Case: 19-11495 Date Filed: 01/31/2020 Page: 1 of 10
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT ________________________
No. 19-11495 Non-Argument Calendar ________________________
D.C. Docket No. 6:17-cv-01841-DCI
JAMES DEWEY BAILEY,
Plaintiff-Appellant,
versus
COMMISSIONER OF SOCIAL SECURITY,
Defendant-Appellee.
________________________
Appeal from the United States District Court for the Middle District of Florida ________________________
(January 31, 2020)
Before MARTIN, ROSENBAUM, and EDMONDSON, Circuit Judges. Case: 19-11495 Date Filed: 01/31/2020 Page: 2 of 10
PER CURIAM:
James Bailey appeals the district court’s order affirming the Social Security
Commissioner’s denial of Bailey’s application for disability insurance benefits
(“DIB”), 42 U.S.C. § 405(g). Reversible error has been shown; we affirm in part
and reverse in part the district court’s order; we remand with instructions to vacate
the Commissioner’s decision and to remand to the Commissioner for further
proceedings.
Our review of the Commissioner’s decision is limited to whether substantial
evidence supports the decision and whether the correct legal standards were
applied. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011).
“Substantial evidence is more than a scintilla and is such relevant evidence as a
reasonable person would accept as adequate to support a conclusion.” Id. “If the
Commissioner’s decision is supported by substantial evidence, this Court must
affirm, even if the proof preponderates against it.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Under this limited standard of review, we may not
make fact-findings, re-weigh the evidence, or substitute our judgment for that of
the Administrative Law Judge (“ALJ”). Moore v. Barnhart, 405 F.3d 1208, 1211
(11th Cir. 2005). We review de novo the district court’s determination about
2 Case: 19-11495 Date Filed: 01/31/2020 Page: 3 of 10
whether substantial evidence supports the ALJ’s decision. Wilson v. Barnhart, 284
F.3d 1219, 1221 (11th Cir. 2002).
A person who applies for Social Security DIB must first prove that he is
disabled.* See 20 C.F.R. § 404.1512(a). The Social Security Regulations outline a
five-step sequential evaluation process for determining whether a claimant is
disabled. 20 C.F.R. § 404.1520(a)(4). The ALJ must evaluate (1) whether the
claimant engaged in substantial gainful work; (2) whether the claimant has a severe
impairment; (3) whether the severe impairment meets or equals an impairment in
the Listings of Impairments; (4) whether the claimant has the residual functional
capacity (“RFC”) to perform his past relevant work; and (5) whether, in the light of
the claimant’s RFC, age, education, and work experience, there exist other jobs in
the national economy the claimant can perform. Id.
Appling the five-step evaluation process, the ALJ first determined that
Bailey had engaged in no substantial gainful activity since his application date.
The ALJ then determined that Bailey had the following severe impairments:
disorders of the spine, cervical radiculitis, mild carpal tunnel syndrome, left cubital
tunnel syndrome, hypertension, psoriasis, Guillain-Barre Syndrome (“GBS”),
* Disability is 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). 3 Case: 19-11495 Date Filed: 01/31/2020 Page: 4 of 10
chronic inflammatory demyelinating polyneuritis, polyneuropathy, history of
diverticulitis, history of muscle weakness, and history of benign prostatic
hyperplasia.
The ALJ next determined that Bailey had the RFC to perform light work
with limitations. Among other limitations, the ALJ determined that Bailey could
sit, stand or walk for up to 6 hours each within an 8-hour workday, and could lift
and carry up to 20 pounds occasionally and 10 pounds frequently. In the light of
Bailey’s RFC, the ALJ concluded that Bailey was capable of performing his past
relevant work as a dispatcher and, thus, was not disabled. The district court
affirmed.
On appeal, Bailey argues that the ALJ failed to apply the correct legal
standard to the medical opinions of treating physicians Dr. Yee and Dr. Garewal.
Bailey says the ALJ erred in giving only “partial weight” to Dr. Yee’s opinion.
Bailey also contends that the ALJ failed to consider adequately and to specify the
weight given to the medical opinion of Dr. Garewal.
In determining a claimant’s RFC, the ALJ must consider all medical
opinions in the claimant’s case record together with other pertinent evidence. 20
C.F.R. § 404.1520(e). In deciding how much weight to give a medical opinion, the
ALJ considers, among other things, (1) the examining relationship; (2) the
4 Case: 19-11495 Date Filed: 01/31/2020 Page: 5 of 10
treatment relationship; (3) the extent to which the opinion is supported by medical
evidence and explanations; and (4) whether the opinion is consistent with the
record as a whole. 20 C.F.R. § 404.1527(c). Absent “good cause” to the contrary,
the ALJ must give substantial weight to the opinion, diagnosis, and medical
evidence of a treating physician. Crawford v. Comm’r of Soc. Sec., 363 F.3d
1155, 1159 (11th Cir. 2004). Good cause may exist under these circumstances: (1)
the treating physician’s opinion was not bolstered by evidence; (2) evidence
supported a contrary finding; or (3) the treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records. Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
“[T]he ALJ must state with particularity the weight given to different
medical opinions and the reasons therefor.” Winschel, 631 F.3d at 1179. We will
not affirm a decision “when the ALJ fails to state with at least some measure of
clarity the grounds for his decision.” Id. (quotations omitted).
Dr. Yee
Dr. Yee is Bailey’s primary care physician. On 10 March 2014, Bailey
presented to Dr. Yee with weakness, tingling in his arms, and fatigue. Dr. Yee sent
5 Case: 19-11495 Date Filed: 01/31/2020 Page: 6 of 10
Bailey to the hospital emergency room, where Bailey was later diagnosed with
GBS. On 4 April 2014, Bailey saw Dr. Yee for a follow-up appointment. Dr. Yee
reported that Bailey was fatigued and weak, with a motor strength of 3/5 in the
upper and lower extremities, a weak gait, and an “unremarkable” non-focal
neurological exam. Dr.
Free access — add to your briefcase to read the full text and ask questions with AI
Case: 19-11495 Date Filed: 01/31/2020 Page: 1 of 10
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT ________________________
No. 19-11495 Non-Argument Calendar ________________________
D.C. Docket No. 6:17-cv-01841-DCI
JAMES DEWEY BAILEY,
Plaintiff-Appellant,
versus
COMMISSIONER OF SOCIAL SECURITY,
Defendant-Appellee.
________________________
Appeal from the United States District Court for the Middle District of Florida ________________________
(January 31, 2020)
Before MARTIN, ROSENBAUM, and EDMONDSON, Circuit Judges. Case: 19-11495 Date Filed: 01/31/2020 Page: 2 of 10
PER CURIAM:
James Bailey appeals the district court’s order affirming the Social Security
Commissioner’s denial of Bailey’s application for disability insurance benefits
(“DIB”), 42 U.S.C. § 405(g). Reversible error has been shown; we affirm in part
and reverse in part the district court’s order; we remand with instructions to vacate
the Commissioner’s decision and to remand to the Commissioner for further
proceedings.
Our review of the Commissioner’s decision is limited to whether substantial
evidence supports the decision and whether the correct legal standards were
applied. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011).
“Substantial evidence is more than a scintilla and is such relevant evidence as a
reasonable person would accept as adequate to support a conclusion.” Id. “If the
Commissioner’s decision is supported by substantial evidence, this Court must
affirm, even if the proof preponderates against it.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Under this limited standard of review, we may not
make fact-findings, re-weigh the evidence, or substitute our judgment for that of
the Administrative Law Judge (“ALJ”). Moore v. Barnhart, 405 F.3d 1208, 1211
(11th Cir. 2005). We review de novo the district court’s determination about
2 Case: 19-11495 Date Filed: 01/31/2020 Page: 3 of 10
whether substantial evidence supports the ALJ’s decision. Wilson v. Barnhart, 284
F.3d 1219, 1221 (11th Cir. 2002).
A person who applies for Social Security DIB must first prove that he is
disabled.* See 20 C.F.R. § 404.1512(a). The Social Security Regulations outline a
five-step sequential evaluation process for determining whether a claimant is
disabled. 20 C.F.R. § 404.1520(a)(4). The ALJ must evaluate (1) whether the
claimant engaged in substantial gainful work; (2) whether the claimant has a severe
impairment; (3) whether the severe impairment meets or equals an impairment in
the Listings of Impairments; (4) whether the claimant has the residual functional
capacity (“RFC”) to perform his past relevant work; and (5) whether, in the light of
the claimant’s RFC, age, education, and work experience, there exist other jobs in
the national economy the claimant can perform. Id.
Appling the five-step evaluation process, the ALJ first determined that
Bailey had engaged in no substantial gainful activity since his application date.
The ALJ then determined that Bailey had the following severe impairments:
disorders of the spine, cervical radiculitis, mild carpal tunnel syndrome, left cubital
tunnel syndrome, hypertension, psoriasis, Guillain-Barre Syndrome (“GBS”),
* Disability is 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). 3 Case: 19-11495 Date Filed: 01/31/2020 Page: 4 of 10
chronic inflammatory demyelinating polyneuritis, polyneuropathy, history of
diverticulitis, history of muscle weakness, and history of benign prostatic
hyperplasia.
The ALJ next determined that Bailey had the RFC to perform light work
with limitations. Among other limitations, the ALJ determined that Bailey could
sit, stand or walk for up to 6 hours each within an 8-hour workday, and could lift
and carry up to 20 pounds occasionally and 10 pounds frequently. In the light of
Bailey’s RFC, the ALJ concluded that Bailey was capable of performing his past
relevant work as a dispatcher and, thus, was not disabled. The district court
affirmed.
On appeal, Bailey argues that the ALJ failed to apply the correct legal
standard to the medical opinions of treating physicians Dr. Yee and Dr. Garewal.
Bailey says the ALJ erred in giving only “partial weight” to Dr. Yee’s opinion.
Bailey also contends that the ALJ failed to consider adequately and to specify the
weight given to the medical opinion of Dr. Garewal.
In determining a claimant’s RFC, the ALJ must consider all medical
opinions in the claimant’s case record together with other pertinent evidence. 20
C.F.R. § 404.1520(e). In deciding how much weight to give a medical opinion, the
ALJ considers, among other things, (1) the examining relationship; (2) the
4 Case: 19-11495 Date Filed: 01/31/2020 Page: 5 of 10
treatment relationship; (3) the extent to which the opinion is supported by medical
evidence and explanations; and (4) whether the opinion is consistent with the
record as a whole. 20 C.F.R. § 404.1527(c). Absent “good cause” to the contrary,
the ALJ must give substantial weight to the opinion, diagnosis, and medical
evidence of a treating physician. Crawford v. Comm’r of Soc. Sec., 363 F.3d
1155, 1159 (11th Cir. 2004). Good cause may exist under these circumstances: (1)
the treating physician’s opinion was not bolstered by evidence; (2) evidence
supported a contrary finding; or (3) the treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records. Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
“[T]he ALJ must state with particularity the weight given to different
medical opinions and the reasons therefor.” Winschel, 631 F.3d at 1179. We will
not affirm a decision “when the ALJ fails to state with at least some measure of
clarity the grounds for his decision.” Id. (quotations omitted).
Dr. Yee
Dr. Yee is Bailey’s primary care physician. On 10 March 2014, Bailey
presented to Dr. Yee with weakness, tingling in his arms, and fatigue. Dr. Yee sent
5 Case: 19-11495 Date Filed: 01/31/2020 Page: 6 of 10
Bailey to the hospital emergency room, where Bailey was later diagnosed with
GBS. On 4 April 2014, Bailey saw Dr. Yee for a follow-up appointment. Dr. Yee
reported that Bailey was fatigued and weak, with a motor strength of 3/5 in the
upper and lower extremities, a weak gait, and an “unremarkable” non-focal
neurological exam. Dr. Yee prescribed medication for GBS and referred Bailey to
a neurologist for further evaluation. Bailey visited Dr. Yee again on 7 November
2014, complaining of weakness and muscle spasms. Dr. Yee’s physical exam
revealed largely the same physical conditions as on 4 April. Dr. Yee prescribed
additional medications for GBS and recommended “light home exercise” of at least
30 minutes of cardiovascular exercise 3 times per week.
On 12 December 2014, Dr. Yee completed a pre-printed form titled
“Medical Assessment of Ability to do Work-Related Activities (Physical).” On the
form, Dr. Yee opined that Bailey could sit for 1-2 hours at a time for a total of 6-7
hours a day; could stand for 20 minutes at a time for a total of 4 hours a day; and
could walk for 5-10 minutes at a time for a total of 2-3 hours a day. Dr. Yee also
opined that Bailey could lift or carry less than five pounds, needed both hands to
carry things, and had poor hand dexterity and grip. Dr. Yee said that Bailey’s
prognosis was “fair/chronic” given his GBS and neuropathy.
6 Case: 19-11495 Date Filed: 01/31/2020 Page: 7 of 10
The ALJ assigned only “partial weight” to Dr. Yee’s opinion from the
Medical Assessment form, to the extent Dr. Yee’s opinion was consistent with the
ALJ’s RFC assessment. Substantial evidence supports the ALJ’s decision. The
ALJ explained that Dr. Yee’s opinion about Bailey’s physical limitations was
inconsistent with the objective medical evidence in the record, which the ALJ
found showed an overall improvement in Bailey’s neurological symptoms and
medical condition over the course of his treatment by all providers. Dr. Yee’s
assessment was also inconsistent with Dr. Yee’s own treatment records, which
prescribed a “generally conservative/conventional treatment” plan, including
medication management and an at-home exercise routine. Dr. Yee’s opinion was
also contradicted by Bailey’s own testimony that he was able to work part-time as
a delivery driver, had no problems sitting, could lift and carry up to ten pounds,
and could perform (with some difficulty) several activities of daily living,
including cooking, grocery shopping, driving, and mowing the lawn with a riding
mower.
7 Case: 19-11495 Date Filed: 01/31/2020 Page: 8 of 10
Dr. Garewal
Dr. Garewal (a treating neurologist) first saw Bailey on 15 April 2014. Dr.
Garewal reported that Bailey had normal motor strength, reduced sensation in a
stocking-glove distribution, slow fine finger movements, and a good stride. Dr.
Garewal assessed Bailey with idiopathic progressive polyneuropathy, disturbance
of skin sensation, and chronic inflammatory demyelinating polyneuritis. After
conducting EMG/NCV testing, Dr. Garewal noted abnormal study findings with
proximal polyradiculopathy as seen in GBS, mild carpal tunnel syndrome, and left
cubital tunnel syndrome. Dr. Garewal prescribed medications, diagnostic imaging,
and a social work consult.
At a follow-up appointment on 15 May 2014, Bailey presented with largely
the same physical conditions as on 15 April, except Dr. Garewal reported that
Bailey had “mild weakness in distal hands with grip/pad/dabpsoaritic changes in
hands.” Dr. Garewal continued Bailey’s medications.
Also on 15 May, Dr. Garewal signed a handwritten “To Whom It May
Concern” note that said, “I am treating [Bailey] for progressive neuropathy which
is resulting in weakness, pain, and sensory deficits. I don’t presently think he can
work.”
8 Case: 19-11495 Date Filed: 01/31/2020 Page: 9 of 10
On appeal, Bailey contends that the ALJ committed reversible error by
failing to mention or to assign weight to Dr. Garewal’s 15 May handwritten note.
We agree. Although an ALJ may decide to disregard the opinion of a treating
physician upon a finding of “good cause,” the ALJ must articulate clearly his
reasons for doing so. Winschel, 631 F.3d at 1179. Here, where the ALJ made no
mention of Dr. Garewal’s opinion that Bailey was unable to work and failed to
specify the weight given to that opinion, we cannot “determine whether the
ultimate decision on the merits of the claim is rational and supported by substantial
evidence.” See id.
We acknowledge the Commissioner’s contention that the first sentence of
Dr. Garewal’s 15 May note was duplicative of information already considered
expressly by the ALJ. We also recognize that the final determination about
whether a claimant is “unable to work” is one that is reserved to the
Commissioner: a physician’s opinion that a person is “unable to work” is thus not
determinative and is entitled to no “special significance.” See 20 C.F.R. §
404.1527(d). We stress, however, that the ALJ must consider all the claimed
expert, medical opinions in the record and must specify the weight -- including no
weight, if applicable -- given to each purported medical opinion and the reasons
therefor. See id. at §§ 404.1520(e), 404.1527(c); Winschel, 631 F.3d at 1179; see
9 Case: 19-11495 Date Filed: 01/31/2020 Page: 10 of 10
also Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997) (“[T]he ALJ has a
basic obligation to develop a full and fair record.”). We have said that failure to
articulate clearly the reasons for giving less weight to the opinion of a treating
physician constitutes reversible error. MacGregor v. Bowen, 786 F.2d 1050, 1053
(11th Cir. 1986).
The judgment of the district court is affirmed in part and reversed in part,
and this case is remanded to the district court with instructions to vacate the
Commissioner’s decision and to remand to the Commissioner for further
AFFIRMED IN PART, REVERSED IN PART, AND REMANDED.