Maribel Lara v. Commissioner of Social Security, 705 F. App'x 804

Background

Maribel Lara applied for SSI in July 2011 alleging bipolar disorder, anxiety, lupus, hypertension, degenerative spine disease, gallstones, and uterine fibroids; she amended onset to July 6, 2011.
Treating psychiatrist Dr. Berta Guerra treated Lara monthly (2010–2013), diagnosed bipolar disorder and anxiety, and completed two formal opinions finding extreme work limitations; treatment notes often showed improvement and denial of hallucinations/mood swings.
Two state agency consultative psychologists reviewed the record and found only moderate mental limitations.
The ALJ found severe mental impairments (bipolar disorder NOS and generalized anxiety), non-severe physical impairments, concluded Lara’s statements lacked credibility, gave less-than-controlling weight to Guerra’s formal opinions, adopted some state-agency opinions, and found Lara capable of a limited range of unskilled medium work.
The ALJ denied benefits at step five (jobs available); the Appeals Council denied review; the district court affirmed; Lara appealed to the Eleventh Circuit.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Failure to assign weight to records from 10 treating providers	ALJ erred by not stating weight for opinions in multiple treating providers’ records	Many of the records do not contain medical opinions; where they do, the ALJ considered the records and any omission was harmless	No reversible error; some records lack opinions and any failure to state weight was harmless because decision is consistent with those records
Weight assigned to Dr. Guerra’s opinions	ALJ should have given controlling weight to Guerra’s formal reports and treated-notes opinions	Guerra’s formal opinions contradicted her own treatment notes and other record evidence, so ALJ had good cause to give less-than-controlling weight	Affirmed: ALJ provided substantial-evidence reasons (inconsistency with treatment notes and other evidence) for discounting Guerra’s opinions
Credibility of Lara’s symptom testimony	Lara’s testimony that she was bedridden for weeks, had persistent hallucinations, and medication didn’t help was credible	ALJ pointed to treatment notes showing improvement, inconsistencies in Lara’s statements, and attendance at appointments; thus testimony was not fully credible	Substantial evidence supports ALJ’s adverse credibility finding; no reversal
Step 3 — whether mental impairments meet or equal Listings 12.04/12.06	ALJ underestimated limitations in ADLs, social functioning, and concentration/pace	Record (patient reports, observed mental status, and treatment notes) supports only mild-to-moderate limitations, not marked or repeated decompensation	Affirmed: ALJ’s special-technique findings (mild ADL, moderate social and concentration limits, no prolonged decompensation) supported by substantial evidence
RFC and consideration of physical impairments	ALJ failed to account for work-related limitations from gallstones, fibroid, leukopenia, hypertension, spine disease	Plaintiff offered no evidence showing how those impairments produced work limitations; ALJ considered the medical record showing minimal functional impact	Affirmed: ALJ reasonably found physical conditions non-severe / unsupported as limiting and adequately assessed RFC

Key Cases Cited

Moore v. Barnhart, 405 F.3d 1208 (11th Cir. 2005) (standard for substantial-evidence review and scope of appellate review)
Wilson v. Barnhart, 284 F.3d 1219 (11th Cir. 2002) (two-part test for evaluating subjective symptom testimony)
Lewis v. Callahan, 125 F.3d 1436 (11th Cir. 1997) (treating-source rule and good-cause requirement to discount treating opinions)
Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176 (11th Cir. 2011) (when treatment notes can constitute medical opinions)
Barnes v. Sullivan, 932 F.2d 1356 (11th Cir. 1991) (even if evidence preponderates against ALJ, must affirm if supported by substantial evidence)