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Walls v. Berryhill

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

March 13, 2017

BRIAN G. WALLS, Plaintiff,
NANCY A. BERRYHILL, [1]Acting Commissioner of Social Security, Defendant.



         This action is before this court for judicial review of the final decision of the Commissioner of Social Security finding that plaintiff Brian G. Walls is not disabled and, thus, not entitled to either disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq, or Supplemental Security Income (“SSI”) under Title XVI, 42 U.S.C. §§ 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the decision of the Commissioner is affirmed.

         I. BACKGROUND

         Plaintiff was born on February 23, 1970. (Tr. 189, 196). He protectively filed his applications for DIB and SSI on October 10, 2012, eventually amending his disability onset date to the same date. (Tr. 214-15). Plaintiff claimed that the following conditions limited his ability to work: depression, bipolar disorder, attention deficit disorder, lupus, and anxiety. (Tr. 219). Plaintiff's application was denied on January 9, 2013, and he requested a hearing before an administrative law judge (“ALJ”). (Tr. 11, 111-15, 118-19). A hearing was held in October 2014, where plaintiff and a vocational expert (“VE”) testified. (Tr. 33-92). By decision dated November 7, 2014, the ALJ found that plaintiff was not disabled under the Social Security Act. (Tr. 11-23). The ALJ determined that plaintiff retained the residual functional capacity (“RFC”) to perform jobs available in significant numbers in the national economy. Id. On January 14, 2016, the Appeals Council of the Social Security Administration denied plaintiff's request for review of the ALJ's decision. (Tr. 1-3). Consequently, the ALJ's decision stands as the final decision of the Commissioner.

         Plaintiff argues that the ALJ's decision is not supported by substantial evidence. Specifically, he asserts that the ALJ erred in not giving his treating physician's opinion controlling weight, failed to fully develop the record, and failed to perform a proper credibility analysis of plaintiff's testimony. Plaintiff asks that the ALJ's decision be reversed or that the case be remanded for a new administrative hearing.

         A. Medical Record and Evidentiary Hearing

         The court adopts plaintiff's unopposed statement of facts (ECF No. 18), as well as defendant's unopposed statement of facts. (ECF No. 23). These facts, taken together, 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.

         B. ALJ's Decision

         The ALJ found that plaintiff had not engaged in substantial gainful activity since his alleged onset date. (Tr. 13). She also found that plaintiff suffered from the severe impairments of degenerative disc disease of the cervical spine, lumbago, discoid lupus, recurrent bilateral carpal tunnel syndrome, bipolar disorder, and attention deficit disorder. Id. However, the ALJ concluded that none of these impairments, individually or in combination, met or equaled an impairment listed in the Commissioner's regulations. (Tr. 14-15). With respect to plaintiff's mental impairment, the ALJ found that the “paragraph B” and “paragraph C” criteria were not met, because plaintiff had no restrictions in activities of daily living; only mild difficulties in social functioning; moderate difficulties with regard to concentration, persistence, or pace; and no extended episodes of decompensation. Id.

         The ALJ determined that plaintiff's impairments left him with the RFC to “perform light work as defined in 20 C.F.R. 404.1567(b) and 416.967(b), ” except that he can only occasionally lift and carry up to 20 pounds, can frequently lift and carry up to 10 pounds, can only stand or walk six hours in an eight-hour workday, and can sit six hours in an eight-hour workday. (Tr. 15). He cannot crawl or climb on ropes, ladders, or scaffolds, and he must avoid concentrated exposure to extreme cold, vibration, and work hazards like heavy machinery. Id. The ALJ also found that he must avoid ultraviolet light exposure, though fluorescent lights are permissible. Id. Finally the ALJ found that plaintiff can handle and finger bilaterally on a frequent basis. Id. The ALJ found that plaintiff had diagnoses for his impairments, but that plaintiff's statements concerning the intensity, persistence, and limiting effects of the symptoms were “not entirely credible.” (Tr. 16-17).

         The ALJ reasoned that the objective medical evidence did not substantiate plaintiff's allegations. (Tr. 17). Specifically, the ALJ observed that the record was “devoid of any evidence showing a significant degree of nerve compression, muscle atrophy, paravertebral muscle spasm, sensory or motor loss, reflex abnormality, abnormal coordination, or consistent gait disturbance.” Id. The ALJ noted that plaintiff's physical examinations produced normal or mild findings, his impairments required no hospitalization, and his sole visit to the emergency room was to refill a prescription, not because the severity of his pain required such a visit. (Tr. 16-17, 650) (with the doctor stating, “really suspect this is tramadol withdraw[a]l . . . fairly classic presentation. Will give 10 tablets of tramadol to get him through”). The ALJ also considered plaintiff's activities of daily living to be inconsistent with his allegations of debilitating carpal tunnel syndrome. (Tr. 18). He texts messages, uses a computer keyboard, does not drop objects, and is able to manipulate a cigarette out of its package and light it. Id. Ultimately, the ALJ decided that plaintiff may be experiencing some degree of pain, but that his physical impairments are addressed in the limitations of his RFC. Id.

         As to plaintiff's mental impairments, the ALJ emphasized plaintiff's normal mental status examinations; normal appearance, behavior, affect, mood, thought, judgment, and insight; and documented good response to treatment. (Tr. 19). He also noted a number of inconsistent statements in the record that erode plaintiff's credibility. Id. For example, plaintiff reported to the ALJ that he did not play video games, yet he reported to mental health care providers that he played video games on a frequent basis. (Tr. 57, 736, 740, 745).

         In terms of the medical opinions in the record, the ALJ explained that he gave “little weight” to plaintiff's treating physician, Mark Tucker, DO, because his opinion was inconsistent with his own medical records. (Tr. 20). For example, when plaintiff told Dr. Tucker he hurt his back while shoveling, Dr. Tucker showed him correct lifting techniques to avoid injuries while shoveling. (Tr. 697). As the ALJ noted, “[s]uch counsel is inconsistent with the functional limitations opined in the medical source statement.” (Tr. 20).

         The ALJ also gave the opinions of psychiatrists David E. Goldman, DO, and Lyle A. Clark, MD “little weight” because they were not supported by the medical evidence. Id. at 20-21. She noted in particular that their Global Assessment of Functioning (“GAF”) scores[2] of 45 and 36, respectively, which indicate very serious psychological symptoms, were of limited probative value because they were assigned during an initial evaluation. Id. She noted that GAF scores are generally considered “snapshots” of a plaintiff's abilities at the time of examination, and do not reflect his day-to-day capabilities or how treatment may control symptoms. Id.

         The ALJ gave partial weight to the opinion of an examining prison doctor who assigned plaintiff a GAF score of 60, because it indicated the claimant was experiencing moderate psychological symptoms, which ...

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