JONES

v.

COMMISSIONER OF SOCIAL SECURITY

Plaintiff seeks judicial review of the cessation of her disability insurance benefits (“DIB”) and Supplemental Security Income (“SSI”). As the Administrative Law Judge’s (“ALJ”) decision was based on substantial evidence and employed proper legal standards, the Commissioner’s decision is affirmed.

I.

A. Procedural Background

Plaintiff previously filed an application for a period of disability, DIB, and SSI and received a favorable decision, with the ALJ finding Plaintiff disabled since January¹, 2010 and awarding benefits (Tr. 59-68). The Social Security Administration (“SSA”) revisited Plaintiff’s disability status and concluded that

the ALJ found that, given Plaintiff’s age, education, work experience, and RFC, Plaintiff was incapable of performing any jobs and accordingly concluded that Plaintiff had been under a disability since January¹, 2010 (Tr. 66-68). Subsequently, the SSA revisited Plaintiff’s disability status and concluded that Plaintiff was no longer disabled as of October¹, 2017 (Tr. 71-113). As the most recent favorable decision was the September 9, 2011 decision by the prior ALJ, that decision was considered the “comparison point decision” or CPD (Tr. 17). After summarizing the findings from the CPD, the ALJ determined that Plaintiff had not engaged in substantial gainful activity through the date of the decision, or August 30, 2019 (Tr. 17). The ALJ then found that the medical evidence established that,

since October¹, 2017, Plaintiff had the following medically determinable impairments: degenerative disc disease of the lumbar spine, hypertension, obesity, ovarian cyst, polycystic ovaries, and menstrual disorder (Tr. 17). Notwithstanding the noted impairments, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix¹ (Tr. 17). According to the ALJ, medical improvement occurred on October¹, 2017, at which time the impairment present at the time of the CPD had decreased in medical severity to the point where Plaintiff retained the RFC to lift and/or carry 20 pounds occasionally and 10 pounds frequently; stand and/or walk for six hours in an eight-hour workday; sit for six hours in an eight-hour workday; could frequently climb ramps and stairs; could occasionally climb ladders, ropes, and scaffolds; and needed to avoid concentrated exposure to hazards (Tr. 18). The ALJ did not consider the limiting effects of the impairments that Plaintiff developed after the CPD in setting forth the RFC but rather, based on the impairments present since the CPD, concluded that the RFC Plaintiff retained since October¹, 2017 was less restrictive than the RFC Plaintiff had at the time of the CPD (Tr. 18). The ALJ noted that such medical improvement was related to the ability to work because it resulted in an increase in Plaintiff’s RFC (Tr. 18). The ALJ then found that, since October¹, 2017, Plaintiff continued to have a severe impairment or combination of impairments, and based on the current impairments, Plaintiff retained the foregoing RFC (Tr. 18-19). The ALJ indicated that Plaintiff had no past relevant work experience, was a younger individual aged 18-49, had obtained at least a high school education, and transferability of skills was not an issue given the lack of past relevant work experience (Tr. 21). Based on Plaintiff’s age, education, work experience, and RFC relating to her current impairments, the ALJ determined that Plaintiff maintained the ability to perform a significant number of jobs in the national economy, including work as a laundry attendant, a gate attendant, and an office helper (Tr. 21-22). Accordingly, the ALJ concluded that Plaintiff’s disability ended on October¹, 2017 and that Plaintiff had not become disabled again since that date (Tr. 22-23).

II.

To be entitled to benefits, a claimant must be disabled, meaning he or she must be unable 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 twelve months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). A “physical or mental impairment” is an impairment that results from anatomical,

physiological, or psychological abnormalities, which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C. §§ 423(d)(3), 1382c(a)(3)(D). The Social Security Administration (“SSA”), to regularize the adjudicative process, promulgated the detailed regulations currently in effect. These regulations establish a sequential evaluation process to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920.2 The regulations also establish a sequential evaluation process to determine whether a claimant’s disability continues or ends. 20 C.F.R. §§ 404.1594(f), 416.994(b)(5). Under this process, the SSA must determine, in sequence, the following:

(1) Whether the claimant is engaging in substantial gainful activity (SGA).3 If the claimant is engaging in substantial gainful activity, the SSA will find disability to have ended;

416.994(b)(1)(i). To determine medical improvement, therefore, a comparison of prior and current medical evidence must indicate that improvements occurred in the symptoms, signs, or laboratory findings associated with the claimant’s impairment(s). 20 C.F.R. §§ 404.1594(c)(1), 416.994(b)(2)(i). Indeed, “a comparison of the original medical evidence and the new medical evidence is necessary to make a finding of improvement.” Freeman v. Heckler, 739 F. 2d 565, 566 (11th Cir. 1984) (per curiam) (citing Vaughn v. Heckler, 727 F. 2d 1040, 1043 (11th Cir. 1984)). Without such comparison, no adequate finding of medical improvement can occur. Vaughn, 727 F. 2d at 1043. The failure to make such comparison requires reversal and remand for application of the proper legal standard. Id.; see Klaes, 499 F. App’x at 896 (citing Vaughn and noting that, if the ALJ fails to evaluate the prior medical evidence and make the comparison to the

III.

Plaintiff argues that the ALJ erred by failing to provide substantial evidence for the finding that Plaintiff achieved medical improvement. Namely, Plaintiff contends that the ALJ failed to compare the medical evidence in the original claims file at the time of the issuance of the CPD to the medical evidence created since the CPD. To that end, Plaintiff attaches the following as exhibits to the Joint Memorandum: (1) copies of records Plaintiff asserts constitute some of the prior medical records considered in rendering the CPD (Doc. 22-2), and (2) a copy of the Exhibit List from the prior administrative proceedings relating to the CPD (Doc. 22-1). For the following reasons, Plaintiff’s argument fails. Initially, the attachments Plaintiff provided with the Joint Memorandum do not support her position. First, review of the medical records provided by Plaintiff reveals that they all post-date the CPD and therefore cannot constitute any part of the medical record considered by the prior ALJ (Doc. 22-2). Second, the Exhibit List simply identifies five distinct medical records that the prior ALJ purportedly considered in rendering the CPD, totaling 43 pages, with one record consisting of a one-page document noting that no medical records were available from a particular medical source (Doc. 22-1, at 2). The only medical evidence cited by the prior ALJ in support of his disability finding consisted of a 2009 MRI of the lumbar spine, a 2010 nerve conduction study, and a 2011 MRI of the lumbar spine (Tr. 63-68). During the administrative hearing on the cessation decision, Plaintiff’s counsel indicated and the ALJ agreed that the 2010 nerve conduction study was not in the original main file or the exhibit file (Tr. 33-34). Notably, however, included within the prior medical records were diagnostic records from Tower Diagnostics. In the decision, the ALJ explicitly considered records from Tower Diagnostics, including reference to and comparison of the prior diagnostic imaging results to the more current diagnostic imaging results (Tr. 18, 20, 326-40, 349). Given that the sparse medical evidence cited by the prior ALJ consisted of a 2009 MRI of the lumbar spine, a 2010 nerve conduction study, and a 2011 MRI of the lumbar spine (Tr. 63-68), and the nerve conduction study did not appear in the original file, the ALJ properly compared the more recent diagnostic imaging results to the prior MRI results in finding improvement in Plaintiff’s degenerative disc disease (Tr. 18, 20). The ALJ also properly compared Plaintiff’s lack of complaints regarding radiculopathy to Plaintiff’s prior complaints of radiculopathy in finding that the evidence no longer established it as an impairment,

as Plaintiff denied radicular symptoms during her current consultative examination and because the medical record subsequent to the CPD was devoid of any objective findings reasonably supporting such diagnosis (Tr. 17, 374-75). Beyond that, the ALJ provided substantial evidence regarding Plaintiff’s medical improvement and ability to work. As the ALJ discussed, a 2015 X-ray of

Plaintiff’s lumbar spine showed no fractures or significant space narrowing or any other acute findings (Tr. 20, 326). A 2017 X-ray similarly indicated normal lumbar alignment with no evidence of fracture or subluxation, vertebral bodies were normal in height, intervertebral disc spaces were well maintained, no spondylolisthesis was evident, and there appeared only an incidental partial sacralization of the transverse processes at L-5 (Tr. 20, 349). At a consultative examination in 2017, Plaintiff complained of constant back pain but admitted that she did not experience radicular symptoms, had not gone to pain management in three years, and could sit, stand, or walk for fifteen to twenty minutes, which collectively demonstrated Plaintiff’s medical improvement from the restrictions set forth in the prior highly restrictive RFC and which the ALJ squarely addressed during the administrative hearing and in the decision (Tr. 20, 35-37, 65, 374). As the ALJ additionally noted, during the same consultative examination, Plaintiff presented with no gross deformity, joint tenderness, or discomfort with motion as to her upper or lower extremities; normal gross and fine finger dexterity; normal bilateral grip; no pitting edema; intact light touch sensation; normal strength at the elbows and knees; normal gait without the use of an assistive device; normal Romberg test and tandem gait; and an ability to walk on heels and toes (Tr. 20, 375). The ALJ acknowledged that Plaintiff experienced some tenderness and reduced range of motion during the relevant period but otherwise demonstrated normal examinations, including a normal gait (Tr. 20-21, 344-45, 353-54, 358, 361- 62, 365-66, 389-90). He also considered the opinions from the state agency medical consultants, who concluded that Plaintiff retained the ability to perform either a reduced range of light work or light work, although he adjusted the latter to account for non-exertional limitations due to Plaintiff’s decreased range of motion in her lumbar spine and her obesity (Tr. 21, 75-83, 89-97, 380-87). Most importantly, the ALJ highlighted the lack of evidence of orthopedic and/or pain management treatment after issuance of the CPD in September 2011 and prior to the cessation of her benefits and insurance coverage in October 2017 as indicative of the fact that Plaintiff's back 1mpairment was not disabling or as limiting as alleged (Tr. 20). Based on the foregoing, the ALJ properly considered both the prior medical evidence and the current medical evidence in correctly concluding that Plaintiff reached medical improvement since the CPD and thus was no longer disabled. In doing so, the ALJ applied apply the correct legal standards, and the ALJ’s decision is supported by substantial evidence.

IV.

Accordingly, after consideration, it is hereby ORDERED:

1. The decision of the Commissioner is AFFIRMED.

2. The Clerk is directed to enter final judgment in favor of the Commissioner and close the case. DONE AND ORDERED in Tampa, Florida, on this 22nd day of March, 2022. 7 eo | oe JW M / V)

ANTHOM E. PORCELLI

United Sfates Magistrate Judge cc: Counsel of Record