Raheem Ellis v. Acting Commissioner of Social Security ( 2023 )


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  • USCA11 Case: 22-11647    Document: 21-1     Date Filed: 05/31/2023   Page: 1 of 9
    [DO NOT PUBLISH]
    In the
    United States Court of Appeals
    For the Eleventh Circuit
    ____________________
    No. 22-11647
    Non-Argument Calendar
    ____________________
    RAHEEM ELLIS,
    Plaintiff-Appellant,
    versus
    ACTING COMMISSIONER OF SOCIAL SECURITY,
    Defendant-Appellee.
    ____________________
    Appeal from the United States District Court
    for the Northern District of Georgia
    D.C. Docket No. 1:20-cv-02868-AJB
    ____________________
    USCA11 Case: 22-11647         Document: 21-1         Date Filed: 05/31/2023         Page: 2 of 9
    2                          Opinion of the Court                       22-11647
    Before JORDAN, BRANCH, and TJOFLAT, Circuit Judges.
    PER CURIAM:
    Raheem Ellis appeals from the District Court’s order affirm-
    ing the Commissioner of the Social Security Administration’s (the
    “Commissioner”) denial of his application for disability insurance
    benefits (“DIB”), pursuant to 
    42 U.S.C. § 405
    (g). 1
    On appeal, Ellis argues that substantial evidence does not
    support the Administrative Law Judge’s (the “ALJ”) decision to
    give little weight to the opinions of treating psychiatrists, Dr.
    Lantie Quinones and Dr. Linda Welkovich; non-treating psycholo-
    gist, Dr. Roger Raftery; and non-treating Social Security Admin-
    istration (“SSA”) medical expert, Dr. Sridhar Yaratha. He also as-
    serts that, because Dr. Yaratha was a medical expert brought in at
    the ALJ’s behest, the ALJ should have recontacted Dr. Yaratha to
    clarify her opinion as needed before discounting it. He states that,
    by failing to do so, the ALJ abdicated her duty to develop a full and
    fair record.
    Because the Appeals Council declined to review the ALJ’s
    decision, we review it as the Commissioner’s final decision.
    Doughty v. Apfel, 
    245 F.3d 1274
    , 1278 (11th Cir. 2001). We review
    1 According to 
    42 U.S.C. § 405
    (g), “[a]ny individual, after any final decision of
    the Commissioner of Social Security made after a hearing to which he was a
    party, irrespective of the amount in controversy, may obtain a review of such
    decision by a civil action commenced within sixty days after the mailing to
    him of notice of such decision or within such further time as the Commis-
    sioner of Social Security may allow.”
    USCA11 Case: 22-11647        Document: 21-1        Date Filed: 05/31/2023        Page: 3 of 9
    22-11647                  Opinion of the Court                              3
    whether the Commissioner’s DIB decisions are supported by sub-
    stantial evidence and review de novo whether the correct legal
    standards were applied. See Moore v. Barnhart, 
    405 F.3d 1208
    , 1211
    (11th Cir. 2005). Substantial evidence is any relevant evidence,
    greater than a scintilla, that a reasonable person would accept as
    adequate to support a conclusion. Lewis v. Callahan, 
    125 F.3d 1436
    ,
    1440 (11th Cir. 1997). “[T]he threshold for such evidentiary suffi-
    ciency is not high.” Biestek v. Berryhill, 
    139 S. Ct. 1148
    , 1154 (2019).
    If, considering the record as a whole, substantial evidence
    supports the Commissioner’s decision, we will not disturb it.
    Lewis, 125 F.3d at 1439. Even if the evidence preponderates against
    the Commissioner’s decision, we must affirm if substantial evi-
    dence supports the disability determination. Dyer v. Barnhart, 
    395 F.3d 1206
    , 1210 (11th Cir. 2005) (per curiam). Under this standard
    of review, we will not decide the facts anew, make credibility de-
    terminations, or reweigh the evidence. Winschel v. Comm’r of Soc.
    Sec., 
    631 F.3d 1176
    , 1178 (11th Cir. 2011).
    An individual claiming DIB bears the burden of proving that
    he is disabled, and, consequently, he is responsible for producing
    evidence in support of his claim. Ellison v. Barnhart, 
    355 F.3d 1272
    ,
    1276 (11th Cir. 2003) (per curiam); 
    20 C.F.R. § 416.912
    (a). The ALJ
    uses a five-step, sequential evaluation process to determine
    whether a claimant is disabled. 2 Winschel, 
    631 F.3d at 1178
    . If an
    2This five-step, sequential evaluation requires the ALJ to determine “(1)
    whether the claimant is currently engaged in substantial gainful activity; (2)
    whether the claimant has a severe impairment or combination of impair-
    ments; (3) whether the impairment meets or equals the severity of the
    USCA11 Case: 22-11647        Document: 21-1       Date Filed: 05/31/2023        Page: 4 of 9
    4                        Opinion of the Court                     22-11647
    ALJ finds a claimant disabled or not disabled at any given step, the
    ALJ does not proceed to the next step. 
    20 C.F.R. § 404.1520
    (a)(4).
    At the fourth sequential step, the ALJ determines a claimant’s re-
    sidual function capacity (“RFC”) by considering his or her “ability
    to meet the physical, mental, sensory, and other requirements of
    work.” 
    20 C.F.R. § 404.1545
    (a)(4). The RFC is the most a claimant
    can do despite his restrictions. 
    Id.
     § 404.1545(a)(1). The ALJ exam-
    ines all relevant medical and other evidence, including any state-
    ments about what the claimant can still do provided by medical
    sources and descriptions and observations by the claimant, her
    family, her neighbors, her friends, or others, of her limitations, in-
    cluding limitations resulting from pain. Id. § 404.1545(a)(3).
    For claims filed before March 27, 2017, the opinions of treat-
    ing physicians and non-treating physicians are treated differently.
    See Gibson v. Heckler, 
    779 F.2d 619
    , 623 (11th Cir. 1986) (citing Fruge
    v. Harris, 
    631 F.2d 1244
    , 1246 (5th Cir.1980)); see also 
    20 C.F.R. § 404
    .1520c(a) (forbidding ALJs from deferring or giving any spe-
    cific evidentiary weight to any medical opinions for claims filed on
    or after March 27, 2017). A non-treating physician’s opinion based
    on a single examination is “not entitled to great weight.” Crawford
    v. Comm’r of Soc. Sec., 
    363 F.3d 1155
    , 1160 (11th Cir. 2004) (per
    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 claim-
    ant can perform given the claimant's RFC, age, education, and work experi-
    ence.” Winschel, 
    631 F.3d at 1178
    .
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    22-11647                Opinion of the Court                          5
    curiam). However, a treating physician’s opinion “must be given
    substantial or considerable weight unless ‘good cause’ is shown to
    the contrary.” Lewis, 125 F.3d at 1440 (quoting MacGregor v. Bowen,
    
    786 F.2d 1050
    , 1053 (11th Cir. 1986)).
    In determining the weight to give a medical opinion, the ALJ
    considers several factors, including: (1) the examining relationship;
    (2) the treatment relationship, including the length and nature of
    the relationship; (3) the supportability of the opinion; and (4) the
    consistency of the opinion with other evidence. 
    20 C.F.R. § 404.1527
    (c)(1)–(4). Good cause for discounting the opinion of a
    treating physician exists when: (1) the treating physician’s opinion
    was not bolstered by the evidence; (2) the evidence supported a
    contrary finding; or (3) the treating physician’s opinion was conclu-
    sory or inconsistent with her own medical records. Winschel, 
    631 F.3d at 1179
    . When good cause exists, the ALJ may disregard a
    treating physician’s opinion but must clearly articulate the reasons
    for doing so. 
    Id.
    In rejecting a treating physician’s opinion because it is incon-
    sistent with the source’s own medical records, an ALJ must identify
    a “genuine” inconsistency. Schink v. Comm’r of Soc. Sec., 
    935 F.3d 1245
    , 1262 (11th Cir. 2019) (per curiam). A failure to do so is re-
    versible error. Lewis, 125 F.3d at 1440. In the context of mental
    and emotional disorders, we have explained that it is not enough
    for the ALJ to merely point to “positive or neutral observations that
    create, at most, a trivial and indirect tension with the treating phy-
    sician’s opinion by proving no more than that the claimant’s im-
    pairments are not all-encompassing.” Simon v. Comm’r, Soc. Sec.
    USCA11 Case: 22-11647      Document: 21-1       Date Filed: 05/31/2023     Page: 6 of 9
    6                       Opinion of the Court                  22-11647
    Admin., 
    7 F.4th 1094
    , 1107 (11th Cir. 2021) (quoting Lewis, 125 F.3d
    at 1440). We have also observed that when evaluating a claimant’s
    medical records, an ALJ must consider the fundamental differences
    between the relaxed, controlled setting of a medical clinic and the
    more stressful environment of a workplace. Id.
    The ALJ has a basic duty to develop a full and fair record.
    See 
    20 C.F.R. § 416.912
    (b); Graham v. Apfel, 
    129 F.3d 1420
    , 1422
    (11th Cir. 1997) (“Because a hearing before an ALJ is not an adver-
    sary proceeding, the ALJ has a basic obligation to develop a full and
    fair record.”). As such, when the evidence received from a medical
    source is inadequate to determine whether the claimant is disabled,
    the ALJ should take steps to resolve the inadequacy—including re-
    contacting the medical source, requesting additional evidence from
    the claimant, or asking the claimant to undergo a consultative ex-
    amination. 
    20 C.F.R. §§ 404
    .1520b(b)(2). However, an ALJ has no
    obligation to further develop the record when the available evi-
    dence is sufficient to make a disability determination. See Kelley v.
    Heckler, 
    761 F.2d 1538
    , 1540 (11th Cir. 1985) (per curiam) (explain-
    ing that a showing of prejudice, or a showing that the ALJ did not
    have all of the relevant evidence before him in the record or did
    not consider all of the evidence in the record, must be made before
    requiring remand); Wilson v. Apfel, 
    179 F.3d 1276
    , 1278 (11th Cir.
    1999) (per curiam) (holding that the record, “which included the
    opinions of several physicians . . . , was sufficient for a decision and
    additional expert testimony was unnecessary.”).
    In evaluating whether sufficient prejudice exists to warrant
    remand, we are guided by “whether the record reveals evidentiary
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    22-11647                 Opinion of the Court                             7
    gaps which result in unfairness or clear prejudice.” Brown v.
    Shalala, 
    44 F.3d 931
    , 935–36 (11th Cir. 1995) (per curiam) (deter-
    mining that prejudice existed where the ALJ failed to obtain rec-
    ords which were the subject of testimony, to acquire a report
    which he stated he would review, and to question an available wit-
    ness when the claimant herself was unable to explain how her dis-
    abilities prevented her from working).
    In this case, the ALJ’s decision to discount the opinions of
    Dr. Quinones, Dr. Welkovich, Dr. Raftery, and Dr. Yaratha was
    clearly articulated and supported by substantial evidence, and we
    affirm. We briefly address each opinion in turn, keeping in mind
    (1) that the ALJ only needed to find more “than a scintilla” of evi-
    dence to satisfy the substantial evidence standard; and (2) if the ALJ
    met that standard, we will not reweigh the evidence, engage in fact-
    finding, or make our own credibility determinations.
    As to Dr. Quinones’s opinion, substantial evidence supports
    the ALJ’s decision to discount the opinion because it was conclu-
    sory and contradicted by Dr. Quinones’s own treatment notes. 3
    Notably, the ALJ pointed to three main inconsistencies in Dr. Qui-
    nones’s opinion: (1) Dr. Quinones indicated that she saw Ellis
    every three months for three years, but the record indicated she
    had seen him more sporadically than that; (2) Dr. Quinones incor-
    rectly reported her own GAF scores for Ellis, as well as the GAF
    3 Because this was a sufficient basis for discounting the opinion, we do not
    reach the ALJ’s additional rationale for her decision—that Dr. Quinones’s
    opinion was inconsistent with other evidence in the record.
    USCA11 Case: 22-11647      Document: 21-1     Date Filed: 05/31/2023     Page: 8 of 9
    8                      Opinion of the Court                 22-11647
    scores of other providers; and (3) Dr. Quinones described Ellis as
    having side effects from Citalopram and Clonazepam such as seda-
    tion, nausea, and cognitive dulling, but Ellis only reported sedation
    as a side effect regarding those two drugs—he attributed the other
    side effects he reported (roughly a year later) to a new antidepres-
    sant medication, which Dr. Quinones stopped prescribing him.
    The ALJ also found that Dr. Quinones did not cite any clinical find-
    ings demonstrating the severity of symptoms, choosing instead to
    base her findings on Ellis’s uncorroborated reports. These discrep-
    ancies are enough to constitute “good cause” for discounting Dr.
    Quinones’s opinion.
    Similarly, as to Dr. Welkovich’s opinion, substantial evi-
    dence supports the ALJ’s decision to discount that opinion because
    her opinion was unsupported by her notes and objective clinical
    findings. Dr. Welkovich’s examinations never showed any of the
    deficits she noted in her statement and opinion about Ellis’s ability
    to work, nor did her exams support the extreme impairment she
    claimed Ellis had.
    Lastly, the ALJ did not err in discounting Dr. Raftery and Dr.
    Yaratha’s opinions as both were entitled to little weight as opinions
    from non-treating medical sources. Dr. Raftery had only seen Ellis
    once; Dr. Yaratha had never seen Ellis. Both opinions suffered
    from issues with supportability. Dr. Yaratha, specifically, failed to
    properly support her findings, despite explicit and repeated instruc-
    tions to do so.
    Ellis also argues that we must remand the case because the
    ALJ did not comply with its duty to develop a full or fair record,
    USCA11 Case: 22-11647     Document: 21-1     Date Filed: 05/31/2023   Page: 9 of 9
    22-11647              Opinion of the Court                       9
    and the ALJ should have recontacted Dr. Yaratha prior to denying
    his DIB request. But Ellis has not pointed to any gaps in the evi-
    dentiary record, and nothing suggests that the record, which in-
    cluded the opinions of several medical professionals, was insuffi-
    cient. See Apfel, 
    179 F.3d at 1278
    . Thus, the ALJ’s duty to develop
    a full and fair record did not compel her to recontact Dr. Yara-
    tha. Accordingly, we affirm.
    AFFIRMED