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Welch v. Colvin

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

September 26, 2016

ROBERT WELCH, Plaintiff,
v.
CAROLYN COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          AUDREY G. FLEISSG UNITED STATES DISTRICT JUDGE

         This action is before this Court for judicial review of the final decision of the Commissioner of Social Security finding that Plaintiff Robert Welch was not disabled, and, thus, not entitled to Supplemental Security Income under Title XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 1381-1383f, or disability insurance benefits under Title II of the Act. For the reasons set forth below, the decision of the Commissioner will be reversed and the case remanded for further development of the record.

         BACKGROUND

         Plaintiff, who was born on February 19, 1967, filed his applications for benefits on August 10, 2012, alleging a disability onset date of August 23, 2007 (when he was 40½ years old), due to degenerative disc disease, a shoulder disorder, restless leg syndrome, kidney disease, and depressive disorder. After Plaintiff's application was denied at the initial administrative level, he requested a hearing before an Administrative Law Judge (“ALJ”). Such a hearing was held on November 21, 2013. By decision dated January 22, 2014, the ALJ found that Plaintiff had the residual functional capacity (“RFC”) to perform certain jobs that were available in the national economy, and was thus not disabled under the Act. Plaintiff's request for review by the Appeals Council of the Social Security Administration was denied on April 20, 2015. Plaintiff has thus exhausted all administrative remedies and the ALJ's decision stands as the final agency action now under review.

         Plaintiff argues that the ALJ's RFC determination is not supported by substantial evidence in the record because the ALJ did not have any evidence from a medical source that specifically addressed Plaintiff's work-related limitations and abilities. Plaintiff argues that the ALJ improperly gave significant weight to the opinion of a consulting physician, and improperly rejected statements from two treating sources as constituting issues reserved for the ALJ. Plaintiff also argues that while the ALJ described the medical record, he failed to provide a proper narrative describing how the medical evidence supported the ALJ's physical RFC conclusions. Plaintiff asks that the ALJ's decision be reversed and the case remanded for the ALJ to obtain evidence from a medical professional that addresses Plaintiff's RFC.

         Medical Record and Evidentiary Hearing

         The Court adopts Plaintiff's unopposed Statement of Facts (Doc. No. 12-1) as supplemented by Defendant's unopposed Statement of Additional Material Facts (Doc. No. 15-2). Together, these facts present a fair and accurate summary of the medical record and testimony at the evidentiary hearing. The Court will discuss specific facts as they are relevant to the parties' arguments.

         ALJ's Decision Under Review

         The ALJ found that Plaintiff had not engaged in substantial gainful activity since his alleged disability onset date, and that he had the severe impairments of degenerative disc disease, a shoulder disorder, restless leg syndrome, kidney disease, and depressive disorder, but that none of these impairments, individually or in combination, met the requirements of a deemed-disabling impairment listed in the Commissioner's regulations. The ALJ found that Plaintiff had the RFC to lift, carry, push and/or pull 20 pounds occasionally and 10 pounds frequently; stand and/or walk 30 minutes at a time for a total of 4 hours out of an 8 hour workday; sit 30 minutes at a time for a total of 4 hours out of an 8 hour workday; occasionally climb ramps or stairs, balance, stoop, kneel, and crouch; frequently reach and handle; and understand, remember, and carry out simple instructions working in a non-public setting where interaction with the general public would be limited to frequent interaction over the telephone. (Tr. at 15).

         The ALJ described Plaintiff's extensive history of treatment for degenerative disc disease and bilateral shoulder pain, and acknowledged that Plaintiff continued to experience pain, tenderness, and some neuropathic symptoms, despite Plaintiff's course of pain management, which included medication; periodic epidural, sacroiliac joint, and shoulder steroid injections; and home exercises. But the ALJ pointed to Plaintiff's pain management treatment provider who observed in August 2012 and September 2013 that, with medications, Plaintiff's pain continued to remain at a “manageable level, ” with no adverse side effects (Tr. at 414, 439), and physical examinations in July and August 2012 (Tr. at 412, 336), that reported “no acute distress” and normal gait.

         In sum, the ALJ found that Plaintiff's statements regarding the disabling effects of his impairments were not “fully credible” in that the medical record showed only limitations addressed in the RFC. The ALJ stated that in making his RFC determination, he accorded “significant weight” to the February 14, 2013 opinion of State agency medical consultant Mary Rees, M.D., who, according to the ALJ stated that “the evidence did not establish disability.” In fact, Dr. Rees stated that the medical evidence in the file was “insufficient to determine Plaintiff's functionality and severity of impairments [from the alleged onset date].” She further noted that Plaintiff may have had some work activity since his alleged onset date, so she was “unable to make a fully favorable determination, ” and referred the claim back to the Office of Disability Adjudication and Review. (Tr. at 422).

         The ALJ found it “notable” that in August 2012, “staff from the Columbia Interventional Pain Clinic declined [Plaintiff's] request for them to complete a functional capacity form.” (Tr. at 19.) He also stated that he afforded “little weight” to the August 2012 treatment note from Julia Halsey, M.D., that Plaintiff had “a pretty good chance” with respect to an application for disability, because he could not “go back to doing heavy construction work or heavy equipment operation due to many problems in his spine and chronic pain” (Tr. at 329); and “little weight” to the December 2007 treatment note from Michael Acuff, M.D., that Plaintiff “had a reason for disability with some multiple injuries and physical impairment” (Tr. at 479). The ALJ believed that these opinions addressed matters reserved to the ALJ's determination, and were thus “not entitled to controlling weight or given special significance.” (Tr. at 19.)

         Because the RFC included non-exertional limitations, the ALJ elicited the testimony of a vocational expert (“VE”) to determine whether there were jobs a person with Plaintiff's RFC and vocational factors (age, education, and work experience) could perform. The ALJ looked to the VE's testimony and relied thereon in concluding that there were jobs that existed in significant numbers in the national economy ...


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