noting that the ALJ “was required to consider all impairments regardless of severity, in conjunction with one another in performing the latter steps of the sequential evaluation.”
How later courts described this case
- noting that the ALJ “was required to consider all impairments regardless of severity, in conjunction with one another in performing the latter steps of the sequential evaluation.”
- explaining that, generally, “there is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision”
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
MIDDLE DIVISION
TYRONE L. SPEARS, }
}
Plaintiff, }
}
v. } Case No.: 4:20-cv-01574 MHH
}
ANDREW SAUL, }
Acting Commissioner of the }
Social Security Administration, }
}
Defendant. }
MEMORANDUM OPINION
Tyrone Spears has asked the Court to review a final adverse decision of the
Commissioner of Social Security. The Commissioner denied Mr. Spears’s claims
for a period of disability and disability insurance benefits and supplemental security
income based on an Administrative Law Judge’s finding that Mr. Spears was not
disabled. (Doc. 9-3, pp. 18-39). Mr. Spears argues that the Administrative Law
Judge—the ALJ—erred in finding that Mr. Spears’s migraine headaches and
fibromyalgia were non-severe impairments. (Doc. 12, pp. 16-20). Mr. Spears also
argues that the ALJ failed to consider relevant medical opinions and the VA’s
disability determination. (Doc. 12, pp. 20-24). The Court examines these arguments
in this opinion.
LEGAL STANDARD FOR DISABILITY AND SSI
To succeed in his administrative proceedings, Mr. Spears had to prove that he
was disabled. Gaskin v. Comm’r of Soc. Sec., 533 Fed. Appx. 929, 930 (11th Cir.
2013). “A claimant is disabled if he is unable to engage in substantial gainful activity
by reason of a medically-determinable impairment that can be expected to result in
death or which has lasted or can be expected to last for a continuous period of at
least 12 months.” 42 U.S.C. § 423(d)(1)(A)).1 A claimant must prove that he is
disabled. Gaskin, 533 Fed. Appx. at 930 (citing Ellison v. Barnhart, 355 F.3d 1272,
1276 (11th Cir. 2003)).
To determine whether a claimant has proven that he is disabled, an ALJ
follows a five-step sequential evaluation process. The ALJ considers:
(1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or
combination of impairments; (3) whether the impairment meets or
equals the severity of the specified impairments in the Listing of
Impairments; (4) based on a residual functional capacity (“RFC”)
assessment, whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there are
significant numbers of jobs in the national economy that the claimant
1 Title II of the Social Security Act governs applications for benefits under the Social Security
Administration’s disability insurance program. Title XVI of the Act governs applications for
Supplemental Security Income or SSI. “For all individuals applying for disability benefits under
title II, and for adults applying under title XVI, the definition of disability is the same.”
https://www.ssa.gov/disability/professionals/bluebook/general-info.htm (lasted visited February
7, 2023).
can perform given the claimant’s RFC, age, education, and work
experience.
Winschel v. Comm’r of Soc. Sec. Admin, 631 F.3d 116, 1178 (11th Cir. 2011). “The
claimant has the burden of proof with respect to the first four steps.” Wright v.
Comm’r of Soc. Sec., 327 Fed. Appx. 135, 136-37 (11th Cir. 2009). “Under the fifth
step, the burden shifts to the Commissioner to show that the claimant can perform
other jobs that exist in the national economy.” Wright, 327 Fed. Appx. at 137.
ADMINISTRATIVE PROCEEDINGS
Mr. Spears applied for disability insurance benefits and supplemental security
income on October 16, 2017. (Doc. 9-7, p. 2). Mr. Spears alleges that his disability
began on September 30, 2016. (Doc. 9-7, p. 2). The Commissioner initially denied
Mr. Spears’s claims. (Doc. 9-6, pp. 2-4). Mr. Spears requested a hearing before an
Administrative Law Judge. Mr. Spears appeared at the hearing on June 25, 2019;
his attorney attended the hearing too. (Doc. 9-4, p. 4). A vocational expert testified
at the hearing. (Doc. 9-4, pp. 51-56). After the hearing, the ALJ submitted written
questions to the vocational expert, seeking clarification of the testimony she gave at
the June 2019 hearing. (Doc. 9-8, pp. 97-99). Mr. Spears also submitted written
questions to the vocational expert after the administrative hearing. (Doc. 9-8, pp.
108-10). To allow Mr. Spears to present his questions to the vocational expert in
person, the ALJ held a supplemental hearing on March 19, 2020. (Doc. 9-3, pp. 45-
65).
The ALJ issued an unfavorable decision on May 6, 2020. (Doc. 9-3, pp. 15-
39). On August 13, 2020, the Appeals Council declined Mr. Spears’s request for
review (Doc. 9-3, p. 2), making the Commissioner’s decision final and a proper
candidate for this Court’s judicial review. See 42 U.S.C. § 405(g).
EVIDENCE IN THE ADMINISTRATIVE RECORD
Mr. Spears’s Medical Records
To support his application, Mr. Spears submitted medical records that relate
to the diagnoses and treatment of osteoarthritis of the lumbar spine, irritable bowel
syndrome, obesity, diabetes, kidney disease, sleep apnea, depression, post-traumatic
stress disorder, fibromyalgia, migraine headaches, asthma, gout, hypertension, and
hyperlipidemia. Mr. Spears challenges the ALJ’s findings regarding his traumatic
brain injury, migraine headaches, and fibromyalgia and the ALJ’s treatment of
opinion evidence from the VA Hospital and Dr. Calvin Harris, Mr. Spears’s
psychiatrist. The following medical records are most relevant to Mr. Spears’s
arguments for relief from the ALJ’s decision.
Headaches and Traumatic Brain Injury (TBI)
Mr. Spears’s records concerning his diagnosis of TBI and migraine headaches
date to August of 2016. On August 13, 2016, Mr. Spears visited the Crestwood
Medical Center Emergency Department; he complained of “pain to the right base of
the skull.” (Doc. 9-9, p. 168). Mr. Spears reported that he had experienced migraine
headaches for a week and that he had been out of blood pressure medication for more
than 30 days. (Doc. 9-9, p. 173). Mr. Spears rated his pain as 8/10 and his blood
pressure was 209/156. (Doc. 9-9, p. 175). Mr. Spears reported associated symptoms
of nausea, neck stiffness, sinus tenderness, and vomiting. (Doc. 9-9, p. 168). Mr.
Spears reported that he had a history of headaches and stated that the headaches he
had experienced over the preceding seven days were more severe than past
headaches. (Doc. 9-9, p. 168). Mr. Spears reported that to alleviate his symptoms,
he would sit in a dark room and take over-the-counter medication. (Doc. 9-9, p.
168). Mr. Spears was diagnosed with hypertensive headaches, and he received a
prescription for Lisinopril, his blood pressure medication. (Doc. 9-9, pp. 171-72).
In December of 2017, Mr. Spears’s primary care physician, Dr. Rani Gill,
ordered a CT scan because of Mr. Spears’s uncontrolled blood pressure and
complaints of headaches. (Doc. 9-11, pp. 5, 54). The scan showed “no evidence of
hemorrhage, mass or extra-axial fluid collection.” (Doc. 9-11, p. 5). The radiologist
noted that, for his age, Mr. Spears’s ventricles were mildly prominent in comparison
to the sulci, and Mr. Spears’s sylvian fissures were dilated. (Doc. 9-11, p. 5).
Because Mr. Spears’s ventricles were mildly prominent, the radiologist
recommended an evaluation for early normal pressure hydrocephalus. (Doc. 9-11,
p. 6).
In February of 2018, Dr. Gill referred Mr. Spears to a neurologist for a
consultation. (Doc. 9-11, p. 38). Mr. Spears reported that he was having headaches
daily and that he had tried taking Imitrex and Topamax to relieve his headache
symptoms. (Doc. 9-11, p. 38). Dr. Gill asked Mr. Spears to schedule an appointment
with Dr. Adeel Memon. (Doc. 9-11, p. 39).
During his visit with Dr. Memon, Mr. Spears reported that he was hit in the
head during his service in the Iraq war. Mr. Spears explained that he was:
hit at the top of his head. He did not loss [sic] consciousness but he was
“zonked out” for at[]least 30 minutes. Since then[,] he started having
headaches. He describes his headaches as throbbing in nature,
bilaterally on the temporal and occipital region. It is associated with
nausea, vomiting, photophobia, and phonophobia. At times they are
also associated with rhinorrhea, lacrimation bilaterally. It lasts for
at[]least a few hours and at times days. He has some benefits from
[E]xcedrin which he takes at[]least 3-4 times per week. He is disabled
now because of his health issues and has stopped working since last
year. He tries to go to bed around 9:30-10pm. He has to wake up in
the middle of the night to go to the restroom multiple times. Also[,] he
has OSA and uses CPAP most of the time. The reason for not using it
daily is that it causes dryness in his nose, which causes nose bleed. No
other neurological symptoms/complaints at this time.
(Doc. 9-11, pp. 55-56). Dr. Memon indicated that Mr. Spears was awake, alert, and
oriented and that his cranial nerve findings were normal. (Doc. 9-11, p. 57). Dr.
Memon noted that Mr. Spears’s headaches were suggestive of migraines, and he
gave Mr. Spears prescriptions for sumatriptan to be used no more than nine times
per month and Topamax to take daily. Dr. Memon advised Mr. Spears to stop taking
Excedrin. (Doc. 9-11, p. 58). Dr. Memon referred Mr. Spears for a greater occipital
nerve block. (Doc. 9-11, p. 59).
On March 15, 2018, Mr. Spears had a routine follow up for his chronic
medical conditions with Dr. Gill. Mr. Spears reported no severe headaches. (Doc.
9-11, p. 170). On February 28, 2019, Mr. Spears saw Dr. Gill again. (Doc. 9-11, p.
85). Mr. Spears was experiencing headaches. Dr. Gill ordered a head CT and a re-
consult with a VA neurologist. Dr. Gill questioned Mr. Spears’s adherence to his
medication. (Doc. 9-11, p. 87). Mr. Spears’s stage 3 kidney disease impacted his
ability to use some medications. (Doc. 9-11, pp. 85, 87).
Fibromyalgia
On February 28, 2017, Mr. Spears visited Dr. Isabel Baren for a VA
Compensation and Pension exam and a Disability Benefits Questionnaire—DBQ.
(Doc. 9-12, p. 72). Dr. Baren examined Mr. Spears and reviewed his virtual claims
folder and patient records. (Doc. 9-12, p. 72). Dr. Baren noted that Mr. Spears was
diagnosed with fibromyalgia in 2013. (Doc. 9-12, p. 73). Dr. Baren indicated that
Mr. Spears had reported body aches and muscle pain since basic training and that
his condition deteriorated in 2003 when he returned from the Middle East. Mr.
Spears reported fatigue and daily headaches that lasted three to four hours. Mr.
Spears reported pain and stiffness in his arms, legs, neck, and back. (Doc. 9-12, p.
73).
Dr. Baren indicated that Mr. Spears was not receiving treatment for his
fibromyalgia and that he did not require continuous medication to control his
symptoms. (Doc. 9-12, pp. 73-74). Based on her examination, Dr. Baren determined
that Mr. Spears had positive tender points bilaterally in all areas and that he
experienced constant or nearly constant widespread musculoskeletal pain, stiffness,
and fatigue. (Doc. 9-12, p. 74). Dr. Baren indicated that Mr. Spears’s fibromyalgia
did not impact his ability to work. (Doc. 9-12, p. 75). Lastly, Dr. Baren noted that
Mr. Spears reported that his PTSD caused poor sleep because of nightmares, anxiety,
and depression. (Doc. 9-9, p. 43; Doc. 9-12, p. 75).
On November 20, 2017, Dr. E.L. Mollohan examined Mr. Spears for a
disability determination. (Doc. 9-9, p. 157). Mr. Spears complained of
fibromyalgia, multiple mood disorders, and lumbar radiculopathy. (Doc. 9-9, p.
157). Regarding his fibromyalgia, Mr. Spears reported that his pain was a 7/10 at
best and a 9/10 at worst. Mr. Spears described his pain as numbness and tingling
down both arms and legs and down the cervical, thoracic, and lumbar spine. (Doc.
9-9, p. 157). Mr. Spears reported that he experienced burning, popping, cramping
muscle spasms and soreness to the touch. (Doc. 9-9, p. 157). Mr. Spears stated that
stretching and changing positions helped to relieve his pain while gripping, lifting
more than five pounds, and weather changes aggravated his pain. (Doc. 9-9, p. 157).
Mr. Spears reported that he was experiencing panic attacks, mood swings,
sweaty nightmares, auditory hallucinations, and easy agitation. (Doc. 9-9, p. 157).
Mr. Spears was using medication, isolation, and therapy to help relieve his
symptoms. Loud noises, crowds, social interactions, and stress aggravated his
symptoms. (Doc. 9-9, p. 157).
Mr. Spears reported that his back pain was 5/10 at best and 8/10 at worst.
(Doc. 9-9, p. 157). Mr. Spears described his pain as dull to sharp, burning, popping,
and cramping with muscle spasms, weakness, numbness, and tingling. (Doc. 9-9, p.
157). Mr. Spears reported that stretches, having his kids walk on his back, and
changing positions helped to relieve his pain. Mr. Spears stated that his pain was
worse with bending, lifting more than ten pounds, sitting more than fifteen minutes,
standing more than 30 minutes, walking with more than five pounds, weather
changes, and lying flat. (Doc. 9-9, p. 158).
During the physical exam, Mr. Spears exhibited an antalgic gait; bilateral hip,
foot, and knee pain; decreased sensation to touch; and positive tender point testing.
(Doc. 9-9, p. 159). Mr. Spears “could sit and/or stand for at least 30 minutes without
complaints during the exam. [Mr. Spears] was able to stand up from a seated
position and get on/off the examination table without difficulty.” (Doc. 9-9, p. 160).
Dr. Mollohan noted that Mr. Spears complained of generalized musculoskeletal
soreness, exhibiting 16 of the 18 palpable muscular tender points, consistent with
the criteria for diagnosis of fibromyalgia. (Doc. 9-9, p. 159). Dr. Mollohan’s
impression was that Mr. Spears’s exam findings were consistent with his complaints
except that Mr. Spears did not complain of lumbar radicular pain with the exam
testing maneuvers. (Doc. 9-9, p. 160). Dr. Mollohan noted that his findings were
consistent with hypertension, fibromyalgia, mood disorder, mechanical lumbar back
pain, type 2 diabetes, generalized osteoarthritis, morbid obesity, and peripheral
neuropathy of the right upper extremity. (Doc. 9-9, p. 160).
PTSD and Depression
On August 25, 2016, Mr. Spears visited Dr. Calvin Harris, a psychiatrist at
the Huntsville VA Clinic. Mr. Spears explained that he was 40 years old, he had
PTSD, and he needed to establish care in Huntsville because he had just moved from
Atlanta. (Doc. 9-12, pp. 113, 117). Dr. Harris evaluated Mr. Spears for PTSD and
depression. (Doc. 9-12, pp. 117, 119). Mr. Spears reported nightmares, insomnia,
hypervigilance, and detachment. (Doc. 9-12, pp. 115, 117). Mr. Spears was working
as a security officer. (Doc. 9-12, p. 117). Notes from the visit indicate that Mr.
Spears was not diagnosed with TBI during his service in Iraq, but there was an
incident in which he hit his head on the roof of the vehicle in which he was riding.
(Doc. 9-12, pp. 115-17). Dr. Harris prescribed Ambien and Effexor and referred Mr.
Spears to Dr. Burleson for counseling for PTSD. (Doc. 9-12, p. 119).
On December 7, 2016, Mr. Spears visited Dr. Harris for a follow up
appointment. (Doc 9-9, p. 106). Mr. Spears reported that he was feeling fair and
that “low frustration tolerance contributed to him resigning from his job.” (Doc. 9-
9, p. 106). Mr. Spears also reported mild insomnia and nightmares, but he indicated
that his sleep improved with Ambien. (Doc. 9-9, pp. 106, 108). Dr. Harris noted
that Mr. Spears’s mood was dysphoric, his affect was constricted, and his thought
processes were logical and goal-directed. Mr. Spears reported no auditory or visual
hallucinations and no suicidal or homicidal hallucinations. (Doc. 9-9, p. 109). Dr.
Harris instructed Mr. Spears to continue Ambien, Effexor, and individual therapy.
(Doc. 9-9, p. 109).
On March 24, 2017, Mr. Spears visited Dr. Harris again. (Doc. 9-9, p. 92).
Mr. Spears reported periodic nightmares and sleep disturbances. Mr. Spears also
reported feelings of sadness, irritability, and lack of motivation. Mr. Spears denied
medication side effects and suicidal or homicidal ideations. (Doc 9-9, p. 92). Dr.
Harris noted that Mr. Spears had not been hospitalized for his mental health
conditions and that Mr. Spears had no auditory or visual hallucinations. Mr. Spears
appeared dysphoric and constricted, but he was oriented, his thoughts were goal
directed, and his insight and judgment were fair. (Doc 9-9, p. 94). Dr. Harris
maintained a diagnosis of chronic PTSD and Major Depressive Disorder, single
episode, unspecified. (Doc 9-9, p. 94).
Mr. Spears saw Dr. Harris again on August 3, 2017. (Doc. 9-9, p. 56). Mr.
Spears reported that he felt calmer and less depressed. (Doc. 9-9, p. 56). Mr. Spears
told Dr. Harris that he was receiving counseling from his pastor at church. (Doc 9-
9, p. 56). Dr. Harris screened Mr. Spears for depression, and Mr. Spears’s “score
was 2 which is suggestive of no depression.” (Doc. 9-9, p. 60).
Mr. Spears called Dr. Harris’s office in October 2017 to request a consultation
for a service dog. (Doc. 9-12, p. 29). A nurse gave Mr. Spears information on how
to apply for a service dog. (Doc. 9-12, p. 29).
During a visit with Dr. Harris on December 12, 2017, Mr. Spears reported
“stress related to issues with his daughters and the community.” (Doc. 9-12, p. 22).
Mr. Spears reported that his anxiety and nightmares had increased, but his depression
was not severe. (Doc. 9-12, p. 22). Dr. Harris instructed Mr. Spears to continue his
medication and therapy regimen and to follow up in four months. (Doc. 9-12, p. 25).
When he visited Dr. Harris on April 17, 2018, Mr. Spears reported that he was
improving and denied significant symptoms of depression. Mr. Spears reported that
he was sleeping well. Mr. Spears was excited and anxious because he and his wife
were buying a house. (Doc. 9-11, p. 161). Mr. Spears had a calm and appropriate
affect, his thought processes were logical and goal-oriented, and he scored 0 on his
depression screen which was “suggestive of no depression.” (Doc. 9-11, pp. 164-
65).
After his visit, Mr. Spears told the patient care coordinator that he forgot to
ask Dr. Harris to write a letter to the disability board to report that he (Mr. Spears)
“could not continue working.” (Doc. 9-11, p. 167). Mr. Spears explained that when
he worked as a security officer, he had to “carry a weapon and he [was]
uncomfortable with that responsibility.” (Doc. 9-11, p. 167). Mr. Spears added that,
due to his PTSD diagnosis, he “[was] not good” with authority figures,
[had] a bad temperament [and was] paranoi[d] and delusional at times.
Also stated he [had] nightmares of prior service events and [did] not
know how he [might] respond to events, stated “I may say something
off the wall and not be me.”
(Doc. 9-11, p. 167).
During an August 17, 2018 visit with Dr. Harris, Mr. Spears reported periodic
anger and irritability, but he denied severe depressive symptoms. (Doc. 9-11, p.
133). Mr. Spears explained that his physician wanted to decrease his dose of Effexor
to see if doing so would improve his cognition, but the decreased dose might elevate
his depression. (Doc. 9-11, p. 133). Dr. Harris instructed Mr. Spears to continue his
medication, declined to adjust Mr. Spears’s Effexor dosage, and asked Mr. Spears
to return to the clinic in four months. (Doc. 9-11, p. 136).
When he saw Dr. Harris on November 30, 2018, Mr. Spears reported stress
from financial problems. Dr. Harris noted that Mr. Spears had mild depressive
symptoms. (Doc. 9-11, p. 113). Dr. Harris indicated that Mr. Spears was attentive
and cooperative with a euthymic mood and a calm and appropriate affect. (Doc. 9-
11, p. 116). Dr. Harris asked Mr. Spears to continue Ambien, Effexor, and individual
therapy and to return to the clinic in four months. (Doc. 9-11, p. 116).
During his July 26, 2019 appointment with Dr. Harris, Mr. Spears reported
stress related to family and finances. (Doc. 9-14, p. 28). Mr. Spears had been
involved in an incident where someone mistakenly “pulled a weapon on him.” (Doc.
9-14, p. 28). Mr. Spears reported a little sadness, but he denied suicidal and
homicidal ideations. He also denied delusions and hallucinations. (Doc. 9-14 pp.
28, 30).
Mr. Spears saw Dr. Harris on September 27, 2019. Mr. Spears reported stress
due to a physical altercation. (Doc. 9-13, p. 154). Dr. Harris increased Mr. Spears’s
Effexor prescription, continued his Ambien, and asked him to return in four months.
(Doc. 9-13, p. 157).
On June 13, 2018, August 10, 2018, December 7, 2018, and February 15,
2019, Mr. Spears visited the VA hospital to attend counseling sessions with Ashley
Madry, a licensed social worker. Mr. Spears complained of daily depression,
irritability, short temperedness, anger, insomnia, night sweats, anxiety,
hypervigilance, intrusive thoughts, flashbacks, and racing thoughts. At many of the
sessions, Mr. Spears presented as dysphoric with a flat affect. (Doc. 9-11, pp. 94-
96, 107-108, 140-41, 149-50).
On June 13, 2018, Mr. Spears reported auditory hallucinations that were
becoming more intense and frequent. (Doc. 9-11, p. 149). Ms. Madry described the
hallucinations as “command hallucinations” that directed Mr. Spears to hurt himself
or others. Because of these hallucinations, Mr. Spears had removed firearms from
his home. (Doc. 9-11, p. 150). Ten months later, Mr. Spears “adamantly denied”
auditory hallucinations, and he reported that he felt called to ministry in his church.
(Doc. 9-11, p. 141). On February 15, 2019, Mr. Spears reported “dreams of someone
coming after him.” (Doc. 9-11, p. 95). The dreams caused hypervigilance. (Doc.
9-11, p. 95). At these visits, the social worker encouraged Mr. Spears to attend
monthly counseling sessions. (Doc. 9-11, pp. 98, 110, 144).2
Opinion Evidence
Mr. Spears submitted records of his VA Disability Ratings from February
2010 through September 2019. (Doc. 9-7, p. 56). The VA determined that Mr.
Spears was 100% disabled as of September 23, 2019. (Doc. 9-7, p. 55). Mr. Spears’s
previous disability ratings were 30% in 2010, 70% in 2012, 80% in 2016, and 90%
in 2016. (Doc. 9-7, p. 56). The VA’s disability ratings were based on a VA contract
2 Mr. Spears missed counseling sessions on September 5, 2018 and October 2, 2018, (Doc. 9-11,
pp. 121, 125, ).
examination on September 23, 2019, VA treatment records from August 25, 2016
through February 19, 2020, and the Board of Veterans Affairs’ Appeals Decision
from February 2020. The Board of Veteran Affairs’ decision elevated Mr. Spears’s
rating to 100% because of an increase in the symptoms associated with his diagnosis
of unspecified depressive disorder with anxious distress. The Board explained:
[a]n evaluation of 100 percent is assigned whenever there is evidence
of total occupational and social impairment due to such symptoms as:
gross impairment in thought processes or communication; persistent
delusions or hallucinations; grossly inappropriate behavior; persistent
danger of hurting self or others; intermittent inability to perform
activities of daily living (including maintenance of minimal personal
hygiene); disorientation to time or place; memory loss for names of
close relatives, own occupation, or own name. (38 CFR 4.126, 38 CFR
4.130)
(Doc. 9-7, p. 58).
Mr. Spears also submitted opinion evidence about his ability to work from Dr.
Harris, his VA psychiatrist. In a letter dated April 19, 2018, Dr. Harris wrote:
To Whom It May Concern:
Mr. Tyrone Spears is currently in treatment for [PTSD] and Depression.
Due to the severity of these clinical disorders, he is felt to be disabled
and unable to maintain employment.
(Doc. 9-9, p. 184). Dr. Harris also completed a medical assessment form, but the
form is undated. (Doc. 9-12, pp. 123-24).3 Dr. Harris indicated that Mr. Spears had
a moderate impairment to following work rules; functioning independently; and
3 The ALJ inferred from Mr. Spears’s medical records that Dr. Harris completed the questionnaire
in 2019. (Doc. 9-3, p. 30). The inference is sound.
understanding, remembering, and carrying out simple job instructions. (Doc. 9-12,
pp. 123-24). Dr. Harris indicated that Mr. Spears was severely impaired in relating
to co-workers; dealing with members of the public; using judgment; interacting with
supervisors; dealing with work stresses; maintaining attention/concentration; and
understanding, remembering, and carrying out detailed and complex job
instructions. (Doc. 9-12, pp. 123-24).
Mr. Spears’s Administrative Hearing
At his June 25, 2019 administrative hearing, Mr. Spears was forty-three years
old. (Doc. 9-4, pp. 2, 10). Mr. Spears had a GED and an associate degree in business
management. (Doc. 9-4, p. 10).
Mr. Spears’s wife was a student who attended class three nights a week. (Doc.
9-4, pp. 14, 29). On evenings that his wife was in class, Mr. Spears took care of his
children for one or two hours. (Doc. 9-4, pp. 14-15, 28). He generally supervised
because his wife would have “ha[d] their dinner prepared and [the children were]
old enough to bathe themselves.” (Doc. 9-4, p. 15). Mr. Spears’s youngest daughter
was three years old. (Doc. 9-4, p. 15). Mr. Spears testified that he had not been able
to pick his daughter up for approximately two years because of his fibromyalgia
pain. (Doc. 9-4, pp. 15-16). One of Mr. Spears’s sons has autism and is non-verbal.
(Doc. 9-4, p. 21). Mr. Spears testified that his son was too heavy for him to handle.
(Doc. 9-4, p. 21). Mr. Spears testified that his pastor and her husband helped him
care for his children once or twice a month. (Doc. 9-4, p. 29). Mr. Spears drove his
children to and from school, helped them with homework, and participated in
telephone conferences with their teachers. (Doc. 9-4, pp. 42-43, 46-47).
Mr. Spears testified that he was able to dress himself, tie his shoes, and use
the microwave to prepare food. (Doc. 9-4, pp. 41-42). Mr. Spears occasionally
accompanied his wife to the grocery store, and he “trie[d] to walk around with her
before [he had] to go and sit in the car.” (Doc. 9-4, p. 45). Mr. Spears testified that
he did not pay the bills. (Doc. 9-4, p. 46).
Regarding migraines, Mr. Spears testified that he took Excedrin to treat his
symptoms. (Doc. 9-4, pp. 17, 45). Mr. Spears stated that he had migraines “[a]bout
seven times a week, probably once a day . . . [that] last[ed] about three to four hours
at a time.” (Doc. 9-4, pp. 17, 30). Mr. Spears explained that he could not move
when he had a migraine, describing his headaches as “almost like paralysis.” (Doc.
9-4, pp. 17, 30). When Mr. Spears had a migraine while he was watching his
children, he received help from his twelve-year-old daughter. (Doc. 9-4, p. 30).
With respect to TBI, Mr. Spears explained that he was injured when he hit a
pothole as he was driving in a military truck in the desert. He bounced from his seat
and smashed his head against the ceiling of the vehicle. Because the padding in his
helmet was not in the proper position, Mr. Spears hit his head on the hard Kevlar of
his helmet and the ceiling. Mr. Spears explained that he was dazed, and he believes
he passed out for a minute because his sergeant had to grab the steering wheel. For
months after the accident, Mr. Spears had “dizzy spells that would last from 15 to
20 minutes.” (Doc. 9-4, p. 31). Mr. Spears testified that he still struggled with
dizziness, explaining that he could experience dizziness from moving or bending
over too quickly, getting up from a seated position too quickly, taking a fast step, or
opening the door for his wife. (Doc. 9-4, pp. 31-32). Mr. Spears testified that he
believed that x-rays taken at the VA showed that he had water on his brain. (Doc.
9-4, p. 31). Mr. Spears stated that he never had a drain or received treatment for his
condition. (Doc. 9-4, p. 32).
As it relates to his PTSD, Mr. Spears explained that though he was a
mechanic, he had to fight with the infantry and provide combat support. (Doc. 9-4,
p. 12). Mr. Spears testified that he saw dead bodies, tragic incidents, and people
who were shot and wounded. (Doc. 9-4, p. 12). Mr. Spears stated that his PTSD
caused paranoia that in turn caused him to avoid large groups of people. (Doc. 9-4,
pp. 12-13, 17, 19). Mr. Spears testified that he did exercises to help with his PTSD
and took medication for depression, but neither helped. (Doc. 9-4, pp. 37, 39-40).
Mr. Spears testified that he experienced hallucinations. (Doc. 9-4, p. 35). Mr.
Spears stated that “sometimes [his] vision [would get] blurry and [he] [had] a very
faint like feeling that [came] over him.” (Doc. 9-4, p. 35). He explained that he
occasionally saw objects or people that were not there, but he knew that the object
or person was not truly present. (Doc. 9-4, pp. 35-36).
Mr. Spears stated that he suffered from sleep apnea. (Doc. 9-4, p. 18). He
used a CPAP and took several medications, but he stated that neither helped with his
condition. (Doc. 9-4, pp. 18, 33). Mr. Spears believed that his sleep apnea
prohibited work because he slept about three to four hours each night, causing
chronic fatigue. (Doc. 9-4, pp. 18-19). Mr. Spears testified that he could fall asleep
any time which he believed could get him fired. (Doc. 9-4, p. 19).
Mr. Spears explained that he could sit, stand, or walk for about forty-five
minutes without needing adjustments. (Doc. 9-4, pp. 13-14). Mr. Spears testified
that he had gained a significant amount of weight since his military discharge. He
was 290 pounds and 5’10” tall. (Doc. 9-4, p. 47). Mr. Spears tried to lose weight
by walking on a treadmill. (Doc. 9-4, p. 48). He explained that, since 2005, his
“knees buckle[d] from time to time as he walk[ed].” (Doc. 9-4, p. 48). Because he
struggled to get up and down the stairs of his two-story townhome, Mr. Spears slept
on the couch. (Doc. 9-4, p. 50).
Mr. Spears testified that he had “inflammation on the inside of [his] body,”
and his “muscles [were] very sore and painful.” (Doc. 9-4, pp. 34-35). Mr. Spears
explained that his joints would swell if he did not take his daily gout medication.
(Doc. 9-4, p. 35). Mr. Spears stated that his gout medicine “help[ed] to control the
outbreaks but it [did not] necessarily stop the outbreaks.” (Doc. 9-4, p. 35). Mr.
Spears testified that he had sharp pains in his lower back. (Doc. 9-4, p. 34).
Mr. Spears stated that he was in constant pain because of his fibromyalgia.
(Doc. 9-4, p. 16). Mr. Spears testified that many doctors treated him for fibromyalgia
over the years, but they did not prescribe medication for his symptoms because “they
said they don’t have anything to give [him] for it.” (Doc. 9-4, p. 16).
Mr. Spears testified that his kidneys were “not functioning normally” and
were “very damaged” because of his high blood pressure and diabetes. (Doc. 9-4,
p. 32). Mr. Spears explained that he had “to drink lots and lots of water to try to
keep them working a lot.” (Doc. 9-4, p. 32). Mr. Spears visited his primary care
physician once every three months for evaluation of his kidney function. (Doc. 9-4,
pp. 32-33).
The ALJ spoke with Mr. Spears’s attorney about Dr. Harris’s opinion
regarding Mr. Spears’s ability to work. (Doc. 9-4, p. 24). The ALJ pointed out that
Dr. Harris checked severe limitations that Dr. Harris believed kept Mr. Spears from
working, but Dr. Harris did not provide objective evidence or narrative support.
(Doc. 9-4, pp. 24-26). The ALJ noted that he could not accept Dr. Harris’s opinion
without support. (Doc. 9-4, pp. 25-26). Mr. Spears’s attorney indicated that Dr.
Harris may have been confused about how to complete the form. (Doc. 9-4, pp. 25-
28).
With respect to past work, Mr. Spears served as a vehicle mechanic in the
military from 2001 until 2004. (Doc. 9-4, pp. 10-11). Mr. Spears served in the
National Guard from 2004 to 2009. (Doc. 9-4, p. 11). Mr. Spears also worked as a
correction’s officer for adult and juvenile males and as a “government contracted
armed security officer.” (Doc. 9-4, pp. 11, 52). As a security officer Mr. Spears
“guarded all of the federal businesses [and] federal buildings around the area of
Huntsville, Alabama.” (Doc. 9-4, p. 11). Mr. Spears testified that he stopped
working as a security guard because his PTSD caused him to frequently “look[] over
[his] shoulder.” (Doc. 9-4, p. 34). He testified that he could not continue to work in
a position that required him to carry a weapon because he did not trust himself, and
he did not feel comfortable around the number of people that he had to interact with
daily. (Doc. 9-4, p. 34). Mr. Spears resigned from his security guard job because
he “did not want to make a terrible mistake based upon how [he] [felt] or an
assumption that maybe [sic] terribly the wrong assumption or the wrong way to feel
that would really affect the rest of [his] life.” (Doc. 9-4, p. 36).
Stephanie Malone testified as a vocational expert. (Doc. 9-4, p. 51). Ms.
Malone stated that Mr. Spears’s past work as a security guard and patrol conductor
were light exertion jobs. (Doc. 9-4, p. 52). Ms. Malone concluded that a
hypothetical person with Mr. Spears’s age, education, work experience, and mental
limitations could not perform the composite jobs described in Mr. Spears’s work
history. (Doc. 9-4, pp. 54-55). Ms. Malone determined that jobs existed in the
national economy for an individual of Mr. Spears’s ability, age, education, work
experience, and limitations, including a marker, a router, and a garment sorter. (Doc.
9-4, p. 55).
Mr. Spears’s Supplemental Administrative Hearing
During Mr. Spears’s supplemental administrative hearing on March 19, 2020,
the ALJ heard testimony from Mr. Spears and Ms. Malone. (Doc. 9-3, pp. 44-65).
Mr. Spears testified that his condition had not improved. Mr. Spears’s attorney
submitted one additional piece of evidence, and he pointed out that Mr. Spears still
was being treated for migraines. (Doc. 9-3, pp. 47-48).
Ms. Malone testified that Mr. Spears’s work in the preceding 15 years as a
security guard and a patrol conductor were light exertional level. (Doc. 9-3, pp. 49-
50). Ms. Malone indicated that an individual of Mr. Spears’s age, education, history,
and limitations would be precluded from performing the work described in Mr.
Spears’s work history. (Doc. 9-3, p. 51). Ms. Malone stated that jobs existed in the
national economy that an individual with Mr. Spears’s limitations could perform at
the unskilled light work level such as a marker, a photocopy machine operator, and
a garment sorter. (Doc. 9-3, pp. 51-52). Ms. Malone testified that the unskilled light
work level jobs she mentioned would not be precluded if the individual had the same
limitations, but the individual needed a sit/stand option job and could stand or walk
for only four hours in an eight-hour workday with the ability to sit and change
positions for a few minutes without being off task. (Doc. 9-3, p. 53).
Mr. Spears’s attorney asked Ms. Malone whether it would be likely that an
individual performing the unskilled light work positions that she mentioned would
have to walk or stand for more than four hours. Ms. Malone testified that she could
not give a straightforward answer to the question because there were a lot of
variables to account for. (Doc. 9-3, p. 55). Mr. Spears’s attorney asked Ms. Malone
how her answer would change if the individual “had to lay down a minimum of two
hours a day during two days [in] a normal five-day workweek . . . due to migraines.”
Ms. Malone testified that that all work would be precluded. (Doc. 9-5, pp. 53-54).
THE ALJ’S DECISION
The ALJ found that Mr. Spears had not engaged in substantial gainful activity
since September 30, 2016, the alleged onset date. (Doc. 9-3, p. 21). The ALJ
determined that Mr. Spears suffered from the severe impairments of osteoarthritis of
the lumbar spine, irritable bowel syndrome, obesity, diabetes mellitus II, kidney
disease, sleep apnea, depression, and PTSD. (Doc. 9-3, p. 21). The ALJ also
determined that Mr. Spears’s had the non-severe impairments of hypertension,
hyperlipidemia, gout, asthma, and migraines. (Doc. 9-3, p. 21). Based on a review
of the medical evidence, the ALJ concluded that Mr. Spears did not have an
impairment or a combination of impairments that met or medically equaled the
severity of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.
(Doc. 9-3, p. 23).
Given these impairments, the ALJ evaluated Mr. Spears’s residual functional
capacity. The ALJ determined that Mr. Spears had the RFC to:
perform less than the full range of light work as defined in 20 CFR
404.1567(b) in that he can occasionally lift and/or carry, including
upward pulling, twenty pounds and frequently lift and/or carry,
including upward pulling, ten pounds; he can sit for six hours in an
eight-hour workday with normal breaks; and he can stand and/or walk
for six hours in an eight-hour workday with normal breaks. The
claimant can occasionally climb ramps and stairs, balance, stoop, kneel,
and crouch, but should never crawl. The claimant should not work on
ladders, ropes or scaffolds; he should not work at unprotected heights
or around dangerous machinery; and he should perform no commercial
driving. The claimant should avoid concentrated exposure to extreme
cold and heat, wetness, and humidity. The claimant can understand,
remember, and carry out short simple instructions. He can concentrate
and remain on task for two-hour periods across an eight-hour workday
and five-day workweek, with customary work breaks. Any changes in
the work environment should be infrequent. The claimant can have
occasional contact with the general-public, coworkers, and supervisors.
(Doc. 9-3, pp. 25-26). “Light work involves lifting no more than 20 pounds at a time
with frequent lifting or carrying of objects weighing up to 10 pounds. Even though
the weight lifted may be very little, a job is in this category when it requires a good
deal of walking or standing, or when it involves sitting most of the time with some
pushing and pulling of arm or leg controls.” 20 C.F.R. § 404.1567(b). “If someone
can do light work . . . he can also do sedentary work, unless there are additional
limiting factors such as loss of fine dexterity or inability to sit for long periods of
time.” 20 C.F.R. § 404.1567(b). “Sedentary work involves 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).
Based on this RFC, the ALJ concluded that Mr. Spears could not perform his
past relevant work as a security guard or patrol conductor. (Doc. 9-3, p. 37). Relying
on testimony from the vocational expert, the ALJ found that jobs existed in
significant numbers in the national economy that Mr. Spears could perform,
including a marker, photocopying machine operator, and garment sorter. (Doc. 9-3,
p. 38). Accordingly, the ALJ determined that Mr. Spears was not under a disability
as defined by the Social Security Act. (Doc. 9-3, p. 39).
STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case,
the ALJ denies benefits and the Appeals Council denies review,” a district court
reviews the ALJ’s “‘factual findings with deference’” and his “‘legal conclusions
with close scrutiny.’” Riggs v. Comm r of Soc. Sec., 522 Fed. Appx. 509, 510-11
(11th Cir. 2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
A district court must determine whether there is substantial evidence in the
record to support the ALJ’s factual findings. “Substantial evidence is 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., 363 F.3d 1155,
1158 (11th Cir. 2004). In evaluating the administrative record, a district court may
not “decide the facts anew, reweigh the evidence,” or substitute its judgment for that
of the ALJ. Winschel, 631 F.3d at 1178 (internal quotations and citation omitted). If
substantial evidence supports the ALJ’s factual findings, then a district court “must
affirm even if the evidence preponderates against the Commissioner’s
findings.” Costigan v. Comm r, Soc. Sec. Admin., 603 Fed. Appx. 783, 786 (11th
Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, a district court must determine
whether the ALJ applied the correct legal standards. If the district court finds an
error in the ALJ’s application of the law, or if the district court finds that the ALJ
failed to provide sufficient reasoning to demonstrate that the ALJ conducted a proper
legal analysis, then the district court must reverse the ALJ’s decision. Cornelius v.
Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
DISCUSSION
Mr. Spears’s Severe Impairments
Mr. Spears contends that the ALJ erred at step two by finding that TBI with
migraines and fibromyalgia were not severe impairments. (Doc. 12, p. 14). Mr.
Spears argues that the ALJ “[did] not discuss the tender point testing, opinion
evidence, or examinations related to fibromyalgia and disregard[ed] Mr. Spears’[s]
complaints of pain and continued treatment for chronic headache[s].” (Doc. 12, p.
16). Mr. Spears asserts that the ALJ’s error is not harmless because the ALJ did not
properly consider the omitted impairments later in the sequential process. (Doc. 12,
p. 15) (citing Freeman v. Comm’r of Soc. Sec., 593 Fed. Appx. 911, 914-15 (11th
Cir. 2014); Gray v. Comm’r of Soc. Sec., 550 Fed. Appx. 850, 853-54 (11th Cir.
2013)).
As the Eleventh Circuit has explained, “step two requires only a finding of ‘at
least one’ severe impairment to continue on to the later steps.” Tuggerson-Brown v.
Comm'r of Soc. Sec., 572 Fed. Appx. 949, 951 (11th Cir. 2014) (quoting Jamison v.
Bowen, 814 F.2d 585, 588 (11th Cir. 1987)); see also Packer v. Comm'r of Soc. Sec.,
542 Fed. Appx. 890, 892 (11th Cir. 2013) (“[T]he ALJ determined at step two that
at least one severe impairment existed; the threshold inquiry at step two therefore
was satisfied. Indeed, since the ALJ proceeded beyond step two, any error in failing
to find that Packer suffers from the additional severe impairments of degenerative
joint disease of the right knee or varicose veins would be rendered harmless.”). As
noted, based on his review of Mr. Spears’s medical records, the ALJ identified eight
severe impairments. Therefore, the ALJ’s failure to identify other alleged severe
impairments at step two is harmless error.
Mr. Spears argues that the ALJ did not consider TBI, migraine headaches, or
fibromyalgia in formulating an RFC. (Doc. 15, p. 4). The ALJ’s lengthy opinion
contradicts the assertion. In discussing the rationale for the RFC that he assigned
Mr. Spears, the ALJ explained that there was no medical evidence to support Mr.
Spears’s contention that he suffered a traumatic brain injury in combat. (Doc. 9-3,
p. 32). The ALJ stated:
The claimant claimed a traumatic brain injury although the medical
records are void of such diagnosis or any treatment. He said he passed
out when he hit his head inside a truck he was driving. He admitted he
was never treated in the Army for such condition. He said he sees his
doctor every three month[s] and has never had any surgeries for his
complaints.
(Doc. 9-3, pp. 21, 32-33). Substantial evidence in Mr. Spears’s medical records
supports these findings.4
Likewise, in discussing the reasons for Mr. Spears’s RFC, the ALJ considered
Mr. Spears’s visit to the Crestwood Medical Center on August 13, 2016, because of
4 At Mr. Spears’s supplemental administrative hearing, his attorney mentioned “water on the brain
that they consistently have to drain off.” (Doc. 9-3, p. 56). The ALJ was not aware of medical
records that substantiated this contention, and the Court has not found any in its review of Mr.
Spears’s medical records.
his headaches. (Doc. 9-3, pp. 28, 33). The ALJ considered a CT scan of Mr. Spears’s
head which showed no mass. (Doc. 9-3 p. 29). The ALJ discussed Mr. Spears’s
treatment record from December 2017 for headaches and a medical record from
February 2019 that indicated that Mr. Spears denied severe headaches. (Doc. 9-3,
pp. 28, 30). The ALJ’s discussion of these medical records is largely consistent with
the Court’s description of the medical records relating to Mr. Spears’s headaches.
Those records are relatively sparse, and they indicate that after a neurologist
instructed Mr. Spears to stop taking Excedrin and to take two prescribed medicines
to treat the headaches, Mr. Spears’s internist questioned whether Mr. Spears was
adhering to his prescribed medication. (Doc. 9-11, p. 87). Thus, substantial weight
supports the ALJ’s evaluation of Mr. Spears’s headaches as they pertain to his RFC.
With respect to his discussion of Mr. Spears’s fibromyalgia as it relates to Mr.
Spears’s RFC, the ALJ wrote that Mr. Spears’s medical records reflected
intermittent complaints about fibromyalgia and conservative treatment. The ALJ
observed that Mr. Spears was diagnosed with fibromyalgia in 2013, and he worked
until 2016. (Doc. 9-3, p. 33). The ALJ noted that although Mr. Spears complained
of pain in February 2019, he reported that he was able to walk one mile. (Doc. 9-3,
p. 35).
Consistent with these findings, the Court has not located in the administrative
record medical records that indicate that Mr. Spears regularly sought treatment for
fibromyalgia. The most significant reports in the administrative record concerning
fibromyalgia are two consultative reports from 2017, one in February from Dr. Baren
for a VA benefits application and the other in November from Dr. Mollohan for a
Disability Determination Examination. (Doc. 9-9, pp. 40, 157). Neither physician
treated Mr. Spears. Dr. Baren reported that Mr. Spears was not being treated for
fibromyalgia when she saw him. (Doc. 9-9, p. 41). None of the prescription
medications that Mr. Spears reported to Dr. Mollohan is used to treat fibromyalgia.
(Doc. 9-9, p. 162). Both physicians found that Mr. Spears complained of pain in
most or all of the 18 palpable muscular tender points in the diagnostic criteria for a
diagnosis of fibromyalgia. (Doc. 9-9, pp. 42, 159-60). Though those complaints of
pain in muscular tender points may be indicative of fibromyalgia, Mr. Spears had no
other findings, symptoms, diagnostic test findings, or conditions consistent with a
diagnosis of fibromyalgia. (Doc. 9-9, pp. 42-43). Mr. Spears had normal strength
in all extremities, and his sensory perception to touch and pressure was normal in all
extremities but his right thumb. (Doc. 9-9, p. 165). Dr. Baren indicated that Mr.
Spears’s fibromyalgia did not impact his ability to work. (Doc. 9-9, p. 43). In the
narrative portion of her report, Dr. Baren pointed out that Mr. Spears’s complaints
of sleep disturbances and depression related to his PTSD, not his fibromyalgia.
(Doc. 9-9, p. 43).
In sum, if the ALJ’s failure to include TBI, migraine headaches, and
fibromyalgia in Mr. Spears’s list of severe impairments constitutes error, the error is
harmless both because it did not prevent the ALJ from moving from step two to step
three of the sequential analysis and because the ALJ properly acknowledged and
accounted for the medically verifiable impairments of migraine headaches and
fibromyalgia in Mr. Spears’s RFC. Tuggerson-Brown v. Comm’r of Soc. Sec., 572
Fed. Appx. 949, 951 (11th Cir. 2014) (noting that the ALJ “was required to consider
all impairments regardless of severity, in conjunction with one another in performing
the latter steps of the sequential evaluation.”). Substantial evidence supports an RFC
for work at the restricted light level.
Evaluation of Medical Opinion Evidence
Mr. Spears contends that he has a VA disability rating of 100%, and he argues
that the ALJ erred because he did not discuss the VA disability determination and
the Disability Benefits Questionnaire in his decision. Mr. Spears also contends that
the ALJ did not consider the medical evidence on which the VA relied in reaching
its disability determination. (Doc. 12, p. 21).
For SSA claims like this one filed after March 27, 2017, an ALJ “will not
provide any analysis in [his] determination or decision about a decision made by any
other governmental agency … about whether you are disabled, blind, employable,
or entitled to benefits.” 20 C.F.R. § 404.1504; see Harner v. Soc. Sec. Admin.,
Comm’r., 38 F.4th 892, 898 (11th Cir. 2022). An ALJ “will consider all of the
supporting evidence underlying the other governmental agency or nongovernmental
entity’s decision” that the claimant places in the SSA administrative record. 20
C.F.R. § 404.1504.
The ALJ acknowledged Mr. Spears’s disability determination from the VA,
(Doc. 9-3, p. 36), but under 20 C.F.R. § 404.1504, the ALJ was not permitted to
provide analysis about the VA’s decision. Although it does not appear that the ALJ
discussed in his opinion Dr. Baren’s evaluation of Mr. Spears’s fibromyalgia for the
VA disability proceeding, the ALJ was not required to discuss the evaluation; he
only had to consider it. See Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005)
(explaining that, generally, “there is no rigid requirement that the ALJ specifically
refer to every piece of evidence in his decision”).5 The ALJ stated that he
“considered the medical opinions and prior administrative medical findings.” (Doc.
9-3, p. 26). Moreover, any error in the ALJ’s failure to specifically refer to Dr.
Baren’s assessment is harmless because Dr. Baren’s findings that Mr. Spears did not
5 In Noble v. Commissioner of Soc. Security, the Eleventh Circuit explained that under the version
of 20 C.F.R. § 404.1504 in place in 2016, a VA disability decision was not binding on the
Commissioner, but the Commissioner had to consider the decision and, under binding Eleventh
Circuit precedent, had to give that agency decision great weight. 963 F.3d 1317, 1329 (11th Cir.
2020). The “great weight” rule was an exception to Dyer’s general rule and obligated an ALJ to
discuss in his decision “another agency’s decision finding the claimant disabled.” 963 F.3d at
1329. Because the Eleventh Circuit has held that courts should implement the updated regulations
that the Commissioner adopted in 2017, an ALJ no longer may discuss a VA disability
determination, and the general rule would appear to apply to supporting evidence underlying a VA
determination.
need continuous medication for fibromyalgia and that his fibromyalgia did not affect
his ability to work, (Doc. 9-9, p. 40-43), were largely consistent with Dr. Mollohan’s
opinion which the ALJ discussed at step four, (Doc. 9-3, pp. 33-34). Therefore, there
is no basis for remand for the ALJ to expressly discuss Dr. Baren’s assessment of
Mr. Spears’s fibromyalgia.
Mr. Spears argues that the ALJ erred in his consideration of Dr. Harris’s
opinion evidence. Dr. Harris completed an undated assessment in which he
indicated that Mr. Spears had considerable limitations in several areas of
functioning. (Doc. 9-12, pp. 123-24). Dr. Harris also wrote a brief letter dated April
19, 2018, in which he opined that Mr. Spears’s PTSD and depression precluded him
from maintaining employment. (Doc. 9-9, p. 184). Mr. Spears contends that the
ALJ substituted his “lay opinion for that of Dr. Harris” and disregarded Dr. Harris’s
opinions “without substantial evidence to support such omissions.” (Doc. 15, p. 7).
Under the applicable 2017 regulations, an ALJ may not defer to or give
specific evidentiary weight to a medical opinion but should focus on the
persuasiveness of the opinion by considering, among other things, the supportability
of the opinion, the consistency of the opinion with objective medical evidence, the
source’s relationship with the claimant, and the source’s field of specialization. 20
C.F.R. § 404.1520(c)(1)-(5); Matos v. Comm’r of Soc. Sec., No. 21-11764, 2022 WL
97144, *4 (11th Cir. Jan. 10, 2022). An ALJ must explain how he considered
supportability and consistency, the two most important factors. 20 C.F.R. §
404.1520(c)(c)(1-2); Matos, 2022 WL 97144 at *4. An ALJ may articulate his
findings on other factors. 20 C.F.R. § 404.1520(c)(2).
The ALJ found that Dr. Harris’s undated “fill in the blank” assessment was
neither inherently valuable nor persuasive because it was incomplete, inconsistent
with Dr. Harris’s treatment records, and unsupported by the record as a whole. (Doc.
9-3, pp. 30-31). The ALJ correctly stated that Dr. Harris indicated Mr. Spears’s
mental impairments by check marks on the “pre-printed form” and “left all support
. . . in the ‘clinical findings’ portion of [the] form . . . blank.” (Doc. 9-3, p. 30). The
ALJ found that limitations that Dr. Harris identified in the form were inconsistent
with Dr. Harris’s treatment records. For example, Dr. Harris indicated that Mr.
Spears had a severe impairment in his ability to use judgement, but Dr. Harris’s
treatment records consistently noted that Mr. Spears’s judgement was fair. (Doc. 9-
3, p. 31; Doc. 9-11, pp. 116, 136, 164; Doc. 9-12, pp. 25, 42, 69, 82, 119). The ALJ
also discussed the inconsistencies he found in Dr. Harris’s ratings on the assessment
form and Mr. Spears’s testimony about his daily activities. (Doc. 9-3, p. 31).
Ultimately, the ALJ determined that Dr. Harris’s assessment was “undated and
unsupported” and “neither probative nor persuasive.” (Doc. 9-3, p. 31).
Similarly, The ALJ found the April 19, 2018, letter from Dr. Harris “To
Whom It May Concern” neither valuable nor persuasive because Dr. Harris’s
opinion that Mr. Spears’s depression and PTSD rendered him disabled was
inconsistent with Dr. Harris’s treatment notes that reflected that Mr. Spears’s PTSD
and depression symptoms generally were stable with medication and counseling.
(Doc. 9-3, p. 31). The ALJ also noted that disability determinations are reserved for
the Commissioner. (Doc. 9-3, p. 32) (citing 20 C.F.R. § 404.1527(e)(2)).
Mr. Spears’s medical records support the ALJ’s findings. For example, on
December 7, 2016, Dr. Harris noted that Mr. Spears was receiving outpatient
treatment for PTSD and depression and that he had never been hospitalized for these
conditions. (Doc. 9-12, p. 79). Mr. Spears exhibited a dysphoric mood and a
constricted affect, but he experienced no hallucinations; he was oriented to time,
place, and event; and his insight and judgment were fair. (Doc. 9-12, p. 82). Dr.
Harris noted that Mr. Spears was receiving treatment for both conditions. (Doc. 9-
12, p. 83). When Mr. Spears visited Dr. Harris in August of 2017, Mr. Spears
reported that he felt calmer and less depressed. (Doc. 9-12, p. 39). Mr. Spears often
denied severe depressive symptoms and described his depression as mild. (Doc. 9-
11, pp. 113, 133, 161; Doc. 9-12, p. 22). Records that post-date Dr. Harris’s April
2018 letter indicate an uptick in Mr. Spears’s depressive symptoms, but Mr. Spears
denied hallucinations, and he showed no overt signs of psychosis. (Doc. 9-11, pp.
94, 106, 140). Therefore, substantial evidence supports the ALJ’s conclusion that
Dr. Harris’s opinion was neither adequately supported by nor consistent with Mr.
Spears’s treatment records.
CONCLUSION
For the reasons discussed above, the ALJ’s decision rests on substantial
evidence, and the ALJ applied proper legal standards. The Court will not reweigh
the evidence or substitute its judgment for that of the Commissioner. Accordingly,
the Court affirms the Commissioner’s decision. The Court will enter a separate final
judgment consistent with this memorandum opinion.
DONE and ORDERED this March 17, 2023.
aan HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE
37