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[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 15-12818
Non-Argument Calendar
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D.C. Docket No. 8:14-cv-00699-EAJ
WESLEY R. MILLS,
Plaintiff-Appellant,
versus
COMMISSIONER OF SOCIAL SECURITY,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Middle District of Florida
________________________
(August 16, 2016)
Before WILSON, ROSENBAUM and BLACK, Circuit Judges.
PER CURIAM:
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Wesley Robert Mills appeals from the district court’s order affirming the
Administrative Law Judge’s (ALJ) denial of his application for a period of
disability and disability insurance benefits (DIB), 42 U.S.C. § 405(g). Mills
contends the ALJ committed reversible error in failing to analyze his mental
impairment using the special technique required by the Social Security regulations
and Moore v. Barnhart, 405 F.3d 1208, 1213-14 (11th Cir. 2005), because the
evidence in the record established that he presented a colorable claim of mental
impairment. 1
The ALJ did not make a specific finding regarding whether Mills presented
a colorable claim of mental impairment. Id. at 1214 (discussing “a colorable claim
of mental impairment”). However, because the ALJ analyzed and discussed Mills’
evidence of mental impairment including complaints of depression and a bipolar
diagnosis, we infer from that analysis and discussion that the ALJ determined that
Mills’ claim was at least colorable. See Richardson v. United States, 468 U.S. 317,
326 n.6 (1984) (“A colorable claim, of course, presupposes that there is some
possible validity to a claim.”).
Because the ALJ implicitly found that Mills presented a colorable claim of
mental impairment, our precedent and the Social Security regulations require the
ALJ to complete a Psychiatric Review Technique Form (PRTF) or incorporate the
1
While Mills asserts other issues on appeal, our disposition of this issue makes
discussion of the other issues unnecessary.
2
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analysis of a PRTF into the decision. Moore, 405 F.3d at 1214 (construing 20
C.F.R. § 4024.1520a and stating “the social security regulations require the ALJ to
complete a PRTF and append it to the decision, or incorporate its mode of analysis
into [the ALJ’s] findings and conclusions” if a claimant has presented a colorable
claim of mental impairment). It is undisputed that the ALJ did not complete a
PRTF and append it to the decision; 2 thus, we must determine if the ALJ’s analysis
of Mills’ mental impairment incorporated the PRTF technique into the decision.
The PRTF technique requires rating the degree of a claimant’s functional
limitations in four broad areas: “[a]ctivities of daily living; social functioning;
concentration, persistence, or pace; and episodes of decompensation.” 20 C.F.R.
§ 404.1520a(c)(3). The regulations provide the first three factors (activities of
daily living; social functioning; and concentration, persistence, or pace) are rated
on a five-point scale of “[n]one, mild, moderate, marked, and extreme” while the
“fourth functional area (episodes of decompensation)” is rated using “the following
four-point scale: [n]one, one or two, three, four or more.” 20 C.F.R.
404.1520a(c)(4). The regulations provide:
At the [ALJ] hearing and Appeals Council levels, the written decision
must incorporate the pertinent findings and conclusions based on the
technique. The decision must show the significant history, including
examination and laboratory findings, and the functional limitations
2
While the record contains a PRTF prepared by a psychologist in December 2010, that
PRTF makes no mention of Mills’ diagnosed bipolar disorder and was not attached to or
referenced in the ALJ’s decision.
3
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that were considered in reaching a conclusion about the severity of the
mental impairment(s). The decision must include a specific finding as
to the degree of limitation in each of the functional areas described in
paragraph (c) of this section.
20 C.F.R. § 404.1520a(e)(4) (emphasis added).
The ALJ’s decision does not specifically reference the PRTF technique. The
ALJ discusses some of the functional areas in analyzing Mills’ claim, however, so
we must determine whether the ALJ’s reasoning was enough to comply with the
PRTF requirement. See Moore, 403 F.3d at 1214. As to activities of daily living,
the ALJ found “[t]he claimant’s activities of daily living do no[t] evidence any
limitations due to mental impairments.” As to concentration, persistence, and
pace, the ALJ’s decision discussed that Mills reported difficulty with concentration
because of pain, but that the limitation was the result of his physical condition.
The ALJ also noted that Mills alleged problems completing tasks, but then reported
he finishes what he starts. This limitation was as a result of Mills’ physical
condition, however. The ALJ noted that on an October 2010, report, that Mills no
longer alleged problems with concentration.
The ALJ’s opinion references one episode of decompensation.3 The ALJ
discussed Mills’ involuntary hospitalization under the Baker Act 4 in January 2009.
3
Episodes of decompensation are exacerbations or temporary increases in
symptoms or signs accompanied by a loss of adaptive functioning, as manifested
by difficulties in performing activities of daily living, maintaining social
relationships, or maintaining concentration, persistence, or pace. Episodes of
decompensation may be demonstrated by an exacerbation in symptoms or signs
4
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In this episode of decompensation, the claimant’s wife “called the police after
[Mills] turned off the electricity in his home, kept his father-in-law confined to his
room, and indicated that he thought he was God and Bin Laden lived next door.”
Mills denied feeling depressed, having hallucinations, or having suicidal or
homicidal ideations. Mills denied ever seeing a psychiatrist or taking any
psychotropic medications. Mills admitted to mood swings and racing thoughts,
and was diagnosed with bipolar disorder. Mills was discharged with medications,
and was to follow up with an outpatient clinic. There was no record of any follow
up treatment, however.
Thus, at the time of the ALJ’s opinion, 5 Mills had one episode of
decompensation in the record. The ALJ then found, despite that single hospital
that would ordinarily require increased treatment or a less stressful situation (or a
combination of the two). Episodes of decompensation may be inferred from
medical records showing significant alteration in medication; or documentation of
the need for a more structured psychological support system (e.g. hospitalizations,
placement in a halfway house, or a highly structured and directing household); or
other relevant information in the record about the existence, severity, and duration
of the episode.
20 C.F.R. Pt. 404, Subpt. P, App. 1, Section 12.00(C)(4).
4
Chapter 394, Part 1 of the Florida Statutes, also known as the “Baker Act,” governs
mental health services, including voluntary admissions, involuntary examinations, and
involuntary placement.
5
Mills included hospital records of another episode of decompensation in November
2009, in his appeal before the Appeals Council. However, this evidence was not before the ALJ
at the time of the ALJ’s decision.
5
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admission, that Mills did not have a severe mental impairment. The ALJ
concluded:
Despite that single admission, there is no evidence of any mental
functional limitations, no complaints of depression to any treating
source, and no treatment for a mental health complaint. The
claimant’s activities of daily living do no[t] evidence any limitations
due to mental impairments. Accordingly, the claimant does not have
a severe mental impairment.
Although the ALJ’s opinion incorporated analysis of three of the four
functional limitations, the decision does not reference social functioning. The
regulations state “[t]he decision must include a specific finding as to the degree of
limitation in each of the functional areas described . . . .” 20 C.F.R.
§ 404.1520a(e)(4) (emphasis added). The ALJ’s decision does not include a
specific finding as to the degree of limitation in social functioning, and therefore
does not comply with the regulations.
The judgment of the district court is reversed and the case is remanded with
instructions to remand the matter to the ALJ for an evaluation of Mills’ mental
impairment that complies with the applicable regulations. 6
REVERSED AND REMANDED.
6
We express no opinion on the ultimate results of the PRTF, only that the technique
must be utilized as mandated by the regulations.
6