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Coleman v. Berryhill

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

May 17, 2017

NANCY A. BERRYHILL, [1]Defendant.



         Sondra Coleman (“Plaintiff”) seeks review of the decision of the Social Security Commissioner, Nancy Berryhill, denying her application for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act.[2] The Court has reviewed the parties' briefs and the administrative record, including the hearing transcript and medical evidence. For the reasons set forth below, the case is reversed and remanded.

         I. Background and Procedural History

         On February 8, 2012, Plaintiff filed applications for Disability Insurance Benefits and Supplemental Security Income alleging that she was disabled as of October 20, 2011 as a result of “back and neck problems, ” migraine headaches, degenerative disc disease, anxiety, and depression. (Tr. 52, 237-45, 246-51). The Social Security Administration (SSA) denied Plaintiff's claims, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 82-86, 97-98).

         The SSA granted Plaintiff's request for review, and an ALJ conducted hearings on December 2, 2013 and March 18, 2014. (Tr. 43-51). On December 2, 2013, Plaintiff failed to appear for the hearing, [3] and the ALJ proceeded with the vocational expert's testimony. (Id.). The vocational expert stated that Plaintiff was a licensed practical nurse who also had work experience as a certified medical technician and certified nursing assistant. (Tr. 47-48). The ALJ asked the vocational expert to consider a hypothetical individual with Plaintiff's age, education, and work experience and the following limitations: “able to do light work with no climbing of ladders, ropes or scaffolds; occasional climbing of ramps or stairs; occasional stooping, crouching, kneeling and crawling; frequent handling of objects bilaterally; frequent fingering of objects bilaterally; must avoid concentrated exposure to excessive noise…, hazardous machinery, …and unprotected heights.” (Tr. 48). The ALJ added that: “The work is limited to simple, as defined in the DOT as SVP levels 1 and 2, routine and repetitive tasks with no strict production quota, with the emphasis being on a per shift rather than a per hour basis.” (Id.). The vocational expert testified that such person could not perform Plaintiff's past work, but could perform the jobs of a cashier, inspector/hand packager, and housekeeper. (Tr. 48-49).

         When the ALJ added to his hypothetical a limitation to occasional fingering and handling, the vocational expert stated that such individual could perform the jobs of information clerk and cashier, “but in a limited environment, such as parking booths and parking garages where there's not a constant steady stream of customers or cashiering activity.” (Tr. 49). The vocational expert testified that, if the hypothetical individual were further limited to sedentary work, the only available job for such person would be surveillance system monitor. (Tr. 50). Two or more unscheduled absences per month or the need to take two or more unscheduled breaks in a workday would “preclude work at all exertional levels.” (Id.).

         Plaintiff appeared at the hearing on March 18, 2014 and testified that she was born on February 26, 1972, had completed two years of college, and lived with her twenty-one-year-old son. (Tr. 34-55). The ALJ observed that Plaintiff arrived with a walker, and Plaintiff stated that Dr. David Myers prescribed it for her. (Tr. 35-36). Plaintiff testified that she was currently taking Percocet, morphine, Tramadol, and a muscle relaxer for her back pain. (Tr. 36). She also took Prozac, valium, and Depakote. (Tr. 38). Plaintiff rated her average pain level at six out of ten, and she had last seen her doctor at the pain clinic the previous day. (Tr. 37, 38).

         Plaintiff testified that she suffered a migraine “at least every other week.” (Tr. 38). Plaintiff's migraines generally lasted “about a day, day-and-a-half, but the aftermath is about two days.” (Tr. 40). When experiencing a migraine, she would take medicine, “[t]hrow a pack of ice on my head, make sure it's dark in the room, no noise.” (Id.). When she was able to “catch [the migraine] soon enough” and take her medication, her migraine would subside about six hours later. (Tr. 40-41). Plaintiff explained, “if I [sic] keep getting stronger and overtime, Dr. [Choudhary] does a spinal tap . . . and pulls the fluid off.” (Tr. 41).

         Plaintiff testified that she had difficulty dressing and bathing herself, but stated she was able to do so “as long as I'm hanging on.” (Tr. 38-39). Plaintiff last drove her car about two months prior. (Tr. 39). She was able to do “a little” housework, such as dusting and laundry, but a caregiver did her dishes. (Id.). Plaintiff explained that a caregiver, provided by Disabled Citizens Alliance, Inc., came to her house five days per week for two and a half to three hours. (Tr. 40).

         In a decision dated May 28, 2014, the ALJ applied the five-step evaluation process set forth in 20 C.F.R. §§ 404.1520, 416.920[4] and determined that Plaintiff “has not been under a disability, as defined in the Social Security Act, from October 20, 2011, through the date of this decision[.]” (Tr. 10-22). The ALJ found that Plaintiff had the following severe impairments: disorder of the back; migraine; carpal tunnel syndrome; anxiety; and depression. (Tr. 12).

         After reviewing Plaintiff's medical records and testimony, the ALJ found that “medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision.” (Tr. 15). The ALJ determined that Plaintiff had the residual functional capacity (RFC) to:

Perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except she cannot climb ladders, ropes, or scaffolds. She can occasionally climb ramps or stairs. She can occasionally stoop, crouch, kneel, or crawl. She can handle objects, that is gross manipulation, bilaterally and on an occasional basis. She can finger, that is fine manipulation of items no smaller than a paper clip, bilaterally on an occasional basis. She must avoid concentrated exposure to excessive noise. She must avoid all use of hazardous machinery and all exposure to unprotected heights. Her work must be limited to simple, as defined by the DOT as SVP levels 1 and 2, routine tasks, and repetitive tasks. She cannot be subject to strict production quotas; the emphasis must be on a per shift rather than per hour basis.

(Tr. 14). The ALJ concluded that Plaintiff could not perform past relevant work, but she could perform the jobs of information clerk or “cashier II in a limited environment such as parking garages[, ]” and was, therefore, not disabled. (Tr. 21-22).

         Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review on August 10, 2015. (Tr. 30, 1-6). Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. Standard of Review

         A court must affirm an ALJ's decision if it is supported by substantial evidence. 42 U.S.C. § 405(g). “Substantial evidence ‘is less than a preponderance, but enough so that a reasonable mind might find it adequate to support the conclusion.'” Cruze v. Chater, 85 F.3d 1320, 1323 (8th Cir. 1996) (quoting Boerst v. Shalala, 2 F.3d 249, 250 (8th Cir. 1993)). In determining whether the evidence is substantial, a court considers evidence that both supports and detracts from the Commissioner's decision. Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th Cir. 2009). However, a court “do[es] not reweigh the evidence presented to the ALJ and [it] defer[s] to the ALJ's determinations regarding the credibility of testimony, as long as those determinations are supported by good reason and substantial evidence.” Renstrue v. Astrue, 680 F.3d 1057, 1064 (8th Cir. 2012) (quoting Gonzales v. Barnhart, 465 F.3d 890, 894 (8th Cir. 2006)).

         “If, after reviewing the record, the court finds it is possible to draw two inconsistent positions from the evidence and one of those positions represents the ALJ's findings, the court must affirm the ALJ's decision.” Partee v. Astrue, 638 F.3d 860, 863 (8th Cir. 2011) (quoting Goff v. Barnhart, 421 F.3d 785, 789 (8th Cir. 2005)). The Eighth Circuit has repeatedly held that a court should “defer heavily to the findings and conclusions” of the Social Security Administration. Hurd v. Astrue, 621 F.3d 734, 738 (8th Cir. 2010); Howard v. Massanari, 255 F.3d 577, 581 (8th Cir. 2001).

         III. Discussion

         Plaintiff claims that substantial evidence does not support the ALJ's determination of her RFC because the ALJ: (1) improperly weighed the medical opinion evidence; and (2) failed to consider Plaintiff's need for an assistive device. (ECF No. 18). In response, Defendant asserts that the ALJ properly considered the medical opinion evidence and adequately accounted for Plaintiff's credible limitations in determining her RFC. (ECF No. 23).

         A. Medical opinion evidence

         Plaintiff argues that, in creating her RFC, the ALJ erred in assigning too little weight to the opinion of her primary care physician, Dr. David Myers, and too much weight to that of Dr. Nancy Ceaser, a non-examining state agency consultant. Defendant counters that the ALJ provided good reason for assigning Dr. Myer's opinion limited weight and properly assigned significant weight to Dr. Ceaser's opinion.

         In determining a claimant's RFC, the ALJ is required to consider the medical opinion evidence of record together with the other relevant evidence. 20 C.F.R. §§ 404.1527(b), 416.927(b). Unless the ALJ assigns controlling weight to a treating physician's opinion, the ALJ must explain the weight given to every medical opinion of record, regardless of its source. See 20 C.F.R. §§ 404.1527(c), 416.927(c). Because the ALJ weighs each medical opinion in light of the entire record, the Court will summarize the relevant medical evidence.

         Plaintiff's voluminous medical records reflect that, in April 2007, when she was thirty-five years of age, a drunk driver struck her vehicle head-on. (Tr. 628-31). An ambulance transported Plaintiff to an emergency room, where doctors treated her for spinal pain, a closed head injury, and a ...

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