# Campbell v. Social Security Administration, Commissioner

> District Court, N.D. Alabama · February 16, 2024

URL: https://www.frixlaw.com/law-library/cases/9992009

## Case

- **Court:** District Court, N.D. Alabama
- **Decided:** February 16, 2024
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

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## Opinion text

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
JASPER DIVISION

LISA CAMPBELL, }
}

}
Plaintiff,
}

} Case No.: 6:21-cv-01681-MHH
v.
}

}
COMMISIONER OF SOCIAL
}
SECURITY ADMINISTRATION,
}

}
Defendant.
}

MEMORANDUM OPINION

Lisa Campbell seeks judicial review of a final adverse decision of the
Commissioner of Social Security pursuant to 42 U.S.C. § 405(g). The
Commissioner denied Ms. Campbell’s applications for a period of disability,
disability insurance benefits, and supplemental security income based on an
Administrative Law Judge’s finding that Ms. Campbell was not disabled. Ms.
Campbell argues that the Administrative Law Judge—the ALJ—improperly rejected
Dr. Tooson’s medical opinion regarding the disabling limitations caused by her
impairments. She also argues that the ALJ improperly applied the pain standard and
that new and material evidence warrants a remand under 42 U.S.C. § 405(g). (Doc.
14, pp. 1-19). After careful consideration of the administrative record, for the
reasons discussed below, the Court remands this matter to the Commissioner for
further proceedings.

ADMINISTRATIVE PROCEEDINGS
To succeed in her administrative proceedings, Ms. Campbell had to prove that
she was disabled. Gaskin v. Comm’r of Soc. Sec., 533 Fed. Appx. 929, 930 (11th

Cir. 2013). “A claimant is disabled if [s]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.” Gaskin, 533 Fed. Appx. at 930 (citing 42 U.S.C. §

423(d)(1)(A)).1
To determine whether a claimant has proven that she 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 January
17, 2024).
can perform given the claimant’s RFC, age, education, and work
experience.

Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 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.

Ms. Campbell applied for a period of disability, disability insurance benefits,
and supplemental security income on February 13, 2020. (Doc. 9-6, pp. 2–8, 9–15).
Ms. Campbell alleged that her disability began on November 6, 2019. (Doc. 9-6,
pp. 3, 9).2 The Commissioner initially denied Ms. Campbell’s claims on July 9,

2020, and she requested a hearing before an ALJ. (Doc. 9-5, pp. 2, 18-22). Ms.
Campbell and her attorney attended a telephone hearing on April 15, 2021. (Doc. 9-
3, p. 42). A vocational expert testified at the hearing. (Doc. 9-3, p. 54).

The ALJ issued an unfavorable decision on June 3, 2021. (Doc. 9-3, pp. 18–
34). The Appeals Council denied Ms. Campbell’s request for review, (Doc. 9-3, pp.
2–4), making the Commissioner’s decision final and a proper candidate for this
Court’s judicial review. See 42 U.S.C. § 405(g) and § 1383(c).

2 Ms. Campbell previously filed an application for social security benefits, and an ALJ denied the
application on November 5, 2019. Because Ms. Campbell did not appeal that decision, the alleged
disability onset date for the applications on appeal in this case had to be “the day after” the prior
adverse decision. (Doc. 9-4, pp. 2-16; Doc. 9-6, p. 3).
EVIDENCE IN THE ADMINISTRATIVE RECORD
Ms. Campbell’s Medical Records

To support her applications, Ms. Campbell submitted medical records relating
to the diagnoses and treatment of Sjogren’s syndrome, primary biliary cirrhosis,
peripheral neuropathy, chronic kidney disease, iron deficiency anemia,

hypothyroidism, hypertension, gastroesophageal reflux disease, depression, anxiety,
and fibromyalgia.3 The Court has reviewed Ms. Campbell’s complete medical

3 Sjogren’s Syndrome is an autoimmune disorder where the immune system attacks the glands
that make moisture in the eyes, mouth, and other parts of the body and causes dryness, itchiness,
and sensitivity in the eyes and dryness in the mouth. See https://www.niams.nih.gov/health-
topics/sjogrens-
syndrome#:~:text=Sj%C3%B6gren's%20syndrome%2C%20also%20known%20as,other%20part
s%20of%20the%20body (last visited January 17, 2024).

Primary biliary cirrhosis is usually associated with Sjogren’s Syndrome. See
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176406/#:~:text=PBC%20is%20occasionally
%20associated%20with,of%20antimitochondrial%20antibodies%20(AMAs) (last visited January
17, 2024). Primary biliary cirrhosis is a chronic autoimmune disease where chronic inflammation
in the liver destroys the bile ducts of the liver and causes liver failure. The most common
symptoms of primary biliary cirrhosis are fatigue, itchy skin, dryness in eyes and mouth,
abdominal pain, swelling in the feet and ankles, fluid in the abdomen, jaundice, high cholesterol,
diarrhea, hypothyroidism, and weight loss. Primary biliary cirrhosis is not curable, but early
intervention with medication can slow the damage to the liver. See
https://www.mayoclinic.org/diseases-conditions/primary-biliary-cholangitis/symptoms-
causes/syc-
20376874#:~:text=When%20bile%20ducts%20become%20damaged,your%20liver%20are%20s
lowly%20destroyed (last visited January 17, 2024).

Cirrhosis is “scarring of liver tissue that makes it difficult for your liver to work properly” and
may “lead to liver failure.” Cirrhosis “indicates a later stage of primary biliary cholangitis,” and
people with primary biliary cirrhosis “have a poor prognosis and higher risk of other
complications.” See https://www.mayoclinic.org/diseases-conditions/primary-biliary-
cholangitis/symptoms-causes/syc-
20376874#:~:text=When%20bile%20ducts%20become%20damaged,your%20liver%20are%20s
lowly%20destroyed (last visited January 17, 2024).
history and summarizes the following medical records because they are most
relevant to Ms. Campbell’s arguments in this appeal.4

In 2009 and 2010, Dr. Charles Wilcox at UAB examined Ms. Campbell and
reported suspected primary biliary cirrhosis based on her abnormal liver function
test results. (Doc. 9-10, pp. 9, 11–12). In 2012, Dr. Dewayne Tooson, Ms.

Campbell’s primary care physician, referred Ms. Campbell to Dr. Omar Massoud at
Kirklin Clinic at UAB for a hepatology consult. (Doc. 9-9, p. 31). Dr. Massoud
reported that a 2012 liver biopsy confirmed that Ms. Campbell had primary biliary
cirrhosis. (Doc. 9-9, pp. 31, 34). Dr. Massoud treated Ms. Campbell’s cirrhosis at

Kirklin Clinic in 2012 and 2013. (Doc. 9-9, pp. 20–36). In a treatment record dated
August 31, 2012, Dr. Massoud noted that Ms. Campbell reported that she “stay[ed]
fatigued most of the time.” (Doc. 9-9, p. 34). Ms. Campbell indicated that she had

“some energy in the morning,” but by midday, she was “quite tired” and needed “to
sit down and rest.” (Doc. 9-9, p. 34).5
By May 23, 2018, when she saw Dr. Garry Magouirk and his physician’s

4 Although Ms. Campbell has a history of depression and anxiety, on appeal, she has not
challenged the ALJ’s findings regarding her mental limitations. Therefore, the Court has not
included a summary of records regarding her mental impairments in this opinion.

5 Most of the medical records submitted by Ms. Campbell begin in 2018, about a year before her
alleged onset date in November 2019. The Court notes a few older records that offer context for
Ms. Campbell’s more recent opinions.
assistant, JoLee Harkness, Ms. Campbell complained of “increased bruising related
to primary biliary cirrhosis.” (Doc. 9-8, p. 34). Ms. Campbell requested refills of

her cholesterol, blood pressure, depression, and hypothyroidism medications. (Doc.
9-8, p. 34). Ms. Campbell’s lab results showed high levels of creatinine and
bilirubin. (Doc. 9-8, pp. 36-37).6 PA Harkness indicated that Ms. Campbell had

primary biliary cirrhosis, depression, high cholesterol, hypothyroidism, and a
systolic heart murmur. (Doc. 9-8, p. 34).
On September 28, 2018, Ms. Campbell saw PA Harkness and “complain[ed]
of chronic itching due to liver disease, and state[d] she ha[d] multiple areas that

[would] not heal due to scratching.” (Doc. 9-8, p. 31). PA Harkness noted that Ms.
Campbell had multiple open sores on her arms in different stages of healing and that
her blood pressure was high at 150/80. (Doc. 9-8, pp. 31-32). PA Harkness noted

Ms. Campbell’s prior diagnoses of primary biliary cirrhosis, hypertension,
hypothyroidism, depression, hyperlipidemia, and non-cardiac chest pain. (Doc. 9-
8, p. 31). Her medication list at this visit included ursodiol to treat primary biliary
cirrhosis. (Doc. 9-8, p. 31).7 PA Harkness assessed Ms. Campbell with hypertension

6 High levels of creatinine may indicate that the kidneys are not working properly. See
https://www.healthline.com/health/high-creatinine-symptoms (last visited January 17, 2024).
High levels of bilirubin may indicate “cute or chronic liver disease.” See
https://my.clevelandclinic.org/health/diagnostics/17845-bilirubin (last visited January 17, 2024).

7 See https://www.mayoclinic.org/drugs-supplements/ursodiol-oral-route/description/drg-
20066618 (last visited January 17, 2024).
and a staph infection. (Doc. 9-8, p. 32). PA Harkness prescribed an antibiotic for
the infection and increased Ms. Campbell’s blood pressure medication. (Doc. 9-8,

p. 32).
On October 19, 2018, Ms. Campbell saw Dr. Magouirk and complained of
lingering cold symptoms, a swollen finger, and lesions that itched and burned on the

insides of her elbows and below her eye. (Doc. 9-8, p. 28). Dr. Magouirk diagnosed
Ms. Campbell with shingles, atopic dermatitis, a bacterial infection of her finger,
and seasonal allergies. (Doc. 9-8, p. 28).8 He prescribed an antibiotic for her
infection and an antihistamine. (Doc. 9-8, p. 28).

Lab results for Ms. Campbell from January 11, 2019 indicated high creatinine
and bilirubin levels. (Doc. 9-8, pp. 25-26). Ms. Campbell’s diagnoses included high
cholesterol, depression, hypothyroidism, obesity, high blood pressure, allergic

rhinitis, dry mouth, and Sjogren’s syndrome. (Doc. 9-8, p. 23). Dr. Magouirk
prescribed Plaquenil, gabapentin, vitamin B6, and milk thistle. (Doc. 9-8, pp. 22–

8 Atopic dermatitis or eczema is a chronic disease that can be caused by problems with the immune
system and causes inflammation, redness, and extreme itching of the skin. See
https://www.niams.nih.gov/health-topics/atopic-dermatitis (last visited January 17, 2024).

“Patients with cirrhosis are at a higher risk for developing bacterial infections.” See
https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-bacterial-infections-in-
cirrhosis-current-S1665268119322707 (last visited January 17, 2024).
23).9 Dr. Magouirk suggested that Ms. Campbell increase her fluid intake and use a
humidifier to help with dry mouth. (Doc. 9-8, p. 24).

Ms. Campbell returned to PA Harkness on August 14, 2019. Ms. Campbell
indicated that she could not see a gastroenterologist because of her lack of insurance
but hoped she would be “eligible for insurance soon.” (Doc. 9-8, p. 17). Lab results

again indicated high levels of creatinine and bilirubin. (Doc. 9-8, p. 19). PA
Harkness’s assessment included high cholesterol, primary biliary cirrhosis,
Sjogren’s Syndrome, and atopic dermatitis. (Doc. 9-8, p. 17).
On November 1, 2019, Ms. Campbell saw Dr. Gregory Stidham in Dr.

Magouirk’s office and complained of problems sleeping, itching all over her body,
sinus problems, a sore on her left hand that would not heal, and brown fingernails.
(Doc. 9-8, p. 15). Dr. Stidham noted that Ms. Campbell was jaundiced and had dark

9 Plaquenil or hydroxychloroquine is a medication “used to treat certain auto-immune diseases”
by reducing swelling, inflammation, and skin problems. See
https://www.webmd.com/drugs/2/drug-6986/plaquenil-
oral/details#:~:text=Tell%20your%20doctor%20right%20away,of%20suicide%2C%20hallucinat
ions)%2C%20hearing (last visited January 17, 2024).

Gabapentin is used in some cases to treat neuropathic pain and restless leg syndrome in patients
with cirrhosis. See
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861975/#:~:text=Gabapentin%20is%20unique
%20among%20many,anticonvulsant%20in%20patients%20with%20cirrhosis (last visited
January 17, 2024); see also https://my.clevelandclinic.org/health/drugs/21561-gabapentin (last
visited January 17, 2024).

Milk thistle is sometimes used to treat liver conditions. See
https://www.webmd.com/vitamins/ai/ingredientmono-138/milk-thistle (last visited January 17,
2024).
discoloration to her fingernails. (Doc. 9-8, p. 14). Dr. Stidham’s assessment
included primary biliary cirrhosis, skin pruritis, high cholesterol, peripheral

neuropathy, insomnia, and “Stage 3 chronic kidney disease.” (Doc. 9-8, pp. 14-15).
Dr. Stidham prescribed gabapentin for pain, trazodone for insomnia, an
antihistamine, and antibiotics. (Doc. 9-8, p. 15). Dr. Stidham noted that Ms.

Campbell was “unable to get ursodiol from [a gastroenterologist] due to lack of
insurance” and that Ms. Campbell was unsuccessful in obtaining it directly from the
company. (Doc. 9-8, p. 14). Dr. Stidham recommended that Ms. Campbell follow
up with a gastroenterologist when she obtained medical insurance and restart

ursodiol for her primary biliary cirrhosis. (Doc. 9-8, p. 15).
On December 12, 2019, Ms. Campbell saw Dr. Stidham for sinus problems,
drainage in her throat, itching in her eyes and right ear, and coughing. (Doc. 9-8, p.

10). Ms. Campbell stated that her symptoms were persistent “for a while” and
caused a lack of sleep. (Doc. 9-8, p. 10). Dr. Stidham’s diagnoses included sinusitis,
primary biliary cirrhosis, skin pruritis, and insomnia. (Doc. 9-8, p. 10). Dr. Stidham
prescribed an antibiotic and increased Ms. Campbell’s trazodone dosage from

100mg to 150 mg. (Doc. 9-8, p. 10).
Ms. Campbell returned to Dr. Stidham on December 17, 2019 and complained
that her sinuses were still bleeding even after she finished the antibiotics. (Doc. 9-

8, p. 8). She requested an increase in her gabapentin prescription. (Doc. 9-8, p. 8).
Dr. Stidham diagnosed Ms. Campbell with epistaxis, primary biliary cirrhosis,
hyperlipidemia, hypothyroidism, and chronic pain. (Doc. 9-8, p. 8).10 Dr. Stidham

increased Ms. Campbell’s gabapentin prescription to 400 mg, ordered more labs,
and suggested Ms. Campbell use a humidifier and Vaseline to keep her nostrils
moist. (Doc. 9-8, p. 8).

Ms. Campbell returned to Dr. Stidham on February 2, 2020 and complained
of coughing up discolored sputum, sore throat, headache, and chest and back pain.
(Doc. 9-8, pp. 5–6). Dr. Stidham noted Ms. Campbell’s history of primary biliary
cirrhosis and diagnosed Ms. Campbell with bronchitis and an acute sinus infection.

(Doc. 9-8, pp. 5-6). Dr. Stidham prescribed an antibiotic, Mucinex, and a steroid
and recommended that Ms. Campbell stay hydrated. (Doc. 9-8, p. 6).
On April 16, 2020, Ms. Campbell returned to Dr. Stidham and complained

primarily of insomnia. (Doc. 9-8, p. 126). She also complained of being hot and
cold and having numbness in her toes. (Doc. 9-8, p. 126). Dr. Stidham’s diagnoses
included primary biliary cirrhosis, high cholesterol, hypothyroidism, high blood
pressure, insomnia, and peripheral neuropathy. (Doc. 9-8, p. 126). Dr. Stidham

replaced trazodone with doxepin for Ms. Campbell’s insomnia. (Doc. 9-8, p. 126).
Ms. Campbell saw Dr. Stidham on May 18, 2020 and complained of fever,

10 Epistaxis is the “medical term for a nosebleed.” See
https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis (last visited January 17,
2024).
back pain, and headaches. (Doc. 9-8, pp. 123–25). Ms. Campbell reported that her
back pain was worse when she stood for long periods and that she could not lie flat

on her back. (Doc. 9-8, p. 123). Dr. Stidham’s diagnoses included allergic rhinitis,
high blood pressure, primary biliary cirrhosis, high cholesterol, hypothyroidism,
obesity, fever, insomnia, and an upper respiratory infection. (Doc. 9-8, p. 124). Dr.

Stidham refilled Ms. Campbell’s prescriptions and added prescriptions for losartan
potassium for her hypothyroidism and amoxicillin. (Doc. 9-8, pp. 124–25).
On July 15, 2020, Dr. Mansoor Mehmood at DCH Regional Medical Center
admitted Ms. Campbell for infective endocarditis. (Doc. 9-8, p. 82).11 Ms. Campbell

complained of body pain, fever, chills, and shortness of breath. (Doc. 9-8, p. 66).
Ms. Campbell had abdominal distention, abdominal pain and weakness, and
“enlarged nodes in the upper abdomen.” (Doc. 9-8, pp. 75, 83). A CT scan showed

moderate pericardial effusions, bilateral pleural effusions, “hepatic splenomegaly,”
and “[e]xtensive bibasilar airspace opacities.” (Doc. 9-8, p. 75).12 Ms. Campbell

11 “Endocarditis is a life-threatening inflammation of the inner lining of the heart’s chambers and
valves,” and it is normally caused by an infection in the bloodstream. See
https://www.mayoclinic.org/diseases-conditions/endocarditis/symptoms-causes/syc-20352576
(last visited January 17, 2024).

“Bacterial endocarditis may complicate cirrhosis, may be more frequent in females, typically
involves the mitral valve, and probably is due to Staphylococcus aureus.” See
https://pubmed.ncbi.nlm.nih.gov/8198106/ (last visited January 17, 2024).

12 Pericardial effusion is the accumulation of excess fluid in the sac that holds the heart. Kidney
disease or cirrhosis of the liver are possible causes of pericardial effusion. Pericardial effusions
can be fatal. See https://my.clevelandclinic.org/health/diseases/17351-pericardial-effusion (last
visited January 17, 2024).
underwent a “right thoracentesis” to drain the pleural effusion. (Doc. 9-8, p. 76).
She remained in the hospital for 12 days. (Doc. 9-8, p. 66).

Dr. Disha Italiya, who treated Ms. Campbell in the hospital, noted that her
acute respiratory failure with hypoxia was “likely due to pleural effusion” and that
Ms. Campbell was weaned off oxygen by discharge. (Doc. 9-8, p. 67). Dr. Italiya

ordered a peripherally inserted central catheter for Ms. Campbell to receive
antibiotics for a month at home; recommended that Ms. Campbell consult with an
interventional radiologist about her thoracentesis; and indicated that Ms. Campbell
needed to “continue diuresis.” (Doc. 9-8, p. 67). Dr. Italiya noted that the pericardial

effusions needed continual monitoring. (Doc. 9-8, p. 67).
Dr. Italiya expressed concern that Ms. Campbell’s macrocytic anemia had
“acutely worsened.” (Doc. 9-8, p. 67). Dr. Italiya indicated that the initial concern

was “for [a] possible upper GI bleed with [history of] cirrhosis,” but that the fecal

“Pleural effusion, sometimes referred to as ‘water on the lungs,’ is the build-up of excess fluid
between the layers of the pleura outside the lungs.” One of the most common causes of pleural
effusion is cirrhosis. See https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion-
causes-signs--treatment (last visited January 17, 2024).

“Hepatosplenomegaly (HPM) is a disorder where both the liver and spleen swell beyond their
normal size, due to one of a number of causes.” See
https://www.healthline.com/health/hepatosplenomegaly (last visited January 17, 2024).

“Bibasilar atelectasis is when there is a collapse in the bottom part of both lungs” that can be
caused by pleural effusions. See https://www.medicalnewstoday.com/articles/322027 (last visited
January 17, 2024).
blood test was negative, and Ms. Campbell had “no gross bleeding.” (Doc. 9-8, p.
67). Dr. Italiya consulted with Dr. Jennifer Palmer, a gastroenterologist at DCH,

regarding Ms. Campbell’s macrocytic anemia and noted that Ms. Campbell received
three doses of iron via an IV. (Doc. 9-8, pp. 67, 72-78, 82-90).13
Dr. Palmer noted Ms. Campbell’s diagnosis of primary biliary cholangitis and

indicated that Ms. Campbell had been noncompliant on ursodiol for seven years
because she did not have insurance coverage. (Doc. 9-8, pp. 82-83). Dr. Palmer
noted that Ms. Campbell had last seen Dr. Tooson in 2018. (Doc. 9-8, p. 82). Dr.
Palmer indicated that Ms. Campbell’s liver disease “likely progressed to cirrhosis

with acute decompensation likely due to endocarditis.” (Doc. 9-8, p. 78). Dr. Palmer
indicated that following treatment for infective endocarditis, Ms. Campbell would
need an esophagogastroduodenoscopy. (Doc. 9-8, p. 83).14 Dr. Palmer suggested

that Ms. Campbell seek continued medical monitoring for anemia and
gastrointestinal bleeding as a possible sign of acute liver failure and that she take
ursodiol for her cirrhosis. (Doc. 9-8, pp. 78, 83).
Dr. Italiya noted Ms. Campbell’s abdominal lymphadenopathy and expressed

13 Macrocytic anemia is where red blood cells are abnormally large and unable to carry sufficient
oxygen through the body; a common cause of macrocytic anemia is liver disease. See
https://www.medicalnewstoday.com/articles/321620#causes (last visited January 17, 2024).

14 An esophagogastroduodenoscopy is a procedure that assesses the lining of the esophagus,
stomach, and small intestine. See https://medlineplus.gov/ency/article/003888.htm (last visited
January 17, 2024).
“a concern of lymphoma due to [Ms. Campbell’s] history of Sjogren’s syndrome.”
(Doc. 9-8, p. 68). Dr. Italiya told Ms. Campbell to follow up with oncology for a

PET scan after she completed her antibiotic treatment. (Doc. 9-8, p. 68). Dr. Italiya
recommended that Ms. Campbell receive physical therapy at a skilled nursing
facility but recognized that the option was not available because Ms. Campbell was

uninsured. Dr. Italiya indicated that Ms. Campbell would have to use a walker, cane,
or crutch at home to ambulate, and Ms. Campbell stated that she had a walker at
home. (Doc. 9-8, pp. 68–69). Upon discharge on July 27, 2020, Dr. Italiya
prescribed two diuretics and 300 mg of ursodiol three times a day. (Doc. 9-8, pp.

70-71).
On August 5, 2020, Ms. Campbell saw Dr. Stidham for a follow-up after her
hospital visit. (Doc. 9-8, p. 117). Dr. Stidham noted that Ms. Campbell had stage 3

chronic kidney disease. (Doc. 9-8, p. 118). Dr. Stidham referred Ms. Campbell to
G.I. Associates of West Alabama, and Ms. Campbell saw PA Marlar there on August
12, 2020. (Doc. 9-8, p. 95). PA Marlar noted that Ms. Campbell’s symptoms had
improved since her discharge from the hospital. (Doc. 9-8, pp. 95, 97). PA Marlar

noted that Ms. Campbell was in a wheelchair, looked older than her age, and
“appear[ed] chronically ill.” (Doc. 9-8, p. 97). PA Marlar assessed that Ms.
Campbell suffered from chronic iron deficiency anemia, primary biliary cirrhosis,

endocarditis, and GERD. (Doc. 9-8, p. 97). Ms. Campbell reported that she had
been unable to fill her ursodiol prescription because she did not have insurance,
wanted to fill the prescription at a clinic in Birmingham, and hoped to “gain

assistance with medication.” (Doc. 9-8, pp. 97-98). PA Marlar stated that Ms.
Campbell required “Moderate to High Severity care,” that her diagnosis and
management options were extensive, and that the “level of risk” was moderate.

(Doc. 9-8, p. 98).
Ms. Campbell saw Dr. Anand Pandey, a cardiologist at Alabama Heart Care,
on September 10, 2020 for the results of an August 25, 2020 cardiac catheterization
and echocardiogram. (Doc. 9-8, pp. 133-36, 140). Dr. Pandey noted that the cardiac

catheterization showed mild coronary artery disease and moderate mitral
regurgitation. (Doc. 9-8, p. 133). During the visit, Ms. Campbell did not have
cardiac symptoms. Dr. Pandey recommended a follow-up in four months. (Doc. 9-

8, p. 133).
Also in September 2020, upon referral from Dr. Stidham, Ms. Campbell saw
Dr. Tooson at G.I. Associates of West Alabama for severe anemia. (Doc. 9-8, p.
91).15 Dr. Tooson noted that Ms. Campbell had been diagnosed with anemia one

month earlier and “required oral iron tablets for replacement therapy.” (Doc. 9-8, p.
91). Ms. Campbell complained of abdominal pain, arthritis, brittle nails, fatigue,

15 Dr. Tooson previously treated Ms. Campbell between 2012 and 2018. (Doc. 9-8, p. 82; Doc.
9-9, p. 31).
sleep apnea, palpitations, and ice cravings. (Doc. 9-8, p. 93). Ms. Campbell did not
have abdominal swelling, black stools, change in her bowel habits, constipation,

diarrhea, dysphagia, gas, heartburn, jaundice, nausea, rectal bleeding, stomach
cramps, vomiting, vomiting blood, or blood in her stool. (Doc. 9-8, p. 93). Dr.
Tooson noted that Ms. Campbell had a frail appearance and that she was “thin, not

cachectic.” (Doc. 9-8, p. 93).16 Dr. Tooson diagnosed Ms. Campbell with primary
biliary cholangitis and stated that her infective endocarditis “was resolved.” (Doc.
9-8, p. 93). Dr. Tooson continued Ms. Campbell on ursodiol and referred her to Dr.
Fettig, a liver specialist. (Doc. 9-8, p. 91). Dr. Tooson rated the level of risk

associated with Ms. Campbell’s condition as “extensive.” (Doc. 9-8, p. 93).
On October 22, 2020, Ms. Campbell saw Dr. Stidham and complained of
“coughing up pale yellow sputum.” She also complained of a runny nose and

headaches. (Doc. 9-8, p. 103). Dr. Stidham indicated that Ms. Campbell had
bronchitis, and he noted diagnoses of primary biliary cirrhosis, high blood pressure,
high cholesterol, and “stage 3 chronic kidney disease.” (Doc. 9-8, p. 104). Dr.
Stidham refilled prescriptions, added prescriptions for an antibiotic and Lasix, and

ordered labs for Ms. Campbell. (Doc. 9-8, p. 105).
On December 20, 2020, Ms. Campbell saw Dr. Michael Fettig, a liver

16 Cachexia is “general physical wasting and malnutrition usually associated with chronic disease.”
See https://www.merriam-webster.com/dictionary/cachexia (last visited Feb. 9, 2024). Someone
described as “cachectic” is affected by cachexia.
specialist at the Kirklin Clinic at UAB. (Doc 9-9, pp. 8–11). Dr. Fettig noted that
Ms. Campbell was “doing well with monotherapy” with ursodiol, and she was not

symptomatic the day of her visit, but her “enzymes [were] still elevated.” (Doc 9-9,
p. 8). An abdominal ultrasound showed that Ms. Campbell had an enlarged liver,
“[h]epatomegaly and cirrhosis,” and abnormal “monophasic hepatic venous

waveforms, which [was] common in the setting of cirrhosis.” (Doc. 9-9, pp. 6-7).
Dr. Fettig noted that Ms. Campbell’s cirrhosis was “compensated,” and her renal
function was “stable.” (Doc 9-9, p. 9).17 A biopsy supported a diagnosis of stage II
primary biliary cirrhosis and indicated “transplant potential.” (Doc 9-9, pp. 10-11).

Dr. Fettig faxed the reports from his visit with Ms. Campbell to Dr. Tooson. (Doc.
9-9, p. 11).
Chronic Fatigue Medical Source Statement

On September 14, 2020, Dr. Tooson completed a chronic fatigue medical
source statement regarding Ms. Campbell. (Doc. 9-8, pp. 52–54). Dr. Tooson
indicated that he had treated Ms. Campbell on more than five occasions. (Doc. 9-8,
p. 52). Dr. Tooson stated that Ms. Campbell suffered from chronic fatigue syndrome

and primary biliary cholangitis and that her prognosis was “guarded.” (Doc. 9-8, p.
52). Dr. Tooson explained that Ms. Campbell would be on “chronic life-long

17 Ms. Campbell’s right kidney was “congenitally absent.” (Doc. 9-9, p. 6). Her left kidney was
normal in size. (Doc. 9-9, p. 6).
medical treatment” for “intractable pruritis,” sleep problems, fatigue, and jaundice.
(Doc. 9-8, p. 52).

Dr. Tooson opined that Ms. Campbell’s severe fatigue, constant itching, and
sleep deprivation would “constantly” “interfere with the attention and concentration
needed to perform even simple work tasks”; that she could not perform “even low

stress jobs”; that she could not sit longer than four hours at a time, stand longer than
two hours at a time, and needed a job that allowed her to shift positions at will; and
that she needed breaks every hour for one or two hours each to sit or lie down. (Doc.
9-8, pp. 52-53). Dr. Tooson indicated that Ms. Campbell would miss work four or

more days each month because of her impairments or treatments. (Doc. 9-8, p. 53).
Dr. Tooson noted that Ms. Campbell’s symptoms and limitations dated to September
2012. (Doc. 9-8, p. 54).18

Fatigue Questionnaire and Function Report
At the request of the Social Security Administration, on March 9, 2020, Ms.
Campbell completed a fatigue questionnaire and a function report. (Doc. 9-7, pp.
35-37). In her fatigue questionnaire, Ms. Campbell stated that she had problems

sleeping and took a nap for 30 to 60 minutes each day. (Doc. 9-7, p. 35). She
indicated that she did not have difficulties caring for her personal needs, could

18 Ms. Campbell’s records from the Kirklin Clinic at UAB indicate that Dr. Tooson consulted with
Dr. Ali Safdar Khan in 2012 regarding Ms. Campbell’s primary biliary cirrhosis and her issues
with severe fatigue. (Doc. 9-9, p. 31).
perform light cleaning, could grocery shop once each week, and could complete
chores. (Doc. 9-7, pp. 35–36). She stated that she could not stand longer than 30

minutes at a time and needed a break for 15 to 30 minutes “before continuing a task
or activity.” (Doc. 9-7, pp. 35–36). Ms. Campbell stated that because of her fatigue,
she could not work full-time and could not work more than the one eight-hour shift

a week she had been working. (Doc. 9-7, p. 37). Ms. Campbell stated that “before
[her] illness [she] didn’t have any problems or limitations on work or housework or
yardwork.” (Doc. 9-7, p. 37).
In her function report, Ms. Campbell stated that she could not be still when

she laid down, she itched all night, she had pain in her feet and legs, and she had
stiff joints. (Doc. 9-7, p. 51). Ms. Campbell stated that she could prepare her own
meals like sandwiches, frozen dinners, or a meat with two vegetables. (Doc. 9-7, p.

52). Ms. Campbell stated that she did not cook as much as she did before her
impairments because of pain in her hands. (Doc. 9-7, p. 52). Ms. Campbell stated
that she did laundry but had difficulty holding the laundry basket, washed dishes,
and did light cleaning. (Doc. 9-7, pp. 40, 52). Ms. Campbell indicated she could

walk, drive, and grocery shop alone. (Doc. 9-7, p. 53). Ms. Campbell reported that
she read and watched television and movies with no problems. (Doc. 9-7, p. 54).
Ms. Campbell explained that she had difficulty using her hands because of

neuropathy, and she could lift only 10 pounds; could sit for 30 minutes at a time;
and had difficulty lifting, bending, standing, kneeling, climbing stairs, following
directions, and concentrating for more than 20 minutes. (Doc. 9-7, p. 55).

Third-Party Function Report
Ms. Campbell’s friend and boss, Cherri Koester, completed a third-party
function report on June 14, 2022. (Doc. 9-7, p. 63). Ms. Koester indicated that she

had known Ms. Campbell for 20 years, saw Ms. Campbell usually two days per
week, and helped Ms. Campbell around the house. (Doc. 9-7, p. 63). Ms. Koester
reported that in the 12 months preceding her report, Ms. Campbell had “deteriorated”
and had experienced “major changes in her physical abilities.” (Doc. 9-7, p. 70).

Ms. Koester indicated that Ms. Campbell no longer could “work, travel, [do] all
household chores, work in the garden, and exercise.” (Doc. 9-7, p. 64). Ms. Koester
stated that Ms. Campbell sometimes could not “get out of bed due to pain and

exhaustion.” (Doc. 9-7, pp. 65–66).
Ms. Koester reported that Ms. Campbell slept “very little” because of “pain,
itching, and general discomfort”; tired easily; was jaundiced; was “always
exhausted”; hurt all the time; and itched “horribly.” (Doc. 9-7, pp. 64, 70). Ms.

Koester stated that Ms. Campbell could not stand for long periods, could not do
much physical activity, and spent “a lot of time sitting or laying down.” (Doc. 9-7,
p. 67).
Ms. Campbell’s Administrative Hearing
The ALJ held Ms. Campbell’s telephone hearing on April 15, 2021. (Doc. 9-

3, pp. 40–58). Ms. Campbell testified that she had lived with her mother for four
years and that her mother helped her a lot. (Doc. 9-3, p. 53). Ms. Campbell stated
she had not worked since March of 2019. (Doc. 9-3, p. 45).

Ms. Campbell testified that she had chronic fatigue, pain in her stomach, and
swelling because of her chronic liver and kidney diseases. (Doc. 9-3, p. 45). Ms.
Campbell stated that her liver disease caused itching and that she took a medication
that helped with the itching “[m]ost of the time.” (Doc. 9-3, pp. 45, 52). She

indicated that she took “ursodiol three times a day” and a cholesterol medication to
help with her liver function. (Doc. 9-3, p. 53).19 Ms. Campbell indicated that her
doctors were monitoring her liver to prevent the final stage of liver disease as long

as possible. (Doc. 9-3, p. 53). Ms. Campbell testified that at the time of her hearing,
her liver was “not to the point yet of doing a transplant.” (Doc. 9-3, p. 53).
Ms. Campbell testified that her chronic kidney disease caused swelling and
bladder issues. (Doc. 9-3, pp. 45–46). She stated that she took Lasix to “keep the

fluid down.” (Doc. 9-3, p. 52). Ms. Campbell explained that the Lasix caused her
to go to the bathroom frequently. (Doc. 9-3, p. 48). On a good day, Ms. Campbell

19 The medical record does not indicate how Ms. Campbell was able to afford ursodiol after years
of not taking it because of lack of insurance coverage.
said she used the bathroom eight times, and on a bad day, she needed to go to the
bathroom “like, every 15 minutes” and had to “hurry up and get there.” (Doc. 9-3,

p. 48). Ms. Campbell testified that the swelling caused pain in her back and legs.
(Doc. 9-3, p. 47). Ms. Campbell stated that she could take only Tylenol for pain
because stronger pain medications would damage her liver. (Doc. 9-3, pp. 47-48).

Ms. Campbell stated that she did not sleep well because of her frequent trips
to the bathroom, her liver and kidney pain, and her restless leg syndrome; that she
slept for three hours on a good night; and that she did not sleep at all on a bad night.
(Doc. 9-3, p. 46). Ms. Campbell testified that her doctors tried to give her medication

to help her rest better at night, but they had difficulty finding medications that would
not worsen her liver and kidney disease. (Doc. 9-3, p. 47). She stated that no
medications she tried had worked. (Doc. 9-3, p. 47).

Ms. Campbell testified that on a normal day, she woke up around 7:00 in the
morning, made breakfast, and had to lie down afterward for 45 minutes to an hour.
(Doc. 9-3, p. 49). Ms. Campbell stated that she could do her own personal hygiene.
(Doc. 9-3, p. 51). Ms. Campbell testified that because of her fatigue, she could did

only small chores around the house, and once she completed a small task—like a
load of laundry—she had to lie down for 30 to 45 minutes to rest before she could
do another task. (Doc. 9-3, pp. 49–51).

Ms. Campbell testified that two months before the hearing, she had lost “a lot
of sight in [her] left eye,” so she could no longer see to drive. (Doc. 9-3, pp. 49–50).
Ms. Campbell stated that an eye infection caused by her liver disease and Sjogren’s

disease had caused her vision loss. (Doc. 9-3, p. 50). Ms. Campbell was taking
medication for her eye infection; doctors believed she would get her sight back over
time. (Doc. 9-3, p. 53). Ms. Campbell stated that when she could drive, she drove

to do errands, but she had to complete them quickly or she would be too fatigued to
continue. (Doc. 9-3, p. 50). Ms. Campbell stated that she often was so fatigued by
2:00 p.m. that she could not do anything for the remainder of the day. (Doc. 9-3, p.
49).

Ms. Campbell estimated that on good days, she spent four to five hours in a
“resting position.” (Doc. 9-3, p. 51). On bad days, Ms. Campbell said that she spent
all day in bed, getting up only to use the restroom or to get something to eat. (Doc.

9-3, pp. 51–52). Ms. Campbell testified she had “bad days” at least four out of seven
days a week. (Doc. 9-3, p. 52). Ms. Campbell stated she could stand, walk, or sit
for 30 or 45 minutes before she needed a break, and she could lift a maximum of 15
pounds. (Doc. 9-3, p. 51).

Patricia Oakes testified as the vocational expert at Ms. Campbell’s
administrative hearing. (Doc. 9-3, p. 54). Ms. Oakes classified Ms. Campbell’s past
work as a cook helper as medium work with an SVP of 2. (Doc. 9-3, p. 54). Ms.

Oakes testified that Ms. Campbell also had past work in a composite job that
consisted of medium work as a balloon machine operator with a SVP of 5 and light
work as an inspector and hand packager with an SVP of 2. (Doc. 9-3, p. 54).

The ALJ’s first hypothetical to Ms. Oakes assumed an individual with the
same education, training, and work experience as Ms. Campbell who could perform
light work with the following restrictions:

[She] could occasionally climb ramps, and stairs, but never climb
ladders, ropes and scaffolds; she could frequently balance; occasionally
stoop, kneel, crouch, and crawl; [and] she should avoid extreme cold,
heat, vibration, and any hazards.

(Doc. 9-3, p. 55). Ms. Oakes testified that this individual could not perform Ms.
Campbell’s past work. (Doc. 9-3, p. 55). Ms. Oakes testified that this individual
could perform light SVP 2 jobs as a small parts assembler, with 176,000 available
jobs nationally; a laundry folder, with 398,000 available jobs nationally; and a
cashier II, with one million available jobs nationally. (Doc. 9-3, p. 55).
The second hypothetical that the ALJ posed consisted of the vocational
background and limitations posed in the first hypothetical and the additional
limitation that the individual had the option to change posture from an upright
position to a seated position as frequently as every 30 minutes. (Doc. 9-3, p. 55).
Ms. Oakes testified that the previous jobs of small parts assembler, laundry folder,

and cashier II would be available, but the “sit/stand option” would reduce the number
of the available jobs by seventy-five percent. (Doc. 9-3, p. 56).
Ms. Oakes testified that an individual would need to stay on-task at work for
“at least 90 percent of the time in addition to regularly scheduled breaks.” (Doc. 9-
3, p. 56). Ms. Oakes stated regularly scheduled breaks included breaks every two

hours for either 15 or 30 minutes or a 30 minute to an hour break for lunch. (Doc.
9-3, p. 57). Ms. Oakes testified that missing four days of work per month would
preclude full-time work. (Doc. 9-3, p. 57).

THE ALJ’S DECISION
The ALJ found that Ms. Campbell had not engaged in substantial gainful
activity since her alleged onset date of November 6, 2019, and that she met the
insured status requirements through December 31, 2024. (Doc. 9-3, p. 23). The ALJ

determined that Ms. Campbell suffered from the severe impairments of primary
biliary cirrhosis, Sjogren’s syndrome, peripheral neuropathy, chronic kidney
disease, and iron deficiency anemia. (Doc. 9-3, p. 24). The ALJ found that Ms.

Campbell suffered from non-severe impairments of depression, anxiety,
hypothyroidism, hypertension, gastroesophageal reflux disease, and coronary artery
disease. (Doc. 9-3, p. 24). The ALJ found that Ms. Campbell’s fibromyalgia was
not a medically determinable impairment because her other impairments could have

caused the symptoms associated with fibromyalgia. (Doc. 9-3, p. 26). Based on a
review of the medical evidence, the ALJ concluded that Ms. Campbell 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. 27).
Considering Ms. Campbell’s impairments, the ALJ evaluated Ms. Campbell’s

residual function capacity. (Doc. 9-3, pp. 27–33). The ALJ determined that Ms.
Campbell had the RFC to perform:
light work . . . except she could occasionally climb ramps and stairs but
never climb ladders, ropes or scaffolds[;] she could frequently balance,
occasionally stoop, kneel, crouch, and crawl. She should avoid extreme
cold, heat, vibration, and any hazards. She require[d] the option to
change posture from upright decision (standing or walking) to seated
posture, or vice versa, as frequently as every 30 minutes.

(Doc. 9-3, p. 27).
Based on this RFC, the ALJ concluded that Ms. Campbell could not perform
her past work as a cook helper or her composite job as a balloon machine operator,
inspector, and hand packager. (Doc. 9-3, p. 32). Relying on testimony from the VE,
the ALJ found that jobs existed in the national economy that Ms. Campbell could
perform at the light exertional level including small parts assembler, laundry folder,
and cashier II. (Doc. 9-3, pp. 32–33). Accordingly, the ALJ determined that Ms.
Campbell had not been under a disability as defined by the Social Security Act since
her alleged disability onset date of November 6, 2019. (Doc. 9-3, p. 33).
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 “review[s]
the ALJ’s ‘factual findings with deference’ and her ‘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 v. Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th

Cir. 2011) (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 court finds an error in the

ALJ’s application of the law, or if the court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 1143,

1145-46 (11th Cir. 1991).
DISCUSSION
Ms. Campbell contends that the ALJ improperly rejected Dr. Tooson’s

opinion regarding her chronic fatigue because the ALJ found, in a conclusory
manner, that Dr. Tooson’s opinion was inconsistent with his treatment notes and
with other evidence in the record and with Ms. Campbell’s daily activities. (Doc.

14, pp. 1–3; see also Doc. 9-8, pp. 52–54). Although the ALJ’s comments about Dr.
Tooson’s opinion are conclusory, the Court has considered the brief comments in
the context of the ALJ’s entire analysis of the medical evidence and in the context
of the evidence in the administrative record. The administrative record does not

contain substantial evidence to support the ALJ’s conclusions regarding Dr.
Tooson’s chronic fatigue opinion.
When evaluating the persuasiveness of a medical opinion, an ALJ must

consider five factors: supportability, consistency, relationship with the claimant,
specialization, and “other factors.” 20 C.F.R. § 416.920c(1)-(5); see Harner v.
Comm’r of Soc. Sec., 38 F.4th 892, 897 (11th Cir. 2022).20 The most important
factors are supportability and consistency, and an ALJ must “explain how [she]

considered the supportability and consistency factors for a medical source’s medical

20 In her brief, Ms. Campbell discusses the “treating physician rule.” (Doc. 14). That rule applied
to disability applications filed before March 27, 2017. Because Ms. Campbell filed her disability
application after March 27, 2017, the Court must apply the new regulation found in 20 C.F.R. §
416.920c. Harner v. Comm’r of Soc. Sec. Admin., 38 F.4th 892, 894 (11th Cir. 2022).
opinions . . . in [her] determination or decision.” 20 C.F.R. § 416.920c(b)(2).21
When considering the supportability of a medical opinion, “[t]he more relevant the

objective medical evidence and supporting explanations presented by a medical
source are . . . the more persuasive the medical opinions . . . will be.” 20 C.F.R. §
416.920c(c)(1). And when considering the consistency of a medical opinion, “[t]he

more consistent a medical opinion[] . . . is with the evidence from other medical
sources and nonmedical sources in the claim, the more persuasive the medical
opinion[] . . . will be.” 20 C.F.R. § 416.920c(c)(2).
Here, the ALJ stated that “when evaluating the persuasiveness of the medical

opinions . . . [she] consider[ed] supportability, consistency, relationship with the
claimant, specialization, and other factors in accordance with 20 CFR 404.1520(c)
and 415.920(c).” (Doc. 9-3, p. 30). In a lengthy review of medical evidence, the

ALJ discussed Dr. Tooson’s chronic fatigue opinion, stating:
Dr. Tooson reported that the claimant had primary biliary cholangitis
and was on chronic lifelong medical treatment to prevent intractable
pruritus, sleep disturbance, fatigue, and jaundice. He reported that [Ms.
Campbell] would constantly experience fatigue or other symptoms
severe enough to interfere with attention and concentration needed to
perform even simple work tasks[;] was incapable of even low stress
jobs[;] could stand/walk less than two hours and sit about four hours in
an eight hour day[;] would need a job that permitted shifting positions
at will from sitting, standing, [and] walking[;] would require hourly

21 An ALJ does not have to articulate how she considered the other three factors. 20 C.F.R. §
416.920c(b)(2) (“We may, but are not required to, explain how we considered the factors in
paragraphs (c)(3) through (c)(5) of this section . . . when we articulate how we consider medical
opinions . . . in your case record.”).
breaks of one to two hours each in order to lie down or sit quietly[;] and
would miss more than four days per month from work as a result of her
impairments or treatment.

(Doc. 9-3, p. 29). The ALJ found that Dr. Tooson’s opinion was not persuasive
because the opinion was not “consistent with his treatment notes or the other
evidence of the record” and was not “supported with the claimant’s activities of daily
living as discussed above.” (Doc. 9-3, p. 31). The ALJ did not elaborate on these
findings; the record contradicts them.
Dr. Tooson’s treatment notes are not inconsistent with his chronic fatigue
opinion. Dr. Tooson’s September 2020 treatment notes reflect Ms. Campbell’s

diagnoses of primary biliary cirrhosis, anemia, and sleep apnea and state that
associated symptoms included “easy fatigability.” (Doc. 9-8, pp. 91, 93). Dr.
Stidham referred Ms. Campbell to Dr. Tooson for treatment of anemia. (Doc. 9-8,

p. 91). Blood tests are used to identify anemia.
A low hemoglobin count is a commonly seen blood test result.
Hemoglobin (Hb or Hgb) is a protein in red blood cells that carries
oxygen throughout the body.
A low hemoglobin count is generally defined as less than 13.2 grams
of hemoglobin per deciliter (132 grams per liter) of blood for men and
less than 11.6 grams per deciliter (116 grams per liter) for women. . . .
In many cases, a low hemoglobin count that’s only slightly lower than
normal doesn’t affect how you feel. A low hemoglobin count that’s
more severe and causes symptoms might mean you have anemia.
https://www.mayoclinic.org/symptoms/low-hemoglobin/basics/definition/sym-
20050760 (last visited Feb. 13, 2024); see also
https://www.ncbi.nlm.nih.gov/books/NBK499994/ (last visited Feb. 13, 2024)
(“Anemia is a reduction in hemoglobin (Hb) or hematocrit (HCT) or RBC count. It

is a presentation of an underlying condition and can be subdivided into macrocytic,
microcytic, or normocytic. Patients with anemia typically present with vague
symptoms such as lethargy, weakness, and tiredness. Severe anemia may present

with syncope, shortness of breath, and reduced exercise tolerance.”).22 Ms.
Campbell’s Hgb reading was 8.7 on August 25, 2020 and 7.9 on August 12, 2020,
hence Dr. Stidham’s diagnosis of anemia, Ms. Campbell’s prescription for iron
replacement therapy, and Dr. Stidham’s referral of Ms. Campbell to Dr. Tooson to

explore the cause of her anemia. (Doc. 9-8, p. 91).23
Dr. Tooson reviewed the nearly two-dozen medications that Ms. Campbell
was using. (Doc. 9-8, p. 92). He noted Ms. Campbell’s weight loss and described

her as “FRAIL APPEARANCE, Thin, not cachectic.” (Doc. 9-8, p. 93).24 Dr.
Tooson rated Ms. Campbell’s level of risk as “extensive” and indicated that her

22 In addition to fatigue, Ms. Campbell was experiencing heart palpitations. (Doc. 9-8, p. 91).

23 On July 15, 2020, Ms. Campbell’s Hgb was 6.7, and her “macrocytic anemia” was described as
“acutely worsened.” (Doc. 9-8, p. 67). Dr. Italiya placed Ms. Campbell on iron replacement
therapy. (Doc. 9-8, p. 67). The medical record from this date indicates that Ms. Campbell had a
walker at home. (Doc. 9-8, p. 68). On July 27, 2020, when she was discharged from the hospital,
Ms. Campbell’s Hgb was 9.4. (Doc. 9-8, p. 69). Her discharge notes include an instruction for
Ms. Campbell to use a walker or cane. (Doc. 9-8, p. 69).

24 Dr. Tooson had perspective for Ms. Campbell’s weight loss and appearance because he had
treated her primary biliary cirrhosis between 2012 and 2018. (Doc. 9-8, p. 82; Doc. 9-9, p. 31).
treatment needs were “multiple.” (Doc. 9-8, p. 93). He referred Ms. Campbell to
Dr. Fettig for examination of her liver, advised her to continue her GI medications,

and instructed her to return in six months. (Doc. 8-9, p. 93).25
Consistent with his treatment record, in his medical source statement, Dr.
Tooson reported that Ms. Campbell was “on chronic life-long medical treatment to

prevent intractable pruritis (itching), sleep disturbance, fatigue, [and] jaundice,” and
he opined that this treatment “may be contributing to chronic fatigue symptoms.”
(Doc. 9-8, p. 52). Dr. Tooson opined that Ms. Campbell’s chronic intractable itching
“day [and] night” and her sleep deprivation made her “[i]ncapable of even low stress

jobs” and would require hourly breaks. (Doc. 9-8, p. 53).
Other medical evidence in the administrative record also supports Dr.
Tooson’s opinion. In rejecting a medical opinion as “inconsistent” with the record,

an ALJ must “identify a genuine inconsistency.” Schink v. Comm’r of Soc. Sec., 935

25 In his brief, the Commissioner states: “It appears that Dr. Tooson examined [Ms. Campbell] on
only one occasion in September 2020, when he evaluated [her] for anemia.” (Doc. 17, pp. 10-11).
Though the administrative record contains only the September 2020 record of Ms. Campbell’s
visit to Dr. Tooson, Dr. Tooson indicated in his chronic fatigue medical source statement that he
had had more than five visits with Ms. Campbell and that his relationship with her began in 2012.
(Doc. 9-8, pp. 52, 54). The Court has not found information in the record that indicates that the
ALJ requested records from Ms. Campbell’s other appointments with Dr. Tooson. See Sims v.
Apfel, 530 U.S. 103, 111 (2000) (“Social Security proceedings are inquisitorial rather than
adversarial. It is the ALJ’s duty to investigate the facts and develop the arguments both for and
against granting benefits. . . .”). Three medical records confirm that Ms. Campbell had multiple
visits with Dr Tooson - an August 2020 record, (Doc. 9-8, p. 95), a July 2020 record, (Doc. 9-8, p.
82), and an August 2012 record, (Doc. 9-9, p. 31).
F.3d 1245, 1262-63 (11th Cir. 2019) (internal quotations and citations omitted).26
Ms. Campbell’s records show that between 2018 and 2020, she consistently received

diagnoses of primary biliary cirrhosis (liver disease) and Stage 3 chronic kidney
disease and reported related symptoms of fatigue, insomnia, itching, bruising, and
jaundice. (Doc. 9-8, pp. 6, 8, 10, 14–15, 31, 34, 67, 70, 77, 78, 82-85, 88-90, 95-98,

104, 111, 117-18, 123-24, 130).27 Though the ALJ correctly noted that many of Ms.
Campbell’s medical records reflect visits in which she sought treatment for sinus-
related issues and other illnesses, (Doc. 9-3, pp. 29-30), doctors also routinely noted
Ms. Campbell’s liver and kidney disease and maintained her prescriptions for

treatment of those chronic conditions and related symptoms.28 Ms. Campbell’s

26 Although the Eleventh Circuit decided this case applying the pre-2017 “treating physician rule,”
the Eleventh Circuit’s discussion regarding the requirement for a genuine inconsistency remains
good law. See Jemison v. Comm’r of Soc. Sec., No. 4:20-cv-1914-SGC, 2022 WL 989021, at *5
(N.D. Ala. Mar. 31, 2022) (applying the new regulations and citing Schink for the proposition that
the ALJ must identify a genuine inconsistency).

27 See https://www.kidneyfund.org/all-about-kidneys/stages-kidney-disease/stage-3-chronic-
kidney-disease-ckd (last visited January 19, 2024) (symptoms of stage three kidney disease include
“[f]eeling weak and tired,” swelling in the hands and feet, dry itchy skin, lower back pain, trouble
sleeping, and restless leg syndrome).

28 For example, Ms. Campbell’s records reveal that she was prescribed Atarax in February 2020
to treat her itching. (Doc. 9-8, p. 5). Common side effects of Atarax are drowsiness, dizziness,
and blurred vision. https://www.rxlist.com/atarax-drug.htm (last visited Feb. 14, 2024). In
November 2019, she was prescribed Cetirizine to treat itching. Side effects of this medication
include drowsiness and fatigue.
https://www.ncbi.nlm.nih.gov/books/NBK549776/#:~:text=Cetirizine%20is%20a%20medication
%20used,over%2Dthe%2Dcounter%20medication (last visited Feb. 14, 2024). At other times,
she was prescribed desonide and hydroxyzine for itching. (Doc. 9-8, pp. 92, 105, 117, 124; Doc.
9-9, p. 8). Lab results from August 15, 2019 show a bilirubin value of 5.6, significantly above the
high end of the reference range. The result indicated that Ms. Campbell was icteric, meaning she
had jaundice. (Doc. 9-8, p. 19). Lab results from August 31, 2019 show a creatinine value of 1.66,
chronic itching, associated with her PBC, impacted her sleep. (Doc. 9-8, pp. 10, 14–
15, 31). Treatment records reflect a history of difficulty sleeping. (Doc. 9-8, pp. 10,

14–15, 124, 126; Doc. 9-9, p. 34). Ms. Campbell testified that her doctors tried to
find medications to help her sleep, but she had few options because her liver and
kidney disease restricted the medication that was available to her. (Doc. 9-3, p.

47).29 These medical records are consistent with Dr. Tooson’s opinion that Ms.
Campbell’s fatigue and insomnia could have interfered with her ability to work full-
time, would have required hourly breaks at work, and could have caused her to miss
more than four days a month.

These medical records also demonstrate that Ms. Campbell did not have
insurance, and her lack of insurance limited her treatment options. (Doc. 9-8, pp.
14-15, 17, 82-83, 90). It appears she visited doctors when she was suffering from a

viral or bacterial infection, and she used those visits to seek prescription renewals
for treatment of her liver and kidney disease and the symptoms related to those

more than 50% higher than the high end of the reference range. (Doc. 9-8, p. 16). One year later,
she had a creatinine value of 1.36, well above the high end of the reference range (.09). (Doc. 9-
8, p. 119). “If kidney function is not normal, the creatinine level in your blood will increase. This
is because less creatinine is excreted through your urine. . . . A normal result is 0.7 to 1.3 mg/dL
(61.9 to 114.9 µmol/L) for men and 0.6 to 1.1 mg/dL (53 to 97.2 µmol/L) for women.”
https://www.mountsinai.org/health-library/tests/creatinine-blood-
test#:~:text=Creatinine%20is%20a%20chemical%20waste,body%20entirely%20by%20the%20k
idneys (last visited Feb. 14, 2024).
.
29 Ms. Campbell’s liver and kidney disease also limited her options for pain medication; she could
use only Tylenol. (Doc. 9-3, p. 47). Her liver disease limited treatment options for her kidney
disease. (Doc. 9-9, p. 11) (discussing Ms. Campbell’s kidney disease and stating that she was not
a “great candidate for Ocaliva given cirrhosis and itching.”).
diseases. Thus, the fact that Ms. Campbell’s medical records reflect complaints of
viral or bacterial illnesses does not diminish her need for treatment for her chronic

conditions, and her lack of insurance helps explain her lack of consistent treatment
for those chronic conditions. See SSR 16-3p (stating that the ALJ “will not find an
individual’s symptoms inconsistent with the evidence in the record” for failure to

seek medical treatment “without considering possible reasons” for her failure to seek
treatment, including “that the individual may not be able to afford treatment and may
not have access to free or low-cost medical services”).
Dr. Tooson’s opinion also was not inconsistent with Ms. Campbell’s daily

activities. In addressing Ms. Campbell’s daily activities, the ALJ stated:
In a Fatigue Questionnaire, the claimant stated she did not have
difficulties caring for personal needs . . . . She stated that she [ate]
meals, washe[d] dishes and clothes, [bought] groceries, [paid] bills,
watche[d] television and [went] to bed. She stated she itche[d] all night
and could not be still when lying down[;] . . . could walk, drive, and
shop alone[;] . . . [and] had no problems walking[] but had trouble
lifting, bending, standing, sitting, kneeling, climbing stairs,
concentrating, and using [her] hands . . . . At the hearing, the claimant
testified that she [was] unable to work because of brain fatigue, pain,
and swelling in her abdomen due to liver and kidney disease. She
testified that she had lost sight in her left eye two months prior and
could no longer see well enough to drive. She stated she was taking
steroid drops and believed she would get her sight back. She stated she
help[ed] her mother with her care, but that her mother ha[d] also been
helping her out a lot. She testified that she was independent with her
self[-]care. She testified that she could stand and walk 30-45 minutes
before needing a break [and] could sit for about the same. She stated
she could lift a maximum of 15 pounds.

(Doc. 9-3, p. 28). The ALJ’s summary of Ms. Campbell’s activities of daily living
omits evidence that substantiates her reports of her limitations, and the ALJ did not
explain how Ms. Campbell’s daily activities were inconsistent with Dr. Tooson’s

opinion.
Ms. Campbell testified that she could do light cleaning, small chores, and
grocery shop, but that she would have to lie down afterward for at least 30 minutes

to an hour after each task, and she had to do these activities quickly or she would be
too tired to continue. (Doc. 9-3, pp. 49–51). Ms. Campbell also testified that when
she did chores, by 2:00 in the afternoon, she often was too fatigued to do anything
but rest. (Doc. 9-3, p. 49). Ms. Campbell testified that on a good day she spent four

to five hours lying down, and on bad days—which were four days a week—she spent
the entire day in bed other than to use the restroom or to get food. (Doc. 9-3, pp.
51–52). An ALJ may not cherry-pick the parts of a claimant’s daily activities that

support her conclusion but disregard testimony regarding limitations in performing
those daily activities. See McCruter v. Bowen, 791 F.2d 1544, 1548 (11th Cir. 1986)
(“It is not enough to discover a piece of evidence which supports [a] decision, but to
disregard other contrary evidence[,]” and a decision is not supported where it was

reached “by focusing upon one aspect of the evidence and ignoring other parts of the
record”); Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010) (“An ALJ has the
obligation to consider all relevant medical evidence and cannot simply cherry-pick

facts that support a finding of non-disability while ignoring evidence that points to
a disability finding.”). Additionally, “participation in everyday activities of short
duration . . . does not disqualify a claimant from disability.” Lewis v. Callahan, 125

F.3d 1436, 1441 (11th Cir. 1997); see also Haugen v. Astrue, 497 F. Supp. 2d 1315,
1327 (N.D. Ala. 2007) (“The ability to watch television, do occasional shopping, or
perform other sporadic activities does not mean the plaintiff is not disabled.”).

The entirety of Ms. Campbell’s activities of daily living are consistent with
Dr. Tooson’s opinion that Ms. Campbell would need breaks every hour for at least
one or two hours, that she could not stand or sit for long periods of time, and that
she would be absent from work for at least four days a month. Ms. Campbell’s

testimony that she had at least four days in a week in which she would be in bed for
the entire day is consistent with Dr. Tooson’s opinion that Ms. Campbell would miss
work at least four days per month. (Doc. 9-3, pp. 51–52; Doc. 9-8, p. 54).

The ALJ provided “broad conclusions without explaining h[er] analysis
regarding consistency and supportability.” See Works v. Saul, No. 4:19-cv-01515-
MHH, 2021 WL 690126, at *15 (N.D. Ala. Feb. 23, 2021). An ALJ does not satisfy
her obligation to “explain how [she] considered the supportability and consistency

factors for a medical source’s medical opinions,” 20 C.F.R. § 416.920c(b)(2), by
stating only that a medical opinion is generally inconsistent with the medical record
or the claimant’s daily activities. Though 20 C.F.R. § 416.920c(b) provides that as

a practical matter, an ALJ cannot articulate for each medical source how the ALJ
considered all of the § 416.920c(c) factors, § 416.920c(b) requires more than a
conclusory statement, at least with respect to the supportability and consistency

factors so that a reviewing court may make a meaningful assessment of a challenge
to an ALJ’s evaluation of the persuasiveness of the medical opinion. Because the
ALJ did not provide sufficient reasoning to demonstrate that she conducted a proper

legal analysis in evaluating Dr. Tooson’s opinion and because the ALJ did not
account for evidence inconsistent with her conclusions, remand is warranted. See
Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991) (The ALJ’s “failure
to apply the correct law or to provide the reviewing court with sufficient reasoning

for determining that the proper legal analysis has been conducted mandates
reversal”); see also Spaar v. Kijakazi, No. 5:20-cv-94, 2021 WL 6498838, at *5,
report and recommendation adopted, 2022 WL 141613 (S.D. Ga. Jan. 14, 2022)

(concluding that error in failing to address the supportability of medical opinions
could not be harmless under the new regulations where the medical opinions, if
adopted as a component of the claimant’s RFC, could have resulted in the difference
between performing light work and a disability finding).30

CONCLUSION
For the reasons discussed above, the Court finds that the ALJ did not properly
evaluate Dr. Tooson’s opinion under 20 C.F.R. § 416.920c. Accordingly, the Court

30 Given this remand, the Court will not address the other issues Ms. Campbell raised in her brief.
reverses the decision of the Commissioner and remands this case for further
proceedings consistent with this opinion.
DONE and ORDERED this February 16, 2024February 16, 2024.

finale HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE

39

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/9992009. Public record. Not legal advice.