United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE
action is before the Court pursuant to the Social Security
Act, 42 U.S.C. §§ 401, et seq. (“the
Act”). The Act authorizes judicial review of the final
decision of the Commissioner of Social Security (the
“Commissioner”) denying Plaintiff Chantal
Ford's application for Disability Insurance Benefits and
Supplemental Security Income. 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 is affirmed.
History & Summary of Memorandum Decision
August 26, 2013, Plaintiff filed applications for Disability
Insurance Benefits (“DIB”) and Supplemental
Security Income (“SSI”) under the Act. Plaintiff
alleged a disability onset date of September 17, 2012. (Tr.
Plaintiff's claims were denied initially on October 4,
2013. (Id.) Thereafter, Plaintiff requested a
hearing before an Administrative Law Judge
(“ALJ”), which was held on June 3, 2015.
Plaintiff and Darrell Taylor, Ph.D., an independent
Vocational Expert (“VE”), testified at the
hearing. (Tr. 29) In a decision dated September 4, 2015, the
ALJ denied benefits, concluding that Plaintiff was not
disabled under the Act. (Tr. 12-22) 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. Plaintiff filed
the instant action on September 27, 2016. (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
the ultimate issue before the Court is whether substantial
evidence supports the Commissioner's decision,
Plaintiff's request for judicial review asks the Court to
consider two inter-related issues, namely:
(1) Whether, in determining Plaintiff's Residual
Functional Capacity (“RFC”), the ALJ erred in
concluding that Plaintiff could perform sedentary work (with
additional limitations) because no medical evidence supported
the ALJ in this regard; and
(2) Whether the hypothetical question posed to the VE was
adequate because it failed to include a limitation that
Plaintiff would miss four work days per month.
these issues require the Court to address other related
issues, including the ALJ's consideration of
Plaintiff's credibility and the medical opinion evidence
in the administrative record.
thorough review of the record, the Court concludes that the
Commissioner's decision is supported by substantial
evidence. The ALJ gave good reasons for discounting
Plaintiff's credibility. Although the ALJ did not give
significant weight to any of the medical opinions in the
record, contrary to Plaintiff's contention, there is
medical evidence in the record, including medical source
opinion evidence, to support a conclusion that Plaintiff is
capable of sedentary work with the additional limitations
noted. Such evidence includes aspects of the opinion provided
by Plaintiff's treating physician, Dr. Gayla Jackson,
was 31 years old at the time of her administrative hearing.
Prior to her alleged disability onset, Plaintiff worked in a
variety of positions, including as a customer services
representative, cashier, and casino security services. (Tr.
20) In her Disability Report - Adult, Plaintiff listed the
following mental and physical conditions as limiting her
ability to work: mental health; bipolar disorder; depression;
anxiety; PTSD; obesity; high blood pressure; migraine
headaches; sleep apnea; and asthma. (Tr. 184) In her Function
Report - Adult, Plaintiff listed the following limitations to
her ability to work: lifting, squatting, bending, standing,
walking, sitting, kneeling, talking, stair climbing, seeing,
memory, completing tasks, concentration, understanding,
following instructions, and getting along with
others. (Tr. 223)
Summary Review of Medical Evidence
is a great deal of medical evidence in the record. The Court
has considered the entire record and summarizes specific
aspects herein to provide context for this memorandum and
Dr. Melissa Hollie, M.D.
are a few treatment records that predate Plaintiff's
alleged disability onset date. Dr. Melissa Hollie apparently
treated Plaintiff's hypertension, but noted that she was
unsure whether Plaintiff had been compliant with her
medications. (Tr. 269-71)
SSM DePaul Health Center
received treatment on numerous occasions, for a variety of
reasons, from providers at SSM DePaul Health Center,
including at the emergency room (“ER”).
(See, e.g., Tr. 273-345, 678-90) For
example, in 2012, Plaintiff received treatment for migraine
headaches, ear pain, a sore finger, a broken tooth, chest
pain, abdominal pain, and coughing. The medical records
indicate that she typically received routine and conservative
treatment for her conditions. For example, in February 2013,
Plaintiff was treated at the ER for chest pain. The treatment
notes indicate, among other things, that Plaintiff had a
normal EKG. She was given a prescription for pain and
referred to her primary care provider. (Tr. 311-16)
Similarly, on June 23, 2013, Plaintiff again appeared at the
ER with chest pain, and again she had a normal EKG and was
found to have no acute disease of the chest. (Tr. 324-34) In
July 2, 2013, Plaintiff was treated at the ER for abdominal
pain with vomiting. The treatment notes reflect that all
laboratory tests were “unremarkable.” (Tr. 335,
341) Furthermore, the treatment notes for many if not most of
her ER visits indicate that she had 100% oxygen saturation.
a review of all of the treatment records from SSM DePaul
Health Center show that the providers regularly found
Plaintiff to be oriented, have a normal mood and affect, and
intact memory and judgment.
Christian Hospital Northwest
2012 and 2015, Plaintiff received treatment numerous times at
Christian Hospital Northwest, including at the ER. Plaintiff
was treated for a variety of complaints, including chest
pain, ear pain, dizziness, knee pain, a finger burn from
Clorox, women's health issues, a hand injury due to
punching a person, breathing issues related to asthma, nausea
and stomach symptoms. Despite her many trips to this
facility, the record shows that Plaintiff typically received
routine and conservative treatment and was not in acute
distress, either physically or mentally. For example, in
December 2012, Plaintiff appeared at the ER complaining of
chest pain. Plaintiff was oriented and did not appear to be
in distress and did not meet the criteria for critical care.
Rather, she was advised to follow up with her primary care
physician. As another example, in August 2014, Plaintiff was
treated at this facility after complaining of difficulty
breathing. She was diagnosed with asthma and tobacco abuse.
In April 2015, Plaintiff returned to this facility,
complaining of chest pain, shortness of breath, numbness, and
a headache. Testing revealed no acute cardiopulmonary
Mercy Hospital / Mercy Clinic & Dr. Gayla Jackson,
administrative record includes a large number of treatment
notes from the Mercy Clinic and Dr. Gayla Jackson, M.D., from
2013 into 2015. The records suggest that Dr. Jackson treated
Plaintiff for a number of different conditions, including but
not limited to, asthma, obstructive sleep apnea, morbid
obesity, and women's health issues. Plaintiff also
reported to Dr. Jackson that she was attempting to conceive
and have a child and received treatment from another
provider, Dr. Marsha Fisher, related to fertility issues.
Plaintiff also received periodic treatment at the Mercy
Jackson's treatment notes reflect problems controlling
Plaintiff's various symptoms. For example, notes from May
2013 represent that Plaintiff's asthma was not well
controlled and that she continued to suffer from morbid
obesity. The notes further indicate that Plaintiff suffered
from occasional anxiety and was receiving multiple
psychiatric-related medications. Dr. Jackson's notes
regularly indicate that Plaintiff exhibited a normal mood and
affect, and was well-oriented.
Jackson's notes, which span about two years, indicate
that one of the substantial issues with Plaintiff's
health care was controlling her asthma and hypertension. This
issue is generally consistent with Plaintiff's frequent
visits to the ER. Dr. Jackson's notes indicate, however,
that Plaintiff was non-compliant with her treatment and/or
medications. Dr. Jackson regularly noted that Plaintiff
continued to smoke cigarettes despite her conditions.
Similarly, Plaintiff was not using her CPAP machine to assist
with her obstructive sleep apnea, and was not compliant with
other medications, including medications for blood pressure,
migraines, and psychiatric issues. Dr. Jackson's notes
also indicate that Plaintiff consumed a poor diet, at one
time reporting that she subsisted largely on fast food. Dr.
Jackson's notes often indicate that she spent more than
50% of her time with Plaintiff on counselling, including
encouraging Plaintiff to modify her lifestyle.
whole, the treatment notes from Dr. Jackson and Mercy Clinic
indicate that Plaintiff typically received routine and
conservative treatment for her various ailments, and that
Plaintiff was non-compliant with the course of treatment
provided and recommended.
Jackson completed an Arthritis Residual Functional Capacity
Questionnaire, dated May 14, 2015, which is one of the
important pieces of opinion evidence in the record. (Tr. 987)
Dr. Jackson indicated that she had treated Plaintiff every
three months for the prior two years, and that Plaintiff had
a diagnosis of arthritis. Of twenty-one positive objective
signs for arthritis listed on the form, Dr. Jackson
identified only “Crepitus” (grinding or popping
sounds) of the knees as applying to Plaintiff. Dr. Jackson
listed morbid obesity, asthma, and bipolar disorder as
additional diagnosed impairments. Although the questionnaire
identified twenty-four more generalized symptoms for
consideration, Dr. Jackson marked only
“breathlessness.” Dr. Jackson indicated that
Plaintiff was not a malingerer and that emotional factors did
not contribute to the severity of Plaintiff's symptoms or
functional limitations. Regarding pain, Dr. Jackson listed
bilateral pain in Plaintiff's knees/ankles/feet, and that
pain would frequently interfere with Plaintiff's
attention and concentration. Dr. Jackson opined that
Plaintiff could sit for more than two hours at a time (and at
least six hours during an eight-hour workday), stand for
fifteen minutes before needing to sit down, stand/walk less
than two hours during an eight hour workday, and that she
would need to shift positions between sitting and
standing/walking. Dr. Jackson further opined that Plaintiff
would need unscheduled breaks hourly. Dr. Jackson also made
specific findings regarding Plaintiff's ability to
perform various work-related tasks such as carry weight,
twist or bend, and reach. Finally, Dr. Jackson estimated that
that Plaintiff would miss about four workdays per month due
to her impairments or treatment requirements. The ALJ's
treatment of Dr. Jackson's opinion is discussed in
greater detail below.
Dr. Jordan Balter, D.O.
administrative record also includes numerous treatment notes
from Dr. Jordan Balter. Dr. Balter was Plaintiff's
treating psychiatrist from around 2012 until at least 2014.
(See, e.g., Tr. 513-85) Many of Dr.
Balter's notes are difficult to read. In a form dated
September 16, 2013, responding to an inquiry for information
relevant to Plaintiff's disability process, Dr. Balter
noted that Plaintiff suffers from bipolar affective disorder
and psychosis, and that she is unable to complete activities
of daily living. (Tr. 513) Dr. Balter also completed a form
entitled “Certification for Health Care Provider for
FMLA Leave & Behavioral Health Provider Statement of
Claim for Disability Benefits, ” dated April 17, 2013.
(Tr. 666-70) In this form, Dr. Balter provided several
opinions concerning Plaintiff's mental and emotional
health, but estimated that Plaintiff might recover
sufficiently to work by late May 2013.
Dr. George Vergolias, Psy.D.
the medical opinions in the record are three related opinions
from Dr. George Vergolias, the last of which was dated
September 11, 2013. (Tr. 644-52) Dr. Vergolias was not a
treating source, but reviewed records and information,
including from Dr. Balter and Plaintiff. Dr. Vergolias
concluded that Plaintiff suffered from a functionally
impairing psychological condition-bipolar disorder. Dr.
Vergolias noted that Plaintiff's functional impairments
would result in decreased abilities in the following areas:
sustaining cognitive focus; multitasking without errors;
problem solving fluidly and without frustration;
appropriately interacting with customers/co-workers; and
accomplishing tasks within demanding timelines. (Tr. 649) Dr.
Vergolias estimated that such limitations would last
approximately eight weeks, and recommended alternative
treatment options to improve Plaintiff's symptoms.
(Id.) Finally, Dr. Vergolias indicated that he
believed the evidence showed Plaintiff had been compliant
with her treatment. (Tr. 651)
Debra Villar, Licensed Mental Health Case
record also includes a “Medical Claim Plan, ”
dated August 27, 2013, and signed by Debra Villar, Mental
Health Case Manager, which includes Plaintiff's answers
to a questionnaire for mental health claims to
“Standard Insurance Company.” (Tr. 653-55)
Dr. James Flax, M.D.
administrative record includes a Physician's Consult
Memo, dated April 30, 2014, from Dr. James Flax, M.D. The
memo appears to be directed to a claim associated with
Plaintiff's long-term disability carrier. The memo also
indicates that Dr. Flax was not an examining source. Rather,
Dr. Flax reviewed the information from Dr. Vergolias, Dr.
Balter, Mental Health Counselor Debra Villar, and Mercy
Dr. Marsha Toll, Psy.D.
Marsha Toll completed a psychiatric review technique and
provided a Mental Residual Functional Capacity assessment in
the Disability Determination Explanations associated with
Plaintiff's DIB and SSI applications. (See,
e.g., Tr. 63-65, 68-69) The records provided to Dr.
Toll included records from Dr. Balter in September 2013.
Among other things, Dr. Toll found Plaintiff to have mild
limitations regarding her activities of daily living and
maintaining social functioning, and moderate limitations
regarding concentration, persistence, or pace. (Tr. 63) The
specific functional limitations found by Dr. Toll are
identified in greater detail in the Court's analysis
3, 2015, the ALJ conducted a hearing on Plaintiff's
disability applications. (Tr. 28-58) Plaintiff, who appeared
with counsel, testified in response to questions posed by the
ALJ. Plaintiff was 31 years old at the time of the hearing.
Among other things, Plaintiff testified that her daily
activities consisted of lying in bed, watching television,
taking medications, and attending doctor's appointments.
Plaintiff noted that she both slept a lot but had been up all
night and could not sleep. Plaintiff discussed her
medications and some of her functional limitations, and that
she had ...