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Day v. Berryhill

United States District Court, N.D. Georgia, Atlanta Division

December 26, 2017

CLEON THELTON DAY, III, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          FINAL REPORT AND RECOMMENDATION

          Catherine M. Salinas United States Magistrate Judge

         Plaintiff Cleon Thelton Day III (“Plaintiff”) brings this action pursuant to the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying Plaintiff's application for a period of disability, disability insurance benefits (“DIB”), and supplemental security income (“SSI”). For the reasons set forth below, I RECOMMEND that the Commissioner's decision be REVERSED AND REMANDED for additional proceedings not inconsistent with this Report and Recommendation.

         I. FIVE-STEP SEQUENTIAL EVALUATION

         A claimant is considered disabled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that is expected to result in death or has lasted or is expected to last for a continuous period of not less than twelve months. See 42 U.S.C. § 1382c(a)(3)(A). The burden of proving disability lies with the claimant. See 20 C.F.R. § 404.1512; Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). To determine whether the claimant has met his burden, the Court looks to the five-step evaluation process set forth in the Social Security Regulations (the “Regulations”). See 20 C.F.R. § 416.920; Dixon v. Astrue, 312 F. App'x 227, 227-28 (11th Cir. 2009); Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999).

         At step one, the claimant must prove that he has not engaged in substantial gainful activity. See 20 C.F.R. § 416.920(b). At step two, he must demonstrate a severe impairment or combination of impairments. See 20 C.F.R. § 416.920(c). Then, at step three, if the claimant's impairment meets or medically equals a listed impairment, he is automatically found disabled. See 20 C.F.R. § 416.920(d). If not, he must advance to step four. See 20 C.F.R. §§ 416.920(e), (f). At that step, the claimant's residual functional capacity (“RFC”) and ability to return to his past relevant work is assessed. See Phillips v. Barnhart, 357 F.3d 1232, 1238 (11th Cir. 2004). “[T]he regulations define RFC as that which an individual is still able to do despite the limitations caused by his or her impairments.” Id. (citing 20 C.F.R. § 404.1545(a)); Moore v. Comm'r of Soc. Sec., 478 F. App'x 623, 624 (11th Cir.

         2012). If the claimant can perform past relevant work, he will be found not disabled. See 20 C.F.R. § 416.920(f). If he cannot perform past relevant work, stage five shifts the burden to the Commissioner to show that “there is other work available in significant numbers in the national economy that the claimant is able to perform.” Moore, 478 F. App'x at 624. If the claimant can perform such other work, he will be found not disabled. See 20 C.F.R. § 416.920(g). If he cannot, he will be found disabled. Id.

         The issue in this appeal is whether the ALJ committed reversible error in failing to evaluate the following evidence in her decision: (1) the records of Christine Lloyd, MHA, a mental health technician at Grady Hospital and Plaintiff's case manager from September 2013 through December 2014; and (2) the records of Dana Abraham, LMSW, a senior licensed mental health clinician at Grady Hospital and the facilitator of Plaintiff's weekly outpatient depression group from September 2013 through November 2013.

         II. BACKGROUND

         Plaintiff and the Commissioner have set forth details of Plaintiff's medical history in their respective briefs. Each has emphasized different aspects of that history; however, neither party has objected to the facts as set forth by the other. I have considered all of these facts and do not find it necessary to repeat the medical evidence in the same level of detail as Plaintiff and the Commissioner. The relevant points are discussed below.

         On October 12, 2012, Plaintiff applied for SSI benefits. [Doc. 8, Transcript (“Tr.”) 224-32]. On October 30, 2012, Plaintiff applied for a period of disability and DIB. [Tr. 217-23]. In both applications, Plaintiff alleged a disability onset date of June 1, 2010. [Tr. 217, 224]. Plaintiff applied for these benefits based on the allegation that he was suffering from diabetes, high blood pressure, and depression. [Tr. 62, 74, 88, 102]. The Social Security Administration denied Plaintiff's applications initially on January 30, 2013, and upon reconsideration on April 4, 2013. [Tr. 60-115]. On April 18, 2013, Plaintiff requested a hearing before an administrative law judge (“ALJ”) [Tr. 137], and the ALJ held a hearing on July 21, 2015, in Atlanta, Georgia [Tr. 32-56]. At the hearing, the ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from Joe Mann, a Vocational Expert. [Tr. 32-56].

         On October 20, 2015, the ALJ issued her decision, finding that Plaintiff was not disabled under the Social Security Act. [Tr. 13-31]. Applying the sequential process required under 20 C.F.R. § 416.920, the ALJ made the following findings. At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since June 1, 2010, the alleged onset date. [Tr. 18]. At step two, the ALJ determined that Plaintiff had the following severe impairments: major depressive disorder, anxiety disorder, diabetes mellitus, hypertension, obesity, and gastroesophageal reflux disease. [Tr. 18-19]. At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that meets or medically equals the severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1. [Tr. 19-21].

         The ALJ went on to determine that Plaintiff had the RFC to perform less than a full range of medium work as defined in 20 C.F.R. §§ 404.1567(c) and 416.967(c), with the following limitations: occasionally lift fifty pounds and frequently lift twenty-five pounds; never climb ropes, ladders, and scaffolds due to symptoms of fatigue and medication side effects; occasionally climb ramps and stairs; occasionally stoop, kneel, crouch, crawl, and balance; avoid concentrated exposure to extreme vibrations, hazardous machinery, and unprotected heights; perform simple, routine, repetitive tasks in a work environment free of fast-paced production requirements; make simple work decisions (with few, if any, workplace changes); occasionally interact with co-workers, supervisors, and the public; and be off task up to ten percent of the workday. [Tr. 21-25]. In doing so, the ALJ evaluated the credibility of Plaintiff's statements regarding the intensity, persistence, and functionally limiting effects of his pain and other symptoms. [Id.].

         Importantly, for purposes of this appeal, the ALJ noted that “there were few treatment records” with respect to Plaintiff's mental impairments. [Tr. 22].

         The record evidence shows that Plaintiff consistently met in-person with Christine Lloyd, a mental health technician at Grady Hospital and Plaintiff's case manager, twice a month from September 2013 through December 2014. [Tr. 518-19, 522-24, 528-30, 568-72, 584-86, 592-95, 600-01, 605-06, 619-22, 625-42, 646-50, 656-61, 670-83, 689-90, 695-96]. Ms. Lloyd's role, in part, was to “educate [Plaintiff] on how to develop more effective coping skills and better manage behavioral health symptoms through the effective utilization of community resources, individual therapy and/or group therapy/training.” [Tr. 523, 585, 605, 619, 632, 634, 639-40, 682]. Ms. Lloyd also noted that she would “provide necessary services to assist [Plaintiff] in his efforts to obtain community services, such as financial, transportation and support to help reduce environmental stressors[.]” [Tr. 594, 621, 625, 627-28, 641]. At each visit, Ms. Lloyd documented Plaintiff's mental and physical state and provided a short summary of their discussions. [Tr. 518-19, 522-24, 528-30, 568-72, 584-86, 592-95, 600-01, 605-06, 619-22, 625-42, 646-50, 656-61, 670-83, 689-90, 695-96]. At various visits, Ms. Lloyd noted that Plaintiff was sweating [Tr. 529, 637], his speech was pressured [Tr. 529, 569, 594, 600, 605, 619, 621, 627, 631, 637, 639], he presented with poor concentration and poor memory [Tr. 594, 628, 640-41], he made limited or poor eye contact [Tr. 529, 592, 600, 605, 631], and his mood appeared depressed or anxious at times. [Tr. 569, 571, ...


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