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Dudley v. Colvin

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

September 21, 2016

MICHELLE KAYE DUDLEY, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          JOHN M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE

         This cause is on appeal from an adverse ruling of the Social Security Administration. This suit involves an Application for Supplemental Security Income. The matter is fully briefed, and for the reasons discussed below, the Commissioner's decision is reversed. All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c).

         I. Procedural History

         On September 18, 2012, Plaintiff Michelle Kaye Dudley (“Plaintiff”) filed an Application for Supplemental Security Income (“SSI”) payments pursuant to Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. (Tr. 122-30)[1] Plaintiff claimed that her disability began on December 30, 2010, as a result of anxiety, depression, and lower back problems. On initial consideration, the Social Security Administration denied Plaintiff's claim for benefits. Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which was held on February 25, 2014. (Tr. 25-55) Plaintiff testified and was represented by counsel. Vocational Expert Alissa Smith also testified at the hearing. (Tr. 50-53, 107-08) Thereafter, on March 19, 2014, the ALJ issued a decision denying Plaintiff's claim for benefits. (Tr. 8-20) After considering the representative's brief, the Appeals Council found no basis for changing the ALJ's decision and denied Plaintiff's request for review on June 30, 2015. (Tr. 1-5, 253-54)

         Plaintiff filed the instant action on August 26, 2015. Plaintiff has exhausted her administrative remedies and the matter is properly before this Court. Plaintiff has been represented by counsel throughout all relevant proceedings.

         In her initial brief to this Court, Plaintiff raises two issues. First, Plaintiff argues that the ALJ erred in weighing treating physician Dr. Courtney Johnson's opinions as it is unclear what weight the ALJ assigned, and he failed to give good reasons for the weight given to Dr. Johnson's opinions. Next, Plaintiff argues that the ALJ's Residual Functional Capacity (“RFC) is not supported by substantial weight. The Commissioner filed a detailed brief in opposition. In her reply brief, Plaintiff again argues that the ALJ failed to indicate what weight was given to Dr. Johnson's opinion and to give good reasons for doing so; and the RFC is not supported by substantial weight.

         As explained below, the Court has considered the entire record in this matter. Because the decision of the Commissioner is not supported by substantial evidence, it will be reversed. The undersigned will first summarize the decision of the ALJ and the administrative record. Next, the undersigned will address the issue regarding the ALJ's failure to accord weight to Dr. Johnson's opinions and to articulate specific reasons in weighing Dr. Johnson's opinions. Because this matter is being remanded, the undersigned will not address Plaintiff's other contentions regarding her RFC.

         II. Decision of the ALJ

         On March 19, 2014, the ALJ issued an adverse decision denying Plaintiff's request for SSI benefits. The ALJ acknowledged that the administrative framework required him to follow a five-step, sequential process in evaluating Plaintiff's claims. (Tr. 11-12) At step one, the ALJ concluded that Plaintiff had not engaged in any substantial gainful activity since September 18, 2012. (Tr. 13) At step two, the ALJ found Plaintiff had the severe impairments of “degenerative disc disease of the lumbar spine, medullary sponge kidney with nephrolithiasis, depression, personality disorder, and anxiety disorder/posttraumatic stress disorder.” (Tr. 13) After considering all of Plaintiff's impairments, severe and non-severe, the ALJ concluded, however, that none of Plaintiff's impairments, either singly or in combination, significantly limited her ability to perform basic work-related activities for 12 consecutive months. (Tr. 13-14)

         The ALJ articulated the following RFC for Plaintiff:

[T]he claimant has the residual functional capacity to lift 10 pounds occasionally and 10 pounds frequently.[2] She can walk or stand for two hours and sit for six hours out of an eight [hour] workday. She may occasionally climb stairs, but should never climb ropes, scaffolds or ladders. She can frequently balance and occasionally stoop, crouch, kneel or crawl. She is limited to occasional pushing and pulling with the lower extremities. She should avoid unprotected heights and hazardous moving machinery. In addition, she is limited to simple, routine, repetitive tasks. She may work in proximity to others, but is limited to jobs that do not require close cooperation and interaction with coworkers, in that, she would work better in relative isolation. She should have no interaction with the general public. She retains the ability to maintain attention and concentration for minimum two-hour period at a time, to adapt to changes in the workplace on a basic level and to accept supervision on a basic level.

(Tr. 15)

         The ALJ also made an adverse credibility finding that no doubt influenced his RFC assessment. The ALJ concluded that Plaintiff's “statements concerning the intensity, persistence and limiting effects of these symptoms are only partially credible for the reasons explained in this decision.” (Tr. 16) The ALJ found that Plaintiff's “allegations of debilitating back pain are not supported by the objective evidence.” (Tr. 16) Likewise, the ALJ found that the medical evidence of record does not fully support Plaintiff's allegations of psychiatric symptoms, and her statements regarding mental impairments are only partially credible. (Tr. 17)

         The ALJ summarized his conclusions regarding weight given to the medical sources' opinions as follows:

[T]he undersigned gives significant weight to the opinions of the State agency psychological consultant.[3] As a State agency consultant, this doctor is familiar with the disability determination process and the Regulations, including the terms of art and legal and medical standards set forth therein. More significantly, the State agency consultant's opinions are consistent with the medical evidence of record, which shows preserved memory, attention and concentration functions, and with her activities of daily living, which show the capacity for limited social interaction.
The undersigned has considered the medical source statement from the [Plaintiff's] psychiatrist, Courtney Johnson, M.D. However, while the medical evidence of record does demonstrate some degree of psychological impairment, it does support the degree of limitation opined by Dr. Johnson. Mental status examinations have consistently revealed normal attention, concentration and memory. Although Dr. Johnson's treatment notes document subjective reports of anxiety and irritability, these allegations are not totally consistent with the [Plaintiff's] activities of daily living. As noted, she goes shopping, she can go out alone, and she goes to the library. This shows that the [Plaintiff] is capable of at least limited social interaction. Likewise, the undersigned gives little weight to the opinions of Charlie Harrison, MS, LPC. The medical evidence of record, as just described, does not support marked and extreme limitations.

(Tr. 18) (internal citations omitted) The ALJ found that Plaintiff has no past relevant work. (Tr. 19) The ALJ further found that, considering Plaintiff's age, education, work experience, and RFC, there were jobs existing in significant numbers in the national economy she could perform, including a document preparer, a pharmaceutical processor, and a printed circuit board screener. (Tr. 19)

         III. Evidence Before the ALJ

         The administrative record in this matter includes the hearing transcript, medical records, and forms completed by Plaintiff and state agency physicians. Although the Court has carefully considered all of the evidence in the administrative record in determining whether the Commissioner's adverse decision is supported by substantial evidence, only the records most relevant to the ALJ's decision and the issues raised by Plaintiff on this appeal are discussed. The following is a summary of pertinent portions of the record.

         A. The Hearing Before the ALJ

         The ALJ conducted a hearing on October 24, 2013. Plaintiff was present and represented by an attorney. Also present was a Vocational Expert (“VE”), Alissa Smith.

         1. Plaintiff's Testimony

         Plaintiff testified primarily in response to questions posed by her attorney, with additional questions interjected by the ALJ. At the time of her hearing, Plaintiff was thirty-five years old. (Tr. 31) Plaintiff testified that she received her GED in 2006. (Id.) Plaintiff is divorced and lives with her disabled, fifty-eight year old father. Plaintiff's father drove her to the hearing even though she has a driver's license. Plaintiff has four children, ages 15, 11, 7, and 5, but she does not have custody of any her children. (Tr. 32)

         Plaintiff testified that her lower back pain and tension in her shoulders prevent her from working. (Tr. 33) As treatment for her back, Plaintiff has received steroid shots, prescribed medications, and an EKG. (Tr. 36) Although Dr. Vaught reportedly recommended surgery, Plaintiff explained that she could not afford the treatment due to lack of medical coverage, and she wanted to consider other options. (Tr. 37) On November 21, 2013, Dr. Sandvoe prescribed a muscle relaxer, and Plaintiff thought that helped. On November 19, 2013, Plaintiff received Medicaid. (Id.) Plaintiff testified that Dr. Lambrou at Chaffee Medical Clinic treated her monthly and prescribed pain medications and administered a steroid shot. (Tr. 40) Plaintiff also has chronic kidney disease that results in kidney stone issues if she does not manage her diet appropriately. (Tr. 43)

         Plaintiff testified that Dr. Courtney Johnson treats her mental health issues which include anxiety, depression, and PTSD. (Tr. 45) Plaintiff reported a history of physical, sexual, and mental assaults. (Tr. 46) Plaintiff testified that she avoids public places because of her panic attacks. Plaintiff takes Cymbalta, Hydrocodone, and Xanax. (Id.) Plaintiff noted that the Hydrocodone and Xanax medications have helped her tremendously but she is uncertain as to the Cymbalta since she just started taking that medication. (Tr. 47) Plaintiff reported no negative side effects from her medications.

         Plaintiff can lift five pounds; can stand for at most fifteen minutes; and can sit on average for fifteen minutes. (Tr. 34) Plaintiff testified that she had used a push walker with a seat for ambulation, but she stopped using the walker after receiving treatment for her pinched sciatic nerve. (Tr. 42)

         Plaintiff spends much of the day, up to two to three hours, lying on her stomach. (Tr. 35)

         She also spends time reading, catching up on junk mail, and making entries in her journal. (Id.) Plaintiff does most of the household chores including the cooking, laundry, mopping, and vacuuming. (Tr. 49) Plaintiff cuts the grass using a riding lawn mower. (Id.)

         2. Testimony of Vocational Expert Alissa Smith

         Vocational Expert Alissa Smith (“VE”) testified at the hearing. The ALJ asked the VE to assume Plaintiff has no past relevant work. (Tr. 51)

         The ALJ asked the VE to assume someone similar to Plaintiff in age, education, and the same past work history who

retains the capacity to occasionally lift 10 pounds, frequently 10 pounds, walk or stand two hours out of an eight hour day, sit for six hours out of an eight hour day. She can occasionally climb stairs. She should never climb ropes, scaffolds or ladders. She can frequently balance but occasionally stoop, crouch, kneel and crawl. She's limited to occasional pushing and pulling with the lower extremities. She should avoid unprotected heights and hazardous moving machinery. She's limited to jobs that consist of simple, routine, repetitive type tasks. She may work in proximity to others but is limited to jobs that consist that do not require close cooperation, interaction with co-workers. She would work better in relative isolation. She should have no interation and cooperation with the general public. Assume she retains the ability to maintain attention and concentration for a minimal two hour periods at a time, adapt to changes in the work place on a basic level, accept supervision on a basic level. Can you identify jobs in the local, national and regional economy this hypothetical person could perform?

(Tr. 52) The VE explained that the example jobs are sedentary, and such individual could perform jobs existing in significant numbers including a document preparer, a pharmaceutical processor, and a printed circuit board screener. (Id., )

         The ALJ's second hypothetical added the following mental limitation: “due to psychologically based symptoms she'd be unable to interact and cooperate with co-workers, unable to interact and cooperate with the general public, she'd be unable to accept supervision and unable to maintain acceptable levels of punctuality and attendance.” (Tr. 52) The VE opined that such individual would be unemployable.

         Plaintiff's counsel then asked if the hypothetical individual could “lift less than five pounds, stand less than one hour total, sit less than one hour total, occasionally reach, handle, finger, feel and needs to lie down once per day for 30 minutes[, ] would that individual be able to work at all?” (Tr. 53) The VE opined that such individual would also be unemployable.

         B. Forms Completed by Plaintiff

         In a Disability Report - Adult form, Plaintiff indicated that she stopped working on December 29, 2010, after being laid off and then fired. (Tr. 165) In a Function Report - Adult form completed on September 28, 2012, Plaintiff reported going grocery shopping weekly and doing the laundry. (Tr. 197-98) Plaintiff indicated that she does not like public places and has problems getting along with others. Plaintiff reported using a computer to look for employment. (Tr. 204)

         C. Medical Records and Source Opinion Evidence

         1.General History

         The medical evidence in the record shows that Plaintiff has a history of degenerative disc disease of the lumbar spine, medullary sponge kidney/kidney stones, depression, personality disorder, and anxiety disorder/post-traumatic stress disorder (“PTSD”). (Tr. 268-553) The relevant medical evidence will be discussed in additional ...


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