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Banks v. Colvin

United States District Court, E.D. Missouri, Northern Division

August 18, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          JOHN M. BODENHAUSEN United States Magistrate Judge.

         This action is before the Court, pursuant to the Social Security Act (“the Act”), 42 U.S.C. §§ 401, et seq. The Act authorizes judicial review of the final decision of the Commissioner of Social Security (the “Commissioner”) denying Plaintiff Deborah Banks’ applications for Supplemental Security Income and Disability Insurance Benefits. All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c). The matter is fully briefed, and for the reasons discussed below, the Commissioner’s decision will be reversed and remanded.

         Procedural History & Summary of Memorandum Decision

         In April 2012, Plaintiff filed applications for Supplemental Security Income (“SSI”) and Disability Insurance Benefits (“DIB”). Plaintiff alleged a disability onset date of August 1, 2011. (Tr. 157, 167)[1] Plaintiff’s claims were initially denied on July 24, 2012. (Tr. 20) Plaintiff thereafter requested a hearing before an Administrative Law Judge (“ALJ”), which was held on October 23, 2013. Plaintiff and Denise Waddell, a Vocational Expert (“VE”), testified at the hearing. On November 21, 2013, the ALJ issued a decision in which he concluded that Plaintiff was not disabled under the Act. (Tr. 20-30) The Social Security Administration Appeals Council denied Plaintiff’s request for review, leaving the ALJ’s decision as the final decision of the Commissioner in this matter. (Tr. 1-3) Plaintiff filed the instant action on July 20, 2015. (ECF No. 1) Accordingly, Plaintiff has exhausted her administrative remedies and the matter is properly before this Court. Plaintiff has been represented throughout all relevant proceedings.

         Although the ultimate issue before the Court is whether substantial evidence supports the Commissioner’s decision, the parties present two specific issues for this Court’s review: (1) whether, at step two, Plaintiff demonstrated that she had a medically determinable mental impairment-depression and anxiety; and (2) whether the ALJ properly considered the opinion evidence in crafting Plaintiff’s residual functional capacity (“RFC”).

         After a thorough review of the record, the Court concludes that the Commissioner’s decision is not supported by substantial evidence because the ALJ’s decision did not fully address the relevant medical evidence supporting Plaintiff’s diagnoses of depression and anxiety. Therefore, the decision must be reversed and the matter remanded for further proceedings.

         Administrative Record[2]

         I. General

         At the time of her hearing, Plaintiff was a 54 year-old woman. In her Disability Report - Adult form, Plaintiff listed the following conditions that impaired her ability to work: (1) “rheumatoid arthritis fibromyalgia depression”; (2) rheumatoid arthritis; (3) fibromyalgia; (4) depression/anxiety; (5) high blood pressure; (6) high cholesterol; (7) high triglycerides; and (8) acid reflux. (Tr. 192) Plaintiff represented that she stopped working in June 2009 because she was laid off. (Tr. 193) Plaintiff reported that she was taking, among other medicine, Lorazepam for anxiety and Prozac for depression/anxiety. (Tr. 194)

         Plaintiff also completed a Function Report - Adult form. In that report, Plaintiff described her daily activities and the difficulties she experiences as a result of her various medical conditions. Plaintiff indicated that she had no issues handling her finances, and did not need reminders to attend to her other affairs. (Tr. 202-03) Plaintiff indicated that her health problems affected her ability to: lift, squat, bend, stand, walk, sit, kneel, climb stairs, and use her hands. (Tr. 204) Plaintiff indicated no impact on her abilities associated with: reaching, talking, hearing, seeing, memory, completing tasks, concentration, understanding, following instructions, and getting along with others. (Id.) Plaintiff indicated that her attention span was “OK, ” that she had no problems with written or spoken instructions, and that she had no problems with authority figures. (Tr. 204-05) Plaintiff also reported that stress makes her hurt worse, that she did not like change but could handle it, and that she would sometimes get anxious or experience panic attacks and did not like going places alone. (Tr. 205)

         II. Medical

         Plaintiff’s primary care physician was Dr. Betty Noll, M.D. Dr. Noll treated Plaintiff numerous times between at least 2008 and 2012. (Tr. 315-29, 507-08) Dr. Noll’s treatment notes indicate that she saw Plaintiff relative to a variety of ailments, including but not limited to, hypertension, cholesterol/triglyceride levels, gastroesophageal reflux (“GERD”), muscle and joint pain (e.g., rheumatic issues and fibromyalgia), and women’s wellness issues. Dr. Noll’s notes also indicate that she referred Plaintiff to Ms. Deanna Davenport, a Nurse Practitioner, relative to Plaintiff’s rheumatic/fibromyalgia problems.[3]

         Dr. Noll’s notes also indicate that she treated Plaintiff relative to depression and anxiety issues on numerous occasions. The record is not entirely clear when Plaintiff’s depression first emerged as a treatment concern for Dr. Noll. The earliest treatment notes in the administrative record in this regard are from December 2008. (Tr. 324) Those notes suggest that Dr. Noll had had previously prescribed Celexa for Plaintiff’s depression and the possibility of using different drugs, if necessary, in the future. Later notes indicate that depression and anxiety concerns prompted further attention from Dr. Noll. For example, in January 2010, Dr. Noll prescribed Prozac to address Plaintiff’s anxiety and depression. (Tr. 323) Dr. Noll’s February 2011 treatment notes likewise indicate a history of depression. In January 2012, after Plaintiff complained of feeling depressed and anxious, Dr. Noll prescribed Prozac and considered adding Cymbalta. (Tr. 319)

         Plaintiff also received treatment at a University of Missouri Rheumatology Clinic during 2012 and 2013. (Tr. 248-64, 339-53) The administrative record indicates that Nurse Practitioner Deanna Davenport, APRN, FNP, saw Plaintiff at this Clinic numerous times relative to her muscle and joint pain, on referral from Dr. Noll. The first record is from Plaintiff’s consultation with Ms. Davenport in February 2012. Those treatment notes indicate Plaintiff had muscle and joint pain, and a medical history of depression and anxiety. Plaintiff reported depression from financial concerns and dealing with her pain. Plaintiff was unable to tolerate Cymbalta and was on a minor dose of Fluoxetine for her depression and anxiety. Ms. Davenport’s notes reflect a diagnosis of fibromyalgia syndrome (“FMS”). (Tr. 251) Ms. Davenport’s notes from follow-up treatment in March 2012 indicate issues of FMS and rheumatoid arthritis (“RA”), noting, “often see FMS accompany RA, though … hard to say which came first.” (Tr. 255) Ms. Davenport was also concerned regarding the lack of treatment for Plaintiff’s depression and noted her poor reactions to antidepressants. (Id.)

         Ms. Davenport’s notes from May 2012 indicate that Plaintiff’s fibromyalgia was active and aggravated by anxiety/depression, and further document Plaintiff’s problems tolerating many antidepressants. Plaintiff was started on the antidepressant Paroxetine. (Tr. 339-41) Ms. Davenport’s notes from August 2012 state that fibromyalgia is “[m]uch more the cause of daily [symptoms], I’m sure. Currently on SAvella [sic] … with mild possible improvement.” (Tr. 347) Ms. Davenport further noted that the severity of Plaintiff’s depression “seems improved with SAvella [sic]” and again refers to Plaintiff’s problems tolerating traditional depression medications based on selective serotonin reuptake inhibitors (“SSRIs”). (Id.) Ms. Davenport noted that Savella is approved for the treatment of fibromyalgia in the United States, and for depression in Europe. (Id.) Ms. Davenport’s notes from November 2012 indicate that Plaintiff was experiencing “some depression” and that Plaintiff was continued on Savella. (Tr. 350-53)

         Plaintiff also received treatment at various times, and for various reasons, at University Hospital - University of Missouri Health System. (Tr. 354-505) The hospital records include extensive documents concerning a hysterectomy performed in early 2013. Most of the records reflect the treatment provider’s impression that Plaintiff exhibited normal psychiatric functioning (see, e.g., Tr. 373, 391, 406, 437, 442, 457, 471), but not always. In April 2013, during a follow-up visit following her surgery, Plaintiff complained of “mood swings” and the physician’s notes indicate “anxiety, no depression” and Plaintiff was advised to see her primary care physician. That note further indicates that Plaintiff “has been through a lot and would not consider [the mood swings] to be abnormal.” (Tr. 496-500)

         Plaintiff was also treated at least twice at the Pershing Memorial Hospital emergency room, including for dizziness and shortness of breath. Each time the records indicate Plaintiff’s mental status as normal. (Tr. 293-313)

         III. Opinion Evidence

         The administrative record includes opinions from three different sources: Nurse Practitioner Davenport; Dr. Margaret Burke, M.D.; and Dr. Charles Watson, Psy.D.

         Ms. Davenport submitted a “Medical Statement Regarding Inflammatory Arthritis for Social Security Disability Claim, ” dated November 10, 2012.[4] (Tr. 337-38) In addition to providing information concerning the limitations associated with Plaintiff’s muscle and joint pain, Ms. Davenport also reported significant malaise. Ms. Davenport opined that Plaintiff experienced mild limitations in her activities of daily living, moderate limitations in her ability to maintain social functioning, and moderate limitations regarding her concentration, persistence or pace. Ms. Davenport concluded that Plaintiff has experienced a marked increase in joint pain and that “[w]e do not have her condition well controlled yet.” (Tr. 338)

         Dr. Burke, a state agency consultant, submitted a “Physical Functional Capacity Assessment, ” dated October 24, 2012. (Tr. 286-92) Dr. Burke’s opinion focused primarily upon Plaintiff’s exertional and other physical limitations. In general, Dr. Burke did not find Plaintiff to have many significant limitations. Dr. Burke did not provide an opinion regarding Plaintiff’s depression or anxiety.[5]

         The administrative record also includes a “Disability Determination Explanation.” (Tr. 78-85) This record includes opinions from two sources, Dr. Watson completed a psychiatric review technique (“PRT”), and Susan Wayne, a disability examiner, completed a physical residual functional capacity assessment. Only Dr. Watson’s opinion is discussed herein.

         Dr. Watson noted that Plaintiff had one or more medically determinable impairments, and listed Plaintiff’s affective disorders as “secondary” in priority, and non-severe. (Tr. 81) Regarding anxiety related disorders, Dr. Watson indicated “[a] medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.” (Id.) Dr. Watson noted that Plaintiff had been seen at an emergency room in the past nine months for a panic attack. Dr. Watson concluded that Plaintiff had mild limitations/restrictions in each of the following areas: (1) activities of daily living; (2) maintaining social ...

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