court will also reverse the Commissioner’s decision on plenary review if the
decision applies incorrect law or if the decision fails to provide the Court with sufficient
reasoning to determine that the Commissioner properly applied the law. Keeton v. Dep’t of
Health and Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994) (citing Cornelius v.

Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991)). There is no presumption that the
Commissioner’s conclusions of law are valid. Id.; Brown v. Sullivan, 921 F.2d 1233, 1236
(11th Cir. 1991) (quoting MacGregor, 786 F.2d at 1053).
II. STATUTORY AND REGULATORY FRAMEWORK

The Social Security Act’s general Disability Insurance Benefits (“DIB”) program
provides income to individuals who are forced into involuntary, premature retirement,
provided they are both insured and disabled, regardless of indigence. See 42 U.S.C.
§ 423(a). The Social Security Act’s Supplemental Security Income (“SSI”) is a separate
and distinct program. SSI is a general public assistance measure providing an additional
resource to the aged, blind, and disabled to assure that their income does not fall below the

poverty line. Eligibility for SSI is based on proof of indigence and disability. See 42 U.S.C.
§§ 1382(a), 1382c(a)(3)(A)–(C). However, despite the fact they are separate programs, the
law and regulations governing a claim for DIB and a claim for SSI are identical; therefore,
claims for DIB and SSI are treated identically for the purpose of determining whether a
claimant is disabled. Patterson v. Bowen, 799 F.2d 1455, 1456 n.1 (11th Cir. 1986).

Applicants under DIB and SSI must prove “disability” within the meaning of the
Social Security Act, which defines disability in virtually identical language for both
programs. See 42 U.S.C. §§ 423(d), 1382c(a)(3), 1382c(a)(3)(G); 20 C.F.R.
§§ 404.1505(a), 416.905(a). A person is entitled to disability benefits when the person is
unable to do the following:

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), 1382c(a)(3)(A). A “physical or mental impairment” is one
resulting from anatomical, physiological, or psychological abnormalities that are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques. 42
U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).
The Commissioner of Social Security employs a five-step, sequential evaluation
process to determine if a claimant is entitled to benefits:
(1) Is the person currently unemployed?
(2) Is the person’s impairment(s) severe?
(3) Does the person’s impairment(s) meet or equal one of the specific
impairments set forth in Listing of Impairments in Appendix I of 20
C.F.R. Pt. 404, Subpt. P?
(4) Is the person unable to perform his or her former occupation?
(5) Is the person unable to perform any other work within the economy?

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986); 20 C.F.R. §§ 404.1520, 416.920
(2010). An affirmative answer to any of the above questions leads either to the next
question or, on Steps 3 and 5, to a finding of disability. A negative answer to any question
except Step 3 leads to a determination of “not disabled.” McDaniel, 800 F.2d at 1030; 20

C.F.R. § 416.920(a)–(f).
The claimant carries the burden of proof through Step 4. See Phillips v. Barnhart,
357 F.3d 1232, 1237–39 (11th Cir. 2004). Claimants establish a prima facie case of
qualifying for disability once they meet their burden of proof from Step 1 through Step 4.
At Step 5, the burden shifts to the Commissioner, who must then show there are a
significant number of jobs in the national economy the claimant can perform. Id.

To complete Steps 4 and 5, the ALJ must first determine the claimant’s Residual
Functional Capacity (“RFC”). Id. at 1238–39. RFC is what the claimant is still able to do
despite his impairments and is based on all relevant medical and other evidence. Id. It also
can contain both exertional and non-exertional limitations. Id. at 1242–43. At Step 5, the
ALJ considers the claimant’s RFC, age, education, and work experience to determine if

there are jobs available in the national economy the claimant can perform. Id. at 1239. To
do this, the ALJ can either use the Medical Vocational Guidelines (“grids”) or hear
testimony from a vocational expert (“VE”). Id. at 1239–40.
The grids allow the ALJ to consider factors such as age, confinement to sedentary
or light work, inability to speak English, educational deficiencies, and lack of job

experience. Each factor can independently limit the number of jobs realistically available
to an individual. Id. at 1240. Combinations of these factors yield a statutorily-required
finding of “disabled” or “not disabled.” Id.
III. BACKGROUND

A. Factual Background
Plaintiff was 45 years old at the time of the ALJ’s decision. T. 46. She previously
obtained her GED and had past relevant work experience as a delivery driver, a fast-food
worker, and a fast-food team leader. T. 46, 61-62. Plaintiff alleges a disability due to
fibromyalgia, PTSD, bipolar disorder, depression, anxiety, and degenerative disc disease.
T. 216.

B. Administrative Proceedings
On August 29, 2016, Plaintiff protectively filed a Title II application for a period of
disability and DIB and a Title XVI application for SSI, alleging disability beginning April
1, 2016. T. 21. The agency denied Plaintiff’s claims at the initial level, and she requested
a hearing before an ALJ. T. 98-132, 136-41, 145-47. Following a hearing (T. 40-68), the
ALJ issued an unfavorable decision on December 19, 2018, finding Plaintiff was not

disabled. T. 18-35. On September 18, 2019, the Appeals Council denied Plaintiff’s request
for review. T. 1-3. Thus, Plaintiff sought judicial review. Doc. 1.
C. The ALJ’s Decision
In her December 19, 2018 decision, the ALJ first found that Plaintiff met the insured
status requirements through December 31, 2019. T. 23. The ALJ then found that Plaintiff

had not engaged in any substantial gainful activity since her alleged onset date of April 1,
2016. Id. Plaintiff had the following severe impairments: fibromyalgia; supraspinatus
tendinitis/degenerative joint disease of the right shoulder; trochanteric bursitis of bilateral
hips; gastroesophageal reflux disease (GERD); dry eye syndrome; headaches; obesity;
bipolar disorder; and PTSD. T. 24. According to the ALJ’s finding, Plaintiff did not have
an impairment or combination of impairments that met or medically equaled the severity

of one of the listed statutory impairments. Id. In making this finding, the ALJ concluded
that Plaintiff had moderate limitations in (1) understanding, remembering, or applying
information; (2) interacting with others; (3) concentrating, persisting, or maintaining pace;
and (4) adapting and managing oneself. T. 25.
Next, the ALJ found that Plaintiff had the RFC to perform light work as defined in
20 C.F.R. §§ 404.1567(b) and 416.967(b) except that she:

can never climb ladders, ropes, or scaffolds. She can occasionally climb
ramps and stairs. She can occasionally balance, stoop, kneel, crouch, and
crawl. She must avoid work at unprotected heights and around hazardous
machinery. She can understand, remember, apply and carry out simple
repetitive instructions. She can persist at that level of complexity for eight
hours a day, five days a week consistently. She can have non-transactional
interaction with the general-public, and she can have occasional interaction
with co-workers and supervisors. She can adapt to routine changes in the
work setting that are gradually introduced and occasional in nature.

T. 26. Based on that RFC, Plaintiff was unable to perform her past relevant work as a
delivery driver, fast-food worker, or fast-food team leader. T. 33-34. However, considering
Plaintiff’s age, education, work experience, and RFC, the ALJ found there were other jobs
that exist in significant numbers in the national economy Plaintiff could perform, such as
an assembler, a marker, and a night cleaner. T. 34-35. Accordingly, the ALJ found that
Plaintiff had not been under a disability from her alleged onset date of April 1, 2016
through the date of the ALJ’s decision on December 19, 2018. T. 35.
IV. ISSUE BEFORE THE COURT

Plaintiff presents a single issue for the Court to consider in its review of the
Commissioner’s decision: Did the ALJ give proper weight to the opinion evidence of
Plaintiff’s psychiatrist, Dr. Fernando Lopez2?
V. DISCUSSION

On April 10, 2017, Dr. Lopez completed a psychiatric evaluation form regarding
Plaintiff. T. 584-86. In her December 19, 2018 decision, the ALJ stated the following
regarding Dr. Lopez’s opinion:
On April 10, 2017, Fernando Lopez, M.D., with SpectraCare completed a
disability questionnaire finding [Plaintiff] to have marked limitations in her
ability to interact appropriately with the general-public; degree of
deterioration of personal habits; ability to perform activities within a
schedule; maintain regular attendance and be punctual with customary
tolerances; and ability to respond to customary work pressures. She was
found to have moderate limitations in all other areas, including her ability to
understand, remember, and carry out repetitive tasks; maintain attention and
concentration for extended periods; sustain a routine without special
supervision; respond appropriately to supervision[;] make simple work-
related decisions[;] and respond appropriately to changes in the work
setting[.]

T. 29. The ALJ then assigned “partial weight” to Dr. Lopez’s opinion, stating: “The records
from SpectraCare are more consistent with waxing and waning symptoms when reviewed
carefully. Thus, overall they are more consistent with moderate limitations. There is
nothing to support ongoing marked limitations as opined by Dr. Lopez.” T. 32.

2 As will be discussed below, Plaintiff claims that Dr. Lopez is Plaintiff’s treating psychiatrist. The
Commissioner argues that, at the time of Dr. Lopez’s opinion, he was not a treating medical source.
Plaintiff argues that the ALJ failed to give great weight to Dr. Lopez’s opinion
without providing sufficient rationale for doing so. Doc. 14 at 8. Accordingly, Plaintiff

argues that the ALJ’s decision is not supported by substantial evidence. In response, the
Commissioner argues that Dr. Lopez was not Plaintiff’s treating psychiatrist at the time of
his opinion—and, therefore, his opinion was not entitled to great weight—and, regardless,
substantial evidence supports the ALJ’s decision to give partial weight to Dr. Lopez’s
opinion. Upon independent consideration of the record, the Court agrees with the
Commissioner.

A. The record does not reflect that Dr. Lopez was Plaintiff’s treating
physician at the time of his opinion and, therefore, his opinion was not
entitled to great weight.

An ALJ should consider several factors when evaluating a doctor’s opinion,
including whether the doctor examined the claimant, whether the doctor treated the
claimant, the evidence the doctor presents to support his or her opinion, and whether the
doctor’s opinion is consistent with the record as a whole. See 20 C.F.R. §§ 404.1527(c),
416.927(c). A treating doctor’s opinion is generally entitled to more weight than a non-
treating doctor’s opinion, and an ALJ must give good reasons for discounting a treating
doctor’s opinion. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); Winschel v. Comm’r of
Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). In contrast, a non-treating doctor’s opinion
is not entitled to any special deference or specific level of consideration. See Crawford v.
Comm’r of Soc. Sec, 363 F.3d 1155, 1160 (11th Cir. 2004) (finding physician who
examined plaintiff on only one occasion was not a “treating physician” and, therefore, her
opinion was not entitled to great weight) (citing McSwain v. Bowen, 814 F.2d 617, 619
(11th Cir. 1987)); Ziglar v. Berryhill, No. 2:18-CV-567, 2019 WL 2387047, at *7 (M.D.
Ala. June 4, 2019) (“As a non-treating physician who examined [plaintiff] only twice, [the

physician’s] opinion is not entitled any special deference.”).
The threshold issue is whether Dr. Lopez constituted a treating source at the time of
his opinion such that his opinion is entitled to great weight. See Rogers v. Colvin, No.
1:14cv1352, 2015 WL 4624812, at *5 (N.D. Ala. Aug. 3, 2015) (“Because [the physician]
was not a treating physician at the time of his opinion, his findings and opinions were not
entitled to any special deference or consideration.”). A “treating source” is defined as the

claimant’s own acceptable medical source who provides the claimant with medical
treatment or evaluation and who has an “ongoing treatment relationship” with the claimant.
20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2). An “ongoing treatment relationship” may be
established when the medical evidence demonstrates that the claimant sees, or has seen,
the medical source “with a frequency consistent with accepted medical practice for the type

of treatment and/or evaluation required for [the claimant’s] medical condition(s).” Id.
However, if the claimant’s relationship with the medical source is not based on her medical
need for treatment or evaluation, but simply on her need to obtain a report in support of her
claim for disability, that medical source will not constitute a treating source. Id.
In her brief, Plaintiff repeatedly refers to Dr. Lopez as her treating psychiatrist.

However, she provides no support that Dr. Lopez provided her with medical treatment or
evaluation on an ongoing basis before, or at the time of, his opinion in April 2017. She
notes that she received treatment at “SpectraCare (Dr. Lopez’s place of practice),” and that
Dr. Lopez treated her “on multiple occasions,” but the treatment records to which she cites
do not establish an ongoing treating relationship between her and Dr. Lopez during the
relevant time period.3 At the time of his opinion, Dr. Lopez was a psychiatrist at

SpectraCare Health Systems. T. 584-86. Plaintiff first presented to SpectraCare for mental
health care on February 8, 2017 (T. 552), and she returned to SpectraCare numerous times
thereafter for various mental health services, on February 13 (T. 574), February 14 (T.
567), February 21 (T. 569), and March 10 (T. 581). There is no indication in these records
that she met with Dr. Lopez, or that he provided her with treatment, on any of these
occasions. Rather, it appears that the first date on which Dr. Lopez appears in the medical

record is April 10, 2017, when he completed the disability survey at issue here. T. 584-86.
In fact, the first record indicating Dr. Lopez performed actual evaluation of Plaintiff
was not until July 14, 2017, more than three months after his completed survey. T. 655. In
his notes from that visit, Dr. Lopez references that Plaintiff was last seen (by the practice)
on May 11, 2017 (T. 656); according to the records, Plaintiff was examined only by Dr.

Esiri Esin on that date, not Dr. Lopez. T. 651-654. Dr. Lopez then examined Plaintiff on
October 6, 2017 (T. 703) and then again on April 18, 2018 (T. 745), long after he filled out
Plaintiff’s disability survey.
Plaintiff’s treatment records reflect that, from February 2017 through the date of Dr.
Lopez’s opinion, Plaintiff saw numerous medical professionals at SpectraCare. However,

this merely indicates that Plaintiff maintained an ongoing relationship with SpectraCare

3 In support of her claim, Plaintiff cites to pages 623-727 and 762-859 of the record. However, these pages
of the record do not establish an ongoing treatment relationship between Plaintiff and Dr. Lopez before, or
at the time of, his April 2017 opinion. Instead, these records appear to indicate that Plaintiff saw numerous
other medical personnel at SpectraCare during that time, including Brianna Grayson, Cindy Woodall, and
Dr. Esiri Esin, but that she did not meet with Dr. Lopez until July 2017 (see T. 655).
and not with Dr. Lopez. Indeed, the Court sees nothing in Plaintiff’s SpectraCare treatment
records that demonstrates such a relationship with Dr. Lopez before or at the time of his

opinion in April 2017. Therefore, the Court cannot find that Dr. Lopez was a treating source
at the time he rendered his April 2017 opinion and, thus, the opinion is not entitled to great
weight. See Medina v. Social Sec. Admin., 636 F. App’x 490, 493 (11th Cir. 2016) (finding
doctor did not constitute a treating source “because he did only one examination of
[plaintiff] and did not have an ongoing treatment relationship with her”).4

B. Substantial evidence supports the ALJ’s decision to assign partial
weight to Dr. Lopez’s opinion.

The Commissioner’s decision can be affirmed on the Court’s conclusion that Dr.
Lopez was not Plaintiff’s treating source and his opinion was, therefore, not entitled to
great weight. In any event, if Dr. Lopez was a treating source at the time he rendered his
opinion, the outcome would not differ. Upon an independent review of the record, the Court

4 See also Stevens o/b/o L.R. v. Colvin, No. 1:14-CV-136, 2015 WL 13021663, at *7 (N.D. Ga. Sept. 11,
2015):

[A] doctor who does not directly examine a claimant, examines a claimant only once or
twice, or examines a claimant solely in relation to a claim for disability does not quali[f]y
as a treating source. See Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1160 (11th Cir.
2004) (noting that doctor who examined claimant on only one occasion was not a treating
physician); Wood v. Astrue, No. 8:10-CV-2373-T-17AEP, 2012 WL 834137, at *5 (M.D.
Fla. Feb. 14, 2012), report and recommendation adopted, No. 8:10-CV-2373-T-17AEP,
2012 WL 834132 (M.D. Fla. Mar. 13, 2012) (psychiatrist who evaluated claimant twice
upon separate admissions to hospital but had no follow-up or ongoing treatment
relationship on an outpatient basis did not qualify as a treating source); Gunter v. Astrue,
No. 1:10-CV-967-SRW, 2012 WL 1031437, at *7 n.11 (M.D. Ala. Mar. 27, 2012)
(concluding that clinical director who reviewed and approved plaintiff’s counselor’s intake
and annual update assessments and treatment plans was not the plaintiff’s treating
psychologist because she never personally evaluated the plaintiff); Yarbrough v. Astrue,
No. 5:12-CV-00754-RDP, 2013 WL 4434013, at *5 (N.D. Ala. Aug. 15, 2013) (finding
that doctor who saw plaintiff more than two months after she filed application for disability
and did not provide any treatment for diagnosed conditions was not a treating physician).
nevertheless finds that (1) the ALJ sufficiently explained her reasoning for assigning the
opinion “partial weight” and (2) her reasoning was supported by substantial evidence. An

ALJ is required to give a treating source’s medical opinion “substantial or considerable
weight absent good cause.” Id. (citing Winschel, 631 F.3d at 1179 and 20 C.F.R. §
404.1527(c)(2)). “Good cause exists ‘when the: (1) treating physician’s opinion was not
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. (quoting Winschel, 631 F.3d at 1179).

Here, the ALJ specifically provides that she assigned Dr. Lopez’s opinion “partial
weight” because “[t]he records from SpectraCare are more consistent with waxing and
waning symptoms when reviewed carefully” and, thus, are overall “more consistent with
moderate limitations.” T. 32. Upon review of those records, the undersigned finds the
ALJ’s reasoning to be properly supported by substantial evidence. See Sarli v. Berryhill,

817 F. App’x 916, 918-19 (11th Cir. 2020) (finding ALJ’s decision to accord only “partial
weight” to the opinions of plaintiff’s treating physicians proper where ALJ provided good
cause for doing so and his reasons were supported by substantial evidence); see also
Medina, 636 F. App’x at 493-94 (“The ALJ explained that he gave [the treating doctor’s]
medical opinion little weight because her opinion was based on [plaintiff’s] subjective

complaints and she did not conduct any objective tests. That articulation of reasons is
sufficient to show good cause, especially in light of the contrary medical evidence[.]”).
Dr. Lopez opined that Plaintiff has marked limitations in her ability to interact
appropriately with the general public, in her ability to maintain regular attendance and be
punctual with customary tolerances, and in her degree of deterioration of personal habits.
T. 584-85. However, as noted by the ALJ, Plaintiff’s treatment records from SpectraCare

demonstrate that Plaintiff regularly attended group sessions and was active in discussion;
her mood was stable; she had a positive response to intervention(s); and she made progress
toward goals and objectives. T. 25, 677, 680, 686. She was also found to have good hygiene
and a cooperative attitude. T. 764, 771.
For instance, in September 2017, Plaintiff was active in her group discussion. T. 30,
677. She had no suicidal or homicidal gestures or ideas. Id. Her mood was stable, and she

reported no new issues. Id. The topic was positive confrontation, and the group worked on
developing skills for positive conflict resolution. Id. Plaintiff had a positive response to the
session, indicating that the information provided would be helpful to address problems with
future confrontations. Id.
Next, in November 2017, Plaintiff was again active in group discussion and showed

interest; she had no suicidal or homicidal gestures or ideas; her mood was stable; and she
reported no new issues. T. 30, 680. The topic was forgiveness, and the group worked on
challenging negative thoughts and enjoying the benefits of forgiveness. Id. Plaintiff again
had a positive response to the session. Id.
Approximately two months later, in January 2018, Plaintiff was again active in

discussion; she had no suicidal or homicidal gestures or ideas; her mood was stable; and
she reported no new issues. T. 30, 686. The topic was changing one’s attitude, and the
group worked on attitude changes that could help in mental health treatment. Id. Plaintiff
again had a positive response to the session. Id. After each of these group sessions, Plaintiff
was told to return to the next group session, which she continued to do.

Additionally, in April and May 2018, SpectraCare case management notes
document that Plaintiff had good hygiene; her attitude was cooperative; and that she was
medication compliant with no side effects. T. 31, 764. In June 2018, SpectraCare case
management notes document that Plaintiff was medication compliant; that she had recently
seen her son and was feeling much better; and that she voiced no issues or concerns. T.
769. Later in June 2018, Plaintiff was again found to have good hygiene; her attitude was

cooperative; she was medication compliant; and she reported that she had attended her last
group therapy session with no issues. T. 771. These records, indicating that Plaintiff
regularly attended her appointments, was active in group discussions with other individuals
and responded positively to those discussions, and maintained good hygiene and a good
attitude, support the ALJ’s finding that Plaintiff had only moderate, rather than marked,

limitations in her ability to interact appropriately with the general public, her ability to
maintain regular attendance and be punctual with customary tolerances, and her degree of
deterioration of personal habits. These records also support the ALJ’s reasoning that “[t]he
records from SpectraCare are . . . consistent with waxing and waning symptoms.” T. 32.
Dr. Lopez also opined that Plaintiff had marked limitations in her ability to respond

to customary work pressures. T. 585. However, as noted by the ALJ, the record indicates
that Plaintiff’s mental status examination findings have generally been found to be normal
or minimally abnormal and, when Plaintiff is compliant with her medication, medication
is successful in helping her maintain control of her symptoms. T. 32, 729-30. Based on this
evidence, the ALJ found that Plaintiff can generally understand, remember, apply and carry
out simple repetitive instructions; she can persist at that level of complexity for eight hours

a day, five days a week; she can have non-transactional interaction with the general public;
she can have occasional interaction with co-workers and supervisors; and she can adapt to
routine changes in the work setting that are gradually introduced and occasional in nature.
T. 26, 33.
Plaintiff argues that there is evidence in the record that supports the opinions of Dr.
Lopez, and she cites to that evidence in her brief. However, this Court’s review “is limited

to an inquiry into whether there is substantial evidence to support the findings of the
Commissioner, and whether the correct legal standards were applied.” Wilson v. Barnhart,
284 F.3d 1219, 1221 (11th Cir. 2002) (citations omitted). In this case, as addressed above,
the Court finds that substantial evidence supports the findings of the Commissioner and
that the correct legal standards were applied. Thus, although there may also be some

evidence in the record supporting a finding contrary to the ALJ’s, the Court is not entitled
to decide the facts anew, reweigh the evidence, or substitute its judgment for that of the
Commissioner. See Winschel, 631 F.3d at 1178. This is true even if the evidence
preponderates against the ALJ’s findings.5 See Gibbs v. Comm’r, Soc. Sec. Admin., 686 F.
App’x 799, 800 (11th Cir. 2017).

5 Plaintiff argues that the ALJ may have “misunderstood” Dr. Lopez’s opinion. For instance, Plaintiff takes
issue with the fact that the ALJ noted a failure to follow prescribed treatment but failed to consider that
perhaps Dr. Lopez believed Plaintiff’s issues with medication compliance were the result of psychiatric
symptoms. See Doc. 14 at 8-9. Plaintiff argues that the ALJ “had a duty to re-contact Dr. Lopez to seek
additional information as to the basis for his opinions.” Id. at 9 (citing 20 C.F.R. §§ 404.1512(e),
416.912(f)). However, the cited provisions indicate that an ALJ will recontact a medical source only when
VI. CONCLUSION
For the reasons set forth above, the undersigned finds that the ALJ’s determinations

are supported by substantial evidence and that the ALJ correctly applied the law.
Accordingly, it is ORDERED that:
1. The decision of the Commissioner is AFFIRMED.
2. A final judgment will be entered separately.
DONE this 26th day of March, 2021.

/s/ Kelly Fitzgerald Pate
KELLY FITZGERALD PATE
UNITED STATES MAGISTRATE JUDGE

the already-provided evidence “is inadequate for [the ALJ] to determine whether [the claimant is] disabled.”
20 C.F.R. § 404.1512(e); Couch v. Astrue, 267 F. App’x 853, 855 (11th Cir. 2008) (citing 20 C.F.R. §§
404.1512(e), 416.912(e)). Here, as discussed above, there is substantial evidence in Plaintiff’s medical
record to support the ALJ’s findings, so the ALJ had no duty to recontact Dr. Lopez. See Couch, 267 F.
App’x at 855 (finding duty to recontact did not arise where substantial evidence supported the ALJ’s
determination that claimant was not disabled).

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/9987257. Public record. Not legal advice.