United States District Court, N.D. Georgia, Atlanta Division
FINAL REPORT AND RECOMMENDATION
Catherine M. Salinas United States Magistrate Judge
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
FIVE-STEP SEQUENTIAL EVALUATION
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).
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.
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.
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.
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.
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].
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].
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.
for purposes of this appeal, the ALJ noted that “there
were few treatment records” with respect to
Plaintiff's mental impairments. [Tr. 22].
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, ...