Cain v. Social Security Administration, Commissioner

UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

WESTERN DIVISION

CHRISTOPHER ALAN CAIN, )

)

Plaintiff, )

)

v. ) Case No. 7:22-cv-28-GMB

)

KILOLO KIJAKAZI, Acting )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

On November 28, 2018, Plaintiff Christopher Cain filed an application for a

period of disability and disability insurance benefits (“DIB”). His alleged disability

onset date is May 7, 2018. Cain’s application for benefits was denied at the initial

administrative level. He then requested a hearing before an Administrative Law

Judge (“ALJ”). The ALJ held a hearing on November 9, 2020, and denied Cain’s

claims on February 2, 2021. Cain requested a review of the ALJ’s decision by the

Appeals Council, which declined review on November 2, 2021. As a result, the

ALJ’s decision became the final decision of the Commissioner of the Social Security

Administration (the “Commissioner”) as of November 2, 2021.

Cain’s case is now before the court for review pursuant to 42 U.S.C.

§§ 405(g) and 1383(c)(3). Under 28 U.S.C. § 636(c)(1) and Rule 73 of the Federal

Rules of Civil Procedure, the parties have consented to the full jurisdiction of a

United States Magistrate Judge. Doc. 14. Based on a review of the parties’

submissions, the relevant law, and the record as a whole, the court concludes that

the decision of the Commissioner is due to be affirmed.

I. STANDARD OF REVIEW1

The court reviews a Social Security appeal to determine whether the

Commissioner’s decision “is supported by substantial evidence and based upon

proper legal standards.” Lewis v. Callahan, 125 F.3d 1436, 1439 (11th Cir. 1997).

The court will reverse the Commissioner’s decision if it is convinced that the

decision was not supported by substantial evidence or that the proper legal standards

were not applied. Carnes v. Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). The

court “may not decide the facts anew, reweigh the evidence, or substitute its

judgment for that of the Commissioner,” but rather “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) (citation and internal quotation marks omitted).

“Even if the evidence preponderates against the Secretary’s factual findings, [the

court] must affirm if the decision reached is supported by substantial evidence.”

Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). Moreover, reversal is not

1 In general, the legal standards are the same whether a claimant seeks DIB or Supplemental

Security Income (“SSI”). However, separate, parallel statutes and regulations exist for DIB and

SSI claims. Therefore, citations in this opinion should be considered to reference the appropriate

parallel provision as context dictates. The same applies to citations for statutes or regulations

found in excerpted court decisions.

warranted even if the court itself would have reached a result contrary to that of the

factfinder. See Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991).

The substantial evidence standard is met “if a reasonable person would accept

the evidence in the record as adequate to support the challenged conclusion.”

Holladay v. Bowen, 848 F.2d 1206, 1208 (11th Cir. 1988) (quoting Boyd v. Heckler,

704 F.2d 1207, 1209 (11th Cir. 1983)). The requisite evidentiary showing has been

described as “more than a scintilla, but less than a preponderance.” Bloodsworth v.

Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). The court must scrutinize the entire

record to determine the reasonableness of the decision reached and cannot “act as

[an] automaton[] in reviewing the [Commissioner’s] decision.” Hale v. Bowen, 831

F.2d 1007, 1010 (11th Cir. 1987). Thus, the court must consider evidence both

favorable and unfavorable to the Commissioner’s decision. Swindle v. Sullivan, 914

F.2d 222, 225 (11th Cir. 1990).

The court will reverse the Commissioner’s decision on plenary review if the

decision applies incorrect law or fails to provide the court with sufficient reasoning

to determine that the Commissioner properly applied the law. Grant v. Astrue, 255

F. App’x 374, 375–76 (11th Cir. 2007) (citing Keeton v. Dep’t of Health & Human

Servs., 21 F.3d 1064, 1066 (11th Cir. 1994)). There is no presumption that the

Commissioner’s conclusions of law are valid. Id.

II. STATUTORY AND REGULATORY FRAMEWORK

To qualify for disability benefits, a claimant must show the “inability to

engage in any substantial gainful activity by reason of any medically determinable

physical or mental impairment which can be expected to result in death or which has

lasted or can be expected to last for a continuous period of not less than 12 months.”

42 U.S.C. §§ 423(d)(1)(A) & 416(i). A physical or mental impairment is “an

impairment that results from anatomical, physiological, or psychological

abnormalities which are demonstrated by medically acceptable clinical and

laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3). Cain bears the burden of

proving that he is disabled and is responsible for producing evidence sufficient to

support his claim. See Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003).

A determination of disability under the Social Security Act requires a five-

step analysis. 20 C.F.R. § 404.1520(a). The Commissioner must determine in

sequence:

(1) Is the claimant presently unable to engage in substantial gainful

activity?

(2) Are the claimant’s impairments severe?

(3) Do the claimant’s impairments satisfy or medically equal one of the

specific impairments set forth in 20 C.F.R. Pt. 404, Subpt. P,

App. 1?

(4) Is the claimant unable to perform his former occupation?

(5) Is the claimant unable to perform other work given his residual

functional capacity, age, education, and work experience?

See Frame v. Comm’r, Soc. Sec. Admin., 596 F. App’x 908, 910 (11th Cir. 2015).

“An affirmative answer to any of the above questions leads either to the next

question, or, [at] steps three and five, to a finding of disability. A negative answer

to any question, other than at step three, leads to a determination of ‘not disabled.’”

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986) (quoting 20 C.F.R.

§ 416.920(a)−(f)). “Once the finding is made that a claimant cannot return to prior

work the burden of proof shifts to the Secretary to show other work the claimant can

do.” Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995) (citing Gibson v. Heckler,

762 F.2d 1516 (11th Cir. 1985)).

III. RELEVANT FACTUAL BACKGROUND

Cain was born on April 2, 1979, and was 39 years old on his alleged onset

date. R. 44 & 263. His primary physical complaint is back pain. R. 51. He has had

two back fusion surgeries. R. 51–52. His primary mental complaints are attention

deficit hyperactivity disorder (“ADHD”), anxiety, and Post Traumatic Stress

Disorder (“PTSD”). R. 54–56. In his disability report, Cain identified the following

medical conditions: back injury, ADHD, sleep apnea, confusional arousal disorder,

and PTSD. R. 303. Cain graduated from high school and attended trade school for

three years. R. 45. He has worked as a brick layer, electrician, front-end loader

operator, and auto parts inspector. R. 45, 48–50, 69, 302 & 304.

Cain testified at his hearing that he has severe back pain that causes his legs

to “go numb.” R. 51 & 54. Sometimes he is unable to walk because the pain shoots

from his back down to his legs and “prevents [him] from moving.” R. 53. Cain can

walk for 35 to 50 yards before having to sit down (R. 57), but if he sits for too long,

his legs go numb and he cannot stand. R. 53. It takes as little as five to ten minutes

for the numbness to occur in his legs, and he can stand for five to ten minutes before

needing to sit down. R. 53 & 57. Cain is able to walk up stairs but walking down

stairs results in radiating pain in his legs. R. 58. He estimates that he can lift only

eight to ten pounds. R. 57. He cannot bend over to pick something off the ground,

does not do laundry, and does not bend his knees to stoop or squat. R. 57–58.

As for his mental impairments, Cain testified that his PTSD affects his ability

to stay on task and to concentrate. R. 55. He takes medicine that controls some of

his PTSD symptoms. R. 55. He has anxiety and panic attacks “where [he] can’t

hardly breathe,” which are caused by circumstances “like talking to people and being

in public places.” R. 56. He worries constantly, wakes up feeling like he is under

attack, and has angry outbursts where he blacks out. R. 56. Cain sees a therapist

every two weeks. R. 56.

As to his daily activities, Cain testified that he makes simple things to eat like

sandwiches. R. 58. He does not perform any housework. R. 59. He cannot bathe

and dress himself but receives help from his wife with tasks like putting on and

removing his socks and shoes. R. 58–59. She sometimes helps him off the toilet or

to get in and out of the shower. R. 59. When asked how he spends his daytime hours,

Cain testified that he walks to his mother-in-law’s house, 35 to 50 yards away from

his own, to visit with her and also helps with his sons’ schoolwork and snacks. R.

59. He also may watch his sons play sports in the yard. R. 60. However, there are

some days his pain is so bad that he cannot get out of bed. R. 61. Those days occur

three or four times per month. R. 61.

One of Cain’s mental health treatment providers is psychologist Dr. Todd

Walborn, who diagnosed him with PTSD, ADHD, and confusional arousal. R. 699.

He explained that

Mr. Cain suffers from chronic pain in his lower back, the three

psychological conditions listed above, and an inability to be gainfully

employed. These problems are interrelated. The chronic pain is

exacerbated by the depression and anxiety of the PTSD. The

depression and anxiety lead to his attention problems (ADHD) being

more severe. His inability to work and support his family contribute to

the depression and anxiety. His inability to work is secondary to his

chronic pain, inattention, depression and anxiety.

R. 699. In a supplemental note, Dr. Walborn observed that Cain “requires

psychotherapy to deal with his emotions related to PTSD as well as the chronic pain.

His emotional response to the chronic pain is understandable but makes him unable

to function in a work environment.” R. 825–26.

The ALJ issued her decision on February 2, 2021. R. 31. Under step one of

the five-step evaluation process, she found that Cain has not engaged in substantial

gainful activity since his alleged onset date of May 7, 2018. R. 18. The ALJ

concluded that Cain suffered from the severe impairment of degenerative disc

disease of the lumbar spine status post L5-S1 and L4-5 fusions.2 R. 18. She found

Cain’s other impairments of depression, anxiety, bipolar disorder, PTSD, ADHD,

and sleep apnea to be non-severe. R. 18–24. The ALJ noted that Cain’s medically

determinable impairments cause more than minimal limitations to his ability to

perform basic work activities. R. 24–25. But she concluded at step three of the

analysis that none of Cain’s impairments satisfied or medically equaled the severity

of one of those listed in the applicable regulations. R. 24–25.

Before proceeding to the fourth step, the ALJ determined that Cain had the

residual functional capacity (“RFC”) to perform a limited range of light work. R. 51.

More specifically, she found that Cain had the following limitations with respect to

light work, as defined in 20 C.F.R. § 404.1567(b):

[H]e can occasionally climb ramps and stairs; he can never claim

ladders, ropes, or scaffolds; he can frequently balance; he can

occasionally stoop, kneel, crouch, and crawl; he can never work at

unprotected heights, with hazardous machinery, or around open bodies

of water; he is precluded from commercial driving; he can have

occasional exposure to extreme cold and vibration; and he can

understand, remember, and carry out simple instructions consistent

with unskilled work activity.

R. 25. At the fourth step, the ALJ considered Cain’s age, education, work

experience, and RFC in determining that he was not capable of performing his past

relevant work as an electrician, brick layer, front end loader, and parts inspector.

2 The ALJ found Cain’s other alleged impairments to be non-severe. R. 20. Cain does not

challenge these findings.

R. 29. However, the ALJ determined that there were other jobs existing in the

national economy that Cain could perform, including work as a ticket taker; mail

sorter, non-postal; and inspector. R. 30. Therefore, the ALJ concluded that Cain was

not disabled within the meaning of the Social Security Act from May 7, 2018,

through the date of the decision. R. 30. Based on these findings, she denied Cain’s

application for benefits. R. 31.

IV. DISCUSSION

Cain makes three3 arguments in favor of remand: (1) the ALJ improperly

assessed the credibility of his subjective complaints of pain; (2) the ALJ improperly

evaluated the opinions of his treating psychologist; and (3) the ALJ erred in framing

the hypothetical to the VE. Doc. 17 at 17–25. For the following reasons, the court

finds that substantial evidence supports the ALJ’s determinations and that she

applied the proper standards to reach her conclusions.

A. Subjective Complaints of Pain

In addressing a claimant’s subjective description of his pain and symptoms,

the law is clear that

3 Instead of clearly delineating his arguments, Cain’s brief moves from one point to the next

without any clear transitions. The court has made every attempt to address each argument Cain

fully develops in his brief in support of remand. Although Cain makes passing reference to other

potential alleged errors, the court does not address any issues unsupported by substantive

arguments containing an explanation of the asserted error, citations to the record, and supporting

case law. These arguments have been abandoned. See Access Now, Inc. v. Sw. Airlines Co., 385

F.3d 1324, 1330 (11th Cir. 2004) (“[A] legal claim or argument that has not been briefed before

the court is deemed abandoned and its merits will not be addressed.”).

to establish a disability based on testimony of pain and other symptoms,

the claimant must satisfy two parts of a three-part test showing:

(1) evidence of an underlying medical condition; and (2) either

(a) objective medical evidence confirming the severity of the alleged

pain; or (b) that the objectively determined medical condition can

reasonably be expected to give rise to the claimed pain. If the ALJ

discredits subjective testimony, he must articulate explicit and adequate

reasons for doing so.

Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002) (citations omitted); see

also 20 C.F.R. §§ 404.1529. If a claimant satisfies the first part of the test, the ALJ

must evaluate the symptoms’ intensity, persistence, and effect on the claimant’s

ability to work. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. §§ 404.1529(c) & (d);

20 C.F.R. §§ 416.929(c) & (d). While evaluating the evidence, the ALJ must

consider whether inconsistencies exist within the evidence or between the claimant’s

statements and the evidence, including his history, medical signs and laboratory

findings, and statements by medical sources or other sources about how his

symptoms affect him. 20 C.F.R. §§ 404.1529(c)(4) & 416.929(c)(4). In determining

whether substantial evidence supports an ALJ’s credibility determination, “[t]he

question is not . . . whether the ALJ could have reasonably credited [the claimant’s]

testimony, but whether the ALJ was clearly wrong to discredit it.” Werner v. Comm’r

of Soc. Sec., 421 F. App’x 935, 939 (11th Cir. 2011). The ALJ is not required to

conduct an explicit symptom analysis, but the reasons for her findings must be clear

enough to be obvious to a reviewing court. See Foote v. Chater, 67 F.3d 1553, 1562

(11th Cir. 1995). “A clearly articulated credibility finding with substantial

supporting evidence in the record will not be disturbed by a reviewing court.” Id.

(citation omitted).

The ALJ found here that Cain’s medically determinable impairments could

reasonably be expected to produce the alleged symptoms but that his statements

regarding the intensity, persistence, and limiting effects of these symptoms were not

entirely consistent with the medical evidence and other evidence in the record.

R. 27. This determination is supported by substantial evidence.

Cain’s contention that the ALJ did not consider the evidence in its entirety or

his condition as a whole (Doc. 17 at 20–22) is incorrect. The ALJ thoroughly

examined the medical evidence in the record in determining that Cain’s subjective

complaints were not entirely credible, and she adequately articulated the reasons her

finding. R. 19–22, 25 & 27–29; see Foote, 67 F.3d at 1562. Substantial evidence

supports this finding. As to his physical impairments, Cain’s complaints of disabling

pain were inconsistent with the following medical evidence:

• In October 2018, Cain saw a new orthopedist and complained of ongoing pain

with weakness and electrical sensations in his lower extremities. A needle

electromyogram showed he had “likely resolving” lumbosacral radiculopathy

consistent with his recent surgery. Physical examination showed a moderately

reduced range of motion and positive straight leg raise testing on both sides

with generalized weakness due to pain but overall 4/5 strength. R. 429–33.

• After a car accident in November 2018, Cain reported moderate pain with

sciatica, but on examination, Cain had normal range of motion, no focal

neurological deficits, normal sensory and motor function, and normal

coordination. An x-ray showed normal alignment and appearance, and there

was no evidence of any other abnormality. R. 446–47.

• At physical therapy in December 2018, Cain was able to complete all

exercises without wincing or rest breaks, and in January 2019 his orthopedist

noted that although Cain reported some ongoing symptoms in his legs, he had

excellent strength with no weakness and was able to stand from a seated

position without assistance. R. 681 & 685.

• A May 2019 MRI of Cain’s lumbar spine showed degeneration at L4–5, but

his L5–S1 fusion remained unremarkable. Cain went to a different

orthopedist, who noted that his lower extremities were areflexic but his

sensory and motor functions were grossly intact, and he had positive straight

leg raise testing and decreased range of motion due to guarding. R. 704 & 712.

Cain underwent a myelogram, CT scan, and discogram of his lumbar spine,

where he was observed to have pain on standing with normal ambulation,

negative straight leg raise testing, normal muscle bulk and tone, and normal

gait and station. R. 694 & 705.

• After L4–5 fusion surgery in June 2019, Cain reported improvement but

discomfort in his buttock. On examination, there was no evidence of new

motor or neurological deficits, and an x-ray showed the fusion hardware was

in the correct position. R. 710.

• An October 2019 examination showed Cain was grossly neurologically intact,

and an x-ray of his lumbar spine showed his bone graft was in a good position.

R. 724.

• Cain continued to complain of pain in December 2019, but an MRI did not

show any recurrent stenosis, herniation, or neural compromise that would

cause pain or that further surgery was warranted. The doctor recommended a

functional capacity evaluation (“FCE”). R. 701–02, 777 & 780. The FCE was

invalidated due to Cain’s inconsistent and submaximal effort. R. 765.

Cain also complains that the ALJ improperly evaluated the limiting effects of

his mental impairments. The court again disagrees. Cain’s complaints of disabling

symptoms due to his mental impairments, such as panic attacks and an inability to

concentrate, are inconsistent with the following medical evidence:

• Between March 2018 and February 2019, Cain’s psychiatrist, Dr. Arnand

Schachter, repeatedly noted that he had no focus problems and was fully alert

and oriented with intact attention, concentration, and average fund of

knowledge. R. 606, 609–10, 612–13, 615–16 & 618–23.

• Treatment notes from St. Vincent’s in May and July 2018 show that Cain did

not report any mental problems, and the examination notes reflect that Cain

was cooperative and pleasant with appropriate mood and affect and normal

judgment. R. 520–21 & 564–66.

• In September 2018, treatment notes from psychologist Dr. Walborn noted that

Cain had appropriate social skills, a pleasant and cooperative demeanor,

normal or above-normal intelligence, no anxiety, no mania, no hypomania,

and appropriate eye contact. R. 420.

• In October and November 2018, Cain sometimes denied and sometimes

admitted having anxiety or depression. Examinations showed he was fully

alert and oriented, had a normal mood and appropriate affect, intact judgment

and insight, normal attention span and ability to concentrate, and a normal

mental status exam. R. 434–35, 447 & 587–88.

• In February 2019, Dr. Schachter noted Cain’s mood as manic and increased

his medications. Otherwise, Cain’s thoughts were goal-directed and he had

good insight and judgment and intact memory. R. 607.

• Later that month, Cain attended a consultative examination with Dr. John

Neville where Cain reported his mood as more stable and better concentration

with the change in medication dosage. During Dr. Neville’s examination,

Cain had a neutral mood, was alert and oriented, could do a variety of memory

and concentration tasks, was not confused, and had no abnormal thought

content, good insight and judgment, and average intellectual functioning. Dr.

Neville observed Cain as attentive and cooperative and that he followed

instructions well. R. 626–28.

• In May 2019, Cain was again observed as having a normal affect and mood

and being active, alert, cooperative, and fully oriented. R. 694.

• In October 2020, Dr. Walborn noted that Cain had appropriate social skills, a

pleasant and cooperative demeanor, and normal or above intelligence, but did

exhibit some signs of anxiety and depression. R. 825.

The ALJ also considered Cain’s daily activities and their relationship to his

alleged physical and mental symptoms. R. 22 & 25–26. For example, Cain reported

to Dr. Neville in February 2019 that he could drive, shop with his wife, perform the

vast majority of his self-care and personal hygiene activities, and accomplish

household chores. R. 627. Similarly, he reported in January 2020 that he performs

light housework, drives short distances, and does not need assistance with his self-

care activities other than putting on his socks and shoes. R. 766. He also stated in

his function report that he participated in the following social activities: assisting

with homework, watching movies, attending basketball practice, going to church,

and attending medical appointments. R. 343. These reported activities further

undermine his claim of disabling limitations. See Lynn v. Comm’r of Soc. Sec., 791

F. App’x 888, 889 (11th Cir. 2020) (determining that substantial evidence supported

the ALJ’s finding that the claimant’s subjective complaints were inconsistent with

objective medical evidence and other aspects of her testimony, including her

reported activities of operating a motor vehicle, preparing meals, performing

household chores, doing laundry, and grooming herself); Meehan v. Comm’r of Soc.

Sec., 776 F. App’x 599, 603 (11th Cir. 2019) (holding that the ALJ properly found

a subjective complaint inconsistent with a record of simple daily activities).

The ALJ also commented on Cain’s noncompliance with his medical

professionals’ recommendations in discrediting his claim of disabling pain.4 R. 20

& 28. For example, Dr. Schachter recommended psychotherapy in March 2018, and

Cain consistently met with Dr. Walborn until September 2018. R. 421, 622–23 &

668–72. Although Dr. Walborn told Cain during their September 2018 visit that he

needed continue psychotherapy (R. 421), the record shows that Cain did not return

to Dr. Walborn for regular therapy after that visit and even refused therapy on several

occasions.5 R. 607, 613 & 616. As another example, Cain’s orthopedist told him to

stop smoking because it could delay bone growth after his surgeries (R. 710–11), but

he continued to smoke. R. 724 & 777. In fact, Cain admitted that he smoked up to

half of a pack of cigarettes every day. R. 51. Cain also stopped using a bone

stimulator and did not regularly attend physical therapy after his L4-5 fusion surgery.

R. 724.

4 The ALJ did not explore Cain’s ability to pay for treatment. As a general rule, “the ALJ may not

draw an adverse inference from a claimant’s lack of medical treatment without first considering

the claimant’s explanation for his failure to seek treatment.” Brown v. Comm’r of Soc. Sec., 425

F. App’x 813, 817 (11th Cir. 2011) (citing S.S.R. 96-7). Poverty can excuse a claimant’s non-

compliance with medical treatment. Id. (citing Dawkins v. Bowen, 848 F.2d 1211, 1213 (11th Cir.

1988)). Accordingly, the ALJ ordinarily must consider whether the claimant can afford medical

treatment before denying an application for disability benefits based on a failure to comply with

prescribed medical treatment. Id. (citing Ellison v. Barnhart, 355 F.3d 1272, 1275 (11th Cir.

2003)). But where, as here, the failure to follow medical treatment is not a principal factor in the

ALJ’s decision, “the ALJ’s failure to consider the claimant’s ability to pay will not constitute

reversible error.” Id. (citing Ellison, 355 F.3d at 1275).

5 The ALJ also noted the inconsistency between Cain’s testimony at the hearing that he continued

to see a therapist every two weeks (R. 56) and the record evidence of his refusal to attend therapy

sessions and failure to visit Dr. Walborn since September 2018. R. 20, 28, 607, 613 & 616; see 20

C.F.R. § 404.1529(c)(4) (permitting an ALJ to consider conflicts between a claimant’s testimony

and the record when evaluating the severity of symptoms).

For all of these reasons, the ALJ correctly considered “the consistency of

[Cain’s] statements” with the remainder of the evidence in the record. See SSR 16-

3p, 2017 WL 5180304, at *8. The court finds that the ALJ’s determinations of

Cain’s credibility with respect to his subjective complaints are supported by

substantial evidence.

B. Mental Health Professional Opinions

Cain argues that the ALJ improperly rejected the opinions of his treating

psychologist Dr. Walborn. Doc. 17 at 23–24. The court disagrees and finds that the

ALJ properly considered and articulated his evaluation of the psychologist’s

opinions consistent with the applicable regulations such that substantial evidence

supports the ALJ’s decision.

As a threshold matter, Cain’s brief relies on an obsolete hierarchy of medical

opinions. Before March 27, 2017, the opinions of examining physicians were given

more weight than non-examining physicians, treating physicians more than non-

treating physicians, and specialists more than non-specialist physicians. 20 C.F.R.

§ 416.927(c)(1–5). Under the new regulations, however, an ALJ must “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 [a

claimant’s] medical sources.” Id. Instead, the new regulation provides several

factors informing the ALJ’s decision on the weight to give a claimant’s proffered

medical opinions. Those factors include the supportability of the medical opinion,

its consistency with other record evidence, the physician’s relationship with the

claimant, the physician’s specialty, and other relevant information, such as the

physician’s familiarity with the other record evidence and with making a claim for

disability. 20 C.F.R. § 404.1520c(c)(1)–(5). In Harner v. Social Security

Administration, 38 F.4th 892, 897–98 (11th Cir. 2022), the Eleventh Circuit

confirmed that these new regulations eliminate the treating physician hierarchy.

Here, the new regulations apply because Cain filed his claim on November 28, 2018.

See 20 C.F.R. § 404.1520c(a) (stating that the new regulations apply to “claims filed

. . . on or after March 27, 2017”).

The new regulations also changed the standards an ALJ should apply when

articulating her assessment of medical source opinions. First, an ALJ need not

assign specific evidentiary weight to medical opinions based on their source. See

Tucker v. Saul, 2020 WL 3489427, at *6 (N.D. Ala. June 26, 2020). Second, the

ALJ does not have to “give good reasons” for the weight she assigns to treating

source opinions. Compare 20 C.F.R. § 416.927(c)(2) (“We will always give good

reasons in our notice of determination or decision for the weight we give your

treating source’s medical opinion.”), with 20 C.F.R. § 416.920c(a) (“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.”).

The court finds that the ALJ properly evaluated Dr. Walborn’s statements

under the new regulations. Put simply, the ALJ followed the relevant regulations

and properly analyzed Dr. Walborn’s findings. She explained how Dr. Walborn’s

opinions were not supported by or consistent with his own examinations and the

other objective medical evidence. R. 20–21. For example, throughout his own

treatment notes, Dr. Walborn noted that Cain had appropriate social skills, a pleasant

and cooperative demeanor, normal or above intelligence, unimpaired speech, no

anxiety, no mania, no hypomania, appropriate eye contact, and no psychosis or

personality disorder. R. 420 & 825. The ALJ also noted that Dr. Walborn’s

statements were inconsistent with examination findings from Dr. Schachter, Cain’s

psychiatrist. Dr. Schachter repeatedly observed that Cain was alert and oriented, had

intact concentration and an average fund of knowledge, goal-directed thoughts, good

insight and judgment, and intact memory. R. 606–23. This evidence undermines Dr.

Walborn’s assertion that Cain’s mental impairments are completely disabling. See

Matos v. Comm’r of Soc. Sec., 2022 WL 97144, at *4 (11th Cir. Jan. 10, 2022)

(finding medical statement unpersuasive where unsupported by source’s own

treatment notes and inconsistent with other medical record).

Moreover, as both the ALJ and the Commissioner argue, Dr. Walborn did not

provide a medical opinion consistent with the regulations. A medical opinion “is a

statement from a medical source about what you can still do despite your

impairment(s).” 20 C.F.R. §§ 404.1513(a)(2), 416.913(a)(2). The opinion must state

whether the claimant has limitations or restrictions in one of four ways: (1) ability

to perform physical demands of work activities; (2) ability to perform mental

demands of work activities; (3) ability to perform other demands of work; or

(4) ability to adapt to environmental conditions. Id. Dr. Walborn’s notes, diagnoses,

and statement that Cain is unable to work do not qualify under these regulations as

a medical opinion.

For these reasons, the court concludes that the ALJ applied the proper standard

in evaluating Cain’s medical evidence and did not err in evaluating Dr. Walborn’s

opinion. The ALJ clearly articulated her reasons for finding that the opinion was not

well supported or consistent with other medical records. Substantial evidence

supported this decision.

C. VE Hypothetical

Finally, Cain argues that the VE hypothetical did not include Dr. Walborn’s

proposed mental limitations. Doc. 17 at 23. An ALJ must pose a hypothetical

question to the VE that comprehensively describes the claimant’s impairments.

Pendley v. Heckler, 767 F.2d 1561, 1563 (11th Cir. 1985). However, the ALJ is not

required to include findings that she properly rejects as unsupported by the record.

Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158–59 (11th Cir. 2004).

The ALJ’s hypothetical to the VE contained all of Cain’s legitimate

limitations. First, the ALJ included Cain’s credible physical limitations in the VE’s

hypothetical. As discussed above, the ALJ properly rejected Cain’s more restrictive

subjective complaints. Second, the ALJ also properly refused to incorporate Dr.

Walborn’s mental limitations because they were not supported by his own findings

or records from other medical sources. Because the law does not require the ALJ to

include in the VE’s hypothetical any unsupported limitations, Crawford, 363 F.3d

at 1161, the ALJ here did not err in framing her hypothetical to the VE.

V. CONCLUSION

For these reasons, the Commissioner’s decision is supported by substantial

evidence and based upon the proper legal standards. Accordingly, the decision of

the Commissioner is due to be affirmed. A final judgment will be entered separately.

DONE and ORDERED on May 17, 2023.

OF on

GRAY M.BORDEN

UNITED STATES MAGISTRATE JUDGE

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