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Rodgers v. Berryhill

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

September 13, 2017

NANCY A. BERRYHILL, [1]Acting Commissioner of Social Security, Defendant.



         Bobbie J. Rodgers (Plaintiff) seeks review of the decision of the acting Social Security Commissioner, Nancy A. Berryhill, denying Plaintiff's application for Disability Insurance Benefits under the Social Security Act. Because the Court finds that substantial evidence supports the decision to deny benefits, the Court affirms the denial of Plaintiff's application.[2]

         I. Background and Procedural History

         On February 5, 2013, Plaintiff filed an application for Disability Insurance Benefits.[3] (Tr. 172-86). The application alleged disability beginning on December 17, 2012, and was based on the following medical conditions: back problems, fibromyalgia pain, nerve damage, muscle spasms, diabetes, nodules on feet, and neuropathy in feet. (Tr. 58). On May 30, 2013, the Social Security Administration (SSA) denied Plaintiff's claim, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 84-90, 91-92). In a decision dated September 17, 2014, the ALJ found that Plaintiff “has not been under disability within the meaning of the Social Security Act from December 17, 2012, through the date of this decision.” (Tr. 20). The SSA Appeals Council denied Plaintiff's subsequent request for review of the ALJ's decision on December 15, 2015. (Tr. 1-3). Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the Commissioner's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. The Administrative Proceeding

         A. Testimony at Hearing

         Plaintiff appeared with counsel at the administrative hearing on August 28, 2014. (Tr. 38). Plaintiff testified that she had a tenth-grade education, lived with her son and his fiancée, and was last employed as a housekeeper at a nursing home. (Tr. 42). Prior to that, Plaintiff worked as a foster-care provider. (Id.).

         Plaintiff testified that she suffered from three herniated discs in her back, fibromyalgia, diabetes with neuropathy, “bad anxiety, ” and migraines. (Tr. 42-43, 49). As a result of these conditions, Plaintiff was only able to walk for five to ten minutes at a time, sit for twenty to thirty minutes, and stand in one place for “about five minutes, if that.” (Tr. 43-44). Plaintiff stated that she had difficulty holding anything in her left hand and that she could carry a gallon of milk a short distance, but it “pinches [her] back really bad.” (Id.). Standing up too quickly also made Plaintiff's back “pinch, ” causing her to “just fall back down.” (Tr. 48). Plaintiff's high blood sugar caused dizziness, nausea, and shaking. (Tr. 46). Her neuropathy caused numbness and tingling in her legs and feet that was painful and made standing or walking difficult. (Tr. 46-47). Plaintiff also testified that she suffered from migraines at least three times per week, with each headache lasting about twenty-four hours and the “symptoms afterwards last[ing] about two days.” (Tr. 49).

         Plaintiff said her anxiety caused physical symptoms, like shaking legs and high blood pressure, when she was “really nervous” or around people she did not know. (Tr. 47). Plaintiff also stated that she suffered from depression which caused her to “have bad thoughts” and crying spells four to five times per week. (Id.).

         Plaintiff testified that she had a driver's license and drove herself “probably every two weeks” to doctor appointments. (Tr. 44). Plaintiff could dress and bathe herself, but her son stayed nearby while she showered because Plaintiff had fallen several times. (Id.). As for housework, Plaintiff stated she could do dishes, but only for five to ten minutes at a time before she would have to sit down, and her son or his fiancée usually cooked and cleaned. (Tr. 44-45).

         On a typical day, Plaintiff stated she would be “up all hours of the night and day” and sleep when possible, usually three to four hours at a time. (Tr. 45). She would spend most of her time lying down watching television or reading, sometimes visiting her sister who “live[d] in the yard with [her].” (Id.). Plaintiff testified that when she was lying down reading or watching television, she was usually in her bedroom because she had “withdrawals” and did not want to be around people because she could not concentrate. (Tr. 48). When Plaintiff had a migraine, she would also stay in her bedroom because light made her nauseous and “it's really dark in there.” (Tr. 49).

         Plaintiff testified that she underwent back surgery “for [her] sciatic nerve.” (Tr. 48). After that surgery, she received two injections to treat her back pain, and her doctor recommended trying one more before undergoing a second back surgery that would consist of “putting a rod in there and some screws, and try to fuse [the three lower discs].” (Tr. 48-49).

         A vocational expert, Denise Weaver, also testified at the hearing. (Tr. 50). The ALJ asked Ms. Weaver to consider a hypothetical claimant with the same age, education, and work history as Plaintiff who was limited to:

sedentary work with a sit/stand option, allowing the person to sit or stand alternatively at will, provided the person is not off task by [sic] 10 percent of the work period; no climbing of ladders, ropes, or scaffolds; occasional climbing of ramps or stairs; occasional stooping, crouching, kneeling, and crawling; must avoid all use of hazardous machinery…and all exposure to unprotected heights. Work is limited to simple…routine and repetitive tasks with no strict production quota, with the emphasis being on a per-shift rather than a per-hour basis.

(Tr. 52-53). Ms. Weaver testified that, with these restrictions, the hypothetical individual would not be able to do any of Plaintiff's past work, but would be able to do other jobs existing in the national economy, such as dowel inspector or lens inserter. (Tr. 53).

         Ms. Weaver stated the additional limitations of only occasional interaction with the general public and coworkers and no crouching, kneeling, or crawling, would not alter her finding that there were available jobs. (Tr. 54). However, when the ALJ further limited the hypothetical to “be[ing] off task by [sic] 20 percent of the day in addition to regularly scheduled breaks[, ]” Ms. Weaver testified that these restrictions would preclude the individual from all work. (Id.). Ms. Weaver also stated that if the hypothetical individual continually needed two or more unscheduled absences a month, the individual would be precluded from all work. (Id.). Finally, Ms. Weaver testified that, if the individual needed to exercise the sit/stand option every ten to fifteen minutes and it interfered with the job, all available jobs would be eliminated. (Tr. 56).

         B. Relevant Medical Records

         On December 5, 2012, prior to the alleged onset date, Dr. Jeff Lehmen performed a “hemilaminotomy, foraminotomy lumbar 5 to sacral 1; disc excision under microscopic assistance” to treat Plaintiff's lower back pain. (Tr. 322). At a follow-up appointment on December 17, 2012, Plaintiff continued to complain of a constant ache in her lower back and shooting pain in her right hip. (Tr. 329). Dr. Lehmen noted that Plaintiff still rated her pain at a four out of ten, but also noted Plaintiff's “function and pain improved.” (Id.).

         In February 2013, Plaintiff met with her primary care physician, Dr. Robert Mason, for depression and a diabetes checkup. (Tr. 346). Dr. Mason recorded that Plaintiff's back motion was “more moderately limited[, ]” but “pain does continue and she may need future surgery[.]” (Id.). Plaintiff also complained of uncontrolled levels of blood sugar and numbness in her legs and feet with pain at times. (Id.). Dr. Mason discontinued Plaintiff's Metformin and prescribed Lantus SoloStar Solution, refilled Plaintiff's Tramadol and Flexeril prescriptions, and increased Plaintiff's Neurontin. (Tr. 346-47).

         Plaintiff completed a Function Report for the SSA in February 2013. (Tr. 228-39). Plaintiff reported she made her bed “if I can” and washed dishes, but she only washed a few at a time and took breaks. (Tr. 229). She stated that she did laundry twice a week, with two or three loads taking the entire day to complete. (Tr. 231). Plaintiff's husband did all of the cooking because her back pain made it difficult to stand long enough to cook. (Tr. 230, 231). Plaintiff also reported that she could not sleep more than two to four hours at a time because of back pain, did not go outside frequently because she had difficulty walking and feared falling, drove to doctor appointments, sewed for one to two hours per week, and went grocery shopping weekly with her husband but “sometimes” used the electric carts or waited while her husband did the shopping. (Tr. 230-33).

         In May 2013, Dr. Stephen Williamson completed a consultative exam at the request of the SSA. (Tr. 354-59). Dr. Williamson noted that Plaintiff “seem[ed] to be a reliable historian.” (Tr. 354). Plaintiff reported that: her blood glucose averaged a value of 116; she had daily low blood sugar which caused her to be shaky, nauseous, and sweaty; and her current diabetes symptoms included “pain, decreased sensation in her toes, paresthesias in her feet and hands, ulcers and retinopathy.” (Id.). Plaintiff described “sharp pain in her lower back on the right side[.]” (Id.). Plaintiff also reported that repositioning helped the pain, but lifting and bending exacerbated the problem. (Id.).

         Dr. Williamson observed that Plaintiff was in “obvious discomfort from the pain in her right buttock” and had a waddling gait, but also a normal station, did not favor one leg, and did not require an assistive device to walk. (Tr. 356-57). He also noted that Plaintiff could move from a chair to the examination table, maneuver to and from the supine position, and stand on heels and toes “with some difficulty, ” but could not squat or touch her toes. (Tr. 358). Plaintiff's muscles had normal bulk and tone and a four out of five strength rating. (Tr. 357). Dr. Williamson found that Plaintiff's feet had sensory and vibratory sensation impairments, but did not have nodules. (Tr. 357-58). Dr. Williamson's exam revealed only ten positive fibromyalgia pressure points, where eleven positive points are necessary for a positive diagnosis. (Tr. 358, 364). Based on this exam, Dr. Williamson found that Plaintiff could: sit occasionally; stand and walk occasionally; lift and carry up to twenty pounds ...

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