United States District Court, E.D. Missouri, Southeastern Division
MEMORANDUM AND ORDER
TERRY I. ADELMAN, Magistrate Judge.
This action is before the Court for judicial review of the final decision of the Commissioner of Social Security ("Commissioner") finding that Claimant Robert Crawford was not disabled and, thus, not entitled to Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("the Act"), 42 U.S.C. §§ 1381-1384f. Claimant has filed a Brief in Support of his Complaint; the Commissioner has filed a Brief in Support of her Answer. The parties consented to the jurisdiction of the undersigned pursuant to 28 U.S.C. § 636(b). For the reasons set forth below, the decision of the Commissioner denying benefits will be affirmed.
I. Procedural History
Claimant, who was born on September 16, 1969, filed his application for benefits on August 14, 2007, alleging a disability onset date of January 1, 2004, due to various physical and mental impairments. After Claimant's application was denied at the initial administrative level, Claimant requested a hearing before an Administrative Law Judge ("ALJ") and such a hearing was held on May 20, 2009. On July 15, 2009, the ALJ found that Claimant had the residual functional capacity ("RFC") to perform a limited range of light work, including his past job working at a service station, and was not disabled under the Act. Claimant requested review by the Appeals Council of the Social Security Administration ("Appeals Council") and submitted additional evidence. The Appeals Council summarily stated that the new evidence did not provide a basis for changing the ALJ's decision, and denied the request for review. Claimant then appealed the decision to the United States District Court for the Eastern District of Missouri. (Tr. 1-3, 13-24, 43-44.)
On February 2, 2012, the District Court reversed the Commissioner's decision and remanded the case to the Commissioner for further proceedings (Tr. 365), and on April 2, 2012, the Appeals Council remanded the case to the ALJ. (Tr. 379-81.) On June 4, 2012, following a supplemental hearing, the ALJ found that Claimant was not under a "disability" as defined in the Act. (Tr. 715-30.) On May 30, 2013, the Appeals Council denied Claimant's request for review. (Tr. 322-24.) Claimant has thus exhausted all administrative remedies and the ALJ's June 4, 2012 decision stands as the final decision of the Commissioner and the subject of this appeal pursuant to 42 U.S.C. § 1383(c)(3), which provides for judicial review of a "final decision" of the Commissioner.
In this appeal Claimant argues that the ALJ's decision that he was not disabled is not supported by substantial evidence on the record as a whole and that the ALJ committed reversible error by finding that Claimant can perform a wide range of sedentary work. Specifically, Claimant argues that the ALJ misapplied the Medical Vocational Guidelines and failed to analyze the demands of Claimant's past job at a service station. In addition, Claimant asserts that the ALJ's RFC assessment was flawed because he (1) improperly assessed Claimant's credibility, (2) incorrectly considered some medical evidence, (3) disregarded the opinion of Claimant's treating nurse practitioner and (4) minimized the effects of Claimant's obesity and mental impairments on his RFC.
II. Work History Reports and Application Forms
On his Work History Report completed on September 25, 2007, Claimant indicated that he had a high school education and had worked at various low-paying jobs such as cashier, stocker, dispatcher, and dish washer for short intervals from 1994 to 2002. One of these jobs, which Claimant held from 1994 to 1995, was listed as "Cashier" at a gas station, but the description of the job included using a dolly to load stock on shelves, and lifting boxes of soda and candy to place on shelves, tasks which required frequent lifting of 25 pounds, occasional lifting of 50 pounds, and stooping three hours in an eight-hour workday. Most of Claimant's other past work had similar physical requirements. (Tr. 115-22.)
Claimant wrote in his Function Report dated October 1, 2007, that he had difficulty with lifting, walking, and other physical activities, and sometimes did not feel like doing anything apart from "sitting around." (Tr.128.) He wrote that the only medication he was taking on a regular basis was aspirin, although he was also supposed to be taking Plavix (used to prevent strokes and heart attacks), Wellbutrin (an antidepressant), and a diet pill, Claimant explained that did not have enough money to fill prescriptions for those medications. He indicated that he could pay bills, count change, handle a savings account, and use a checkbook. He also wrote that he had no problem getting along with family, friends, or authority figures. (Tr. 124-31.) The record includes the notes from the agency employee who spoke to Claimant over the telephone when he filed his application. She noted that Claimant was very polite and had no problem talking, answering, understanding, or concentrating during the conversation. (Tr. 101-02.)
III. Medical Records
With respect to the period from 2004 through January 2008, this Court adopts the summary of Claimant's medical records set forth by the District Court in Crawford v. Colvin, No. 1:10CV166 AGF, slip op. at 3-9 (E.D. Mo. Feb. 2, 2012).
Although Claimant alleged disability beginning January 1, 2004, SSI benefits are payable only from September 2007, the month following the month in which he filed his application. See 20 C.F.R. § 416.335. Prior medical records are appropriately considered for background purposes. On September 11, 2004, Claimant was admitted to the hospital with pneumonia. His diagnosis included hypertension, morbid obesity, unsteady gait, and hyponatremia, with no evidence of deep venous thrombosis. (Tr. 159-62.)
On May 17, 2007, Claimant presented to a medical center for a psychological evaluation to help "get off street drugs." He was in no pain, ambulated independently, and was admitted for treatment for cocaine abuse. Claimant's Global Assessment of Functioning ("GAF") was 45 on admission admission and 65 upon release on May 19, 2007. (Tr. 185-89.) On July 23, 2007, state consultant Price Gholson, Psy.D., examined Claimant and opined that he had depressive disorder and social phobia, with a GAF of 60. In check-box format, Dr. Gholson indicated both that Claimant did not have a mental and/or physical disability which prevented him from working, and also that the duration of Claimant's disability/incapacity was expected to last four to six months. (Tr. 208-09.)
On July 23, 2007, state consultant Benjamin Mozle, M.D., conducted a physical examination of Claimant. Dr. Mozle's notes are somewhat illegible, but indicate that Claimant was morbidly obese at 6' 4" and 422 pounds, had dyspnea upon walking 50 yards, severe peripheral vascular disease, metabolic syndrome, varicose veins, questionable obstructive sleep apnea, with normal pulmonary function, and no limitations in the ability to walk, stand, stoop, and grasp. In check-box format, Dr. Mozle opined that Claimant was permanently disabled. (Tr. 223-24.)
On October 12, 2007, James Spence, Ph.D., completed a Psychiatric Review Technique form, stating that Claimant had depressive disorder that was medically determinable and that resulted in no more than mild functional limitations in activities of daily living, maintaining social functioning, and maintaining concentration, persistence, or pace. Dr. Spence opined that Claimant's mental impairment did not significantly interfere with work-related functions, and was thus "non-severe." (Tr. 227-37.)
On December 12, 2007, Claimant was treated at a health clinic for complaints of shortness of breath and chest pain. He was diagnosed with obstructive sleep apnea, [chronic obstructive pulmonazry disease], "COPD", pre-diabetes, and coronary artery disease. (Tr. 243.) Claimant continued to be treated at the clinic for wheezing, lower extremity edema, varicose veins, obstructive sleep apnea, chronic obstructive pulmonary disease, hypertension, morbid obesity, and peripheral venous insufficiency. He was assessed with anxiety and depression. (Tr. 255-301.)
On January 16, 2008, a sleep study showed severe obstructive sleep apnea. CPAP titration was recommended as well as evaluation of sleep hygiene and medications, weight loss, and smoking cessation. (Tr. 246-47.) Claimant was seen at a clinic for an initial visit on February 5, 2008, stating that he was depressed and not feeling well. He did not feel like doing anything, even making meals for himself. Bilateral lower extremities were swollen and red, "with very large varicose veins, " for which surgery had been discussed with Claimant. (Tr. 250.)
B. Additional Medical Evidence Presented to the Appeals Council
On June 28, 2010, Claimant submitted to the Appeals Council a medications showing that he was taking Lovaza and Trilipix for cholesterol, Metmorfin for diabetes, Naspan for heart and cholesterol, Singulair and Loratidine for respiratory problems, Alprazolam for anxiety, Tektrum and Drovan for high blood pressure, and Hydrocodone and Aspirin for pain. (Tr. 303.) Claimant also submitted to the Appeals Council medical records further documenting his monthly follow-up and medication refill visits to the Steele Family Rural Health Clinic from June through September 2009, and a Medical Source Statement-Physical completed on January 11, 2010, by Patrick Drummond, a nurse practitioner at the clinic. These medical records indicate that Claimant continued to suffer from his chronic conditions, including joint pain and/or back pain and COPD, and received refill prescriptions for hydrocodone, Klonapan, and Lasix. The notes also indicate that Claimant had no sensory deficit, neurologically; and normal insight, judgment, and memory, psychologically. (Tr. 308-18.)
Mr. Drummond indicated on the January 11, 2010 Medical Source Statement that from December 10, 2009 onward, Claimant had been unable to: lift and carry ten pounds even occasionally; stand or walk more than one to two hours in a day; or stand or walk continuously for a full hour. Mr. Drummond further opined that Claimant could sit for a total of eight hours in a day; had limited ability to push/pull; could never climb, balance, stoop, kneel, crouch, bend, or reach, and could only occasionally handle, finger, feel, see, hear or speak. Mr. Drummond also stated that due to his obesity and COPD Claimant had environmental restrictions requiring him to avoid dust and irritants in a working environment. Finally, Mr. Drummond identified the onset of diabetes, a poorly healing ulcer on Claimant's right lower leg, chronic lower knee pain, anxiety, hypertension, high lipids, and other cardiovascular risk factors. (Tr. 304-05.)
As noted above, the Appeals Council summarily stated that the new evidence did not provide a basis for changing the ALJ's decision, and denied Claimant's request for review.
C. Additional Medical Records Adduced after Remand from the District Court
Records of McPherson Medical and Diagnostics from August 24, 2010, show that Claimant underwent testing for chronic airway obstruction, shortness of breath and dyspnea and received a diagnosis of mild obstructive disease of the peripheral airways. (Tr. 567.) On April 26, 2011, further testing showed small amounts of scattered plaque in his leg and foot arteries, definite lower leg edema, venous stasis, venous enlargement and multiple inflamed varicosities, but no narrowing or stenosis was found. (Tr. 564) On August 30, 2011, x-rays of Claimant's lumbar spine showed mild osteoarthritis. (Tr. 565.)
Claimant continued to receive treatment from the Steele Family Rural Health Clinic. (Tr. 510-63.) He was seen at the clinic on July 21, 2010, and every month thereafter through June 2011. On July 27, 2011, the differential diagnoses indicated were: osteoarthritis tenia pedis, diabetes, COPD, hypertension and anxiety disorder. (Tr. 522) On August 29, 2011, Dr. McKenzie diagnosed claudication in Claimant's left leg, COPD, incontinence of stool, hypertension, anxiety disorder, tenia pedis and diabetes. He prescribed Lovaza, Lamisil, Glucophage, Lorcet and Xanax and referred Claimant for a colonoscopy. (Tr. 517) On October 12, 2011, Dr. McKenzie diagnosed hypertension, COPD, incontinence of stool and anxiety and prescribed Xanax and Lorcet. (Tr. 513)
On January 10, 2012, Claimant presented to the Respiratory Care Department of Pemiscot Memorial Hospital for testing and exhibited moderate ventilatory obstruction. (Tr. 634-35.)
On January 18, 2012, Claimant saw Dr. Price Gholson, Psy.D, of The Counseling Center. At that time, Dr. Gholson completed a Family Support Division Medical Report including a Physician's Certification/Disability Evaluation. (Tr. 570.) Dr. Gholson diagnosed Depressive Disorder in Partial Remission and assessed a GAF of 65. (Tr. 571.) Dr. Gholson noted that Claimant showed no evidence of hallucinations, paranoid delusions, grandiose delusions, ideas of reference and illusions, but showed an above average to high degree of compulsion, obsessive thoughts, phobia and depressive trends. (Tr. 576.) Dr. Gholson characterized Claimant's intellectual functioning, affect and thought processes as average but found him low to below average in dress, clothing, facial expression, eye contact, quantity of here- and-now expression of emotion, mood, action to change and appropriateness of goal striving. (Id.) With respect to physical findings, Dr. Gholson noted a limp due to leg swelling and restricted thumb movement. (Tr. 575.)
On January 31, 2012, Claimant was transported by Emergency Medical Services to Pemiscot Memorial Hospital due to complaints of chest pain. (Tr. 580, 586.) A chest X-ray showed no significant abnormality. (Tr. 583.) On February 14, 2012, Claimant was seen at the Steele Family Rural Health Clinic and referred for testing. (Tr. 612.) Testing at McPherson Medical and Diagnostics on that date showed severe obstructive airways disease. (Tr. 598.) On March 14, 2012, Claimant presented to Pemiscot Primary Care Center requesting medication for his depression and nerves and received a diagnosis of major depressive disorder. (Tr. 713-714.)
At the time of his March 14, 2012 visit to the Steele Family Rural Health Clinic Claimant's medications were identified as Lovaza, Tekturna, Crestor, Diovan, Lorcet and Combivent. (Tr. 595.) On April 19, 2012, Claimant reported that his medications were Crestor, Letia, Onglyza, Xanax, Diovan, Tekturna, Tripix, Locor, Niaspan, Lasix, Glucophage, Lorcet, Claritin, Lamisil, Singulair and Aspirin. (Tr. 494-95.) The record also contains prescriptions for Claimant from Greene Pharmacy for the period november 6, 2007 through April 20, 2012. (Tr. 496-508.)
IV. Evidentiary Hearings
A. The May 20, 2009 Hearing
Claimant testified that he was 39 years old, single, lived alone in an apartment, and had a high school education. He could read and write and do basic adding and subtracting. He testified about the various low-paying jobs he had held in past years, including his work in 1994 at a gas station convenience store stocking shelves, cleaning, and doing cashier work. Claimant stated that he could no longer work full time due to problems with his legs, shortness of breath. He also noted that he had dizziness, sleep apnea, COPD, congestive heart failure, and morbid obesity, with a current weight of 420 pounds. Claimant testified that he took medication for cholesterol and blood pressure, aspirin, Prozac, pain pills for his legs, and Ambien for sleep, and used a CPAP machine and nebulizers. He had difficulty sleeping because of cramping in his legs. He could stand for only about 20 to 30 minutes before needing to elevate his legs for about an hour to get to a point where he could stand again. His left leg was swollen all the time and he had discolorations in his legs and fingers. Sitting also aggravated his symptoms and swelling. He could walk only two blocks before experiencing shortness of breath. He did not do housekeeping, cooking, or cleaning. He received home health care seven days a week, two hours per day, and these workers performed the household chores. Claimant's daily activities consisted of sitting on the couch watching TV or listening to the radio with his feet propped up. He no longer hunted or went fishing. Claimant had cut back his smoking to two cigarettes in the ...