United States District Court, E.D. Missouri, Southeastern Division
MEMORANDUM AND ORDER
PATRICIA L. COHEN, UNITED STATES MAGISTRATE JUDGE
Rice (Plaintiff) seeks review of the decision of the Acting
Social Security Commissioner, Nancy A. Berryhill, denying his
applications for Disability Insurance Benefits and
Supplemental Security Income under the Social Security
For the reasons set forth below, the case is reversed and
Background and Procedural History
August 22, 2013, Plaintiff filed applications for
Supplemental Security Income and Disability Insurance
Benefits. (Tr. 144-56). The applications allege disability
beginning on May 1, 2012, and were based on the following
medical conditions: kidney failure, thyroid problems, colon
problems, severe cluster headaches, lower back pain,
neuropathy, left leg problems, high blood pressure, and high
cholesterol. (Tr. 71, 80). On September 27, 2013, the Social
Security Administration (SSA) denied Plaintiff's claims,
and he filed a timely request for a hearing before an
administrative law judge (ALJ). (Tr. 71-88, 99-101). In a
decision dated October 21, 2014, the ALJ found that Plaintiff
“has not been under a disability within the meaning of
the Social Security Act from May 1, 2012, through the date of
this decision.” (Tr. 29). The SSA Appeals Council
denied Plaintiff's subsequent request of review of the
ALJ's decision on February 1, 2016. (Tr. 1-4). 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).
The Administrative Proceeding
Testimony at Hearing
appeared with counsel at an administrative hearing in
September 2014. (Tr. 45-70). Plaintiff testified that he was
fifty-one years old, had a GED, and lived alone in an
apartment. (Tr. 48, 59, 61). Plaintiff most recently worked
in a factory for approximately three months in August 2013
before quitting because his back pain made it difficult to
stand. (Tr. 49, 59). Prior to this, Plaintiff assembled lawn
mower engines from 2008 to 2012, and worked as a truck
driver. (Tr. 49-51).
testified that the sciatic nerves in his back, numbness in
his feet and left leg, and swollen joints, likely caused by
his diabetes, limited his ability to work. (Tr. 54).
Plaintiff took Januvia for his diabetes which “pretty
much” controlled his diabetes, although his blood sugar
levels still fluctuated “quite a bit.” (Tr.
54-55). He took medication for his thyroid and for high blood
pressure, both of which he had been taking since 2009. (Tr.
55). Plaintiff stated that his blood pressure “runs
high” and in the six months before the hearing, his
medication level was increased. (Tr. 56). Plaintiff also
testified that he took gabapentin and Tramadol for his hands,
joints, and back pain and that he was prescribed a muscle
relaxer but was not taking it because he could not afford the
medication. (Tr. 56-57). For depression, Plaintiff took
Cymbalta that “kind of help[ed] a little” but he
was not currently seeing a psychiatrist because he did not
have insurance. (Tr. 58). Plaintiff stated that he did not
have side effects from his medications. (Tr. 64)
pain level before medication was normally a seven out of ten,
and medication reduced it to a six out of ten. (Tr. 57).
Plaintiff also testified that a bath would help relieve his
pain, but he had difficulty getting in and out of the
bathtub. (Tr. 64).
the day, Plaintiff spent most of his time lying down,
sometimes watching television. (Tr. 60). When cleaning his
house, Plaintiff would have to take breaks approximately
every ten minutes. (Tr. 60, 64). Plaintiff's
sister-in-law did his laundry. (Tr. 61). Plaintiff could cook
his own meals and go to the grocery store, but a friend
usually accompanied him. (Tr. 61-62). When Plaintiff tried to
go to the store himself the day before the hearing it
“didn't go too well” and he had to leave his
groceries at the door and rest before retrieving them. (Tr.
61). The only place Plaintiff regularly went was to the
doctor and church on Sundays. (Tr. 61-62). Plaintiff stated
that he did not drive so family usually drove him. (Tr.
59-60). Finally, Plaintiff testified that he could walk half
a block or less before he needed to stop and rest. (Tr. 63).
vocational expert, Susan Shea, also testified at the hearing.
(Tr. 65). The ALJ asked Ms. Shea to consider a hypothetical
individual with the same age, education, and work experience
as Plaintiff who was capable of:
work at the light exertional level with the following
additional limitations. He can occasionally climb ramps and
stairs, stoop, and crouch. He should never climb ladders,
ropes, or scaffolds, kneel, or crawl. He should avoid
concentrated exposure to hazards such as unprotected heights
and dangerous machinery. He should likewise avoid
concentrated exposure to vibration.
(Tr. 67). Ms. Shea stated that with these restrictions, the
hypothetical individual would not be able to perform any of
Plaintiff's past jobs, but would be able to perform other
jobs available in significant numbers in the economy.
(Id.). When the ALJ added the condition that the
hypothetical individual needed to be able to alternate
between sitting and standing at the work station one to three
minutes every hour, Ms. Shea testified that there would still
be available jobs. (Tr. 68). The ALJ further altered the
hypothetical to allow the individual to have at least two
fifteen-minute breaks in addition to regularly scheduled
morning, lunch, and afternoon breaks. (Tr. 68) Ms. Shea
testified that there would be no available jobs in the
economy under those conditions. (Tr. 68-69).
Relevant Medical Records
February 2011, before the alleged onset date, Plaintiff saw
Dr. Christopher Montgomery. (Tr. 313-15). Plaintiff reported
a history of hypertension, diabetes, hypothyroidism,
hyperlipidemia, and colonic polyps. (Tr. 313). Dr. Montgomery
noted that Plaintiff was in “no acute distress”
and had a normal mood, affect, attention span, and
concentration. (Id.). Plaintiff's medications
were updated to include lisinopril, Pravachol, Januvia, and
levothyroxine sodium. (Tr. 314-15).
returned to Dr. Montgomery in June 2011 complaining of
abdominal bloating and rectal pain. (Tr. 310-12). Plaintiff
reported he was not taking his cholesterol medications, but
was trying to eat healthier and had lost some weight. (Tr.
310). Plaintiff's physical exam was unremarkable, and Dr.
Montgomery ordered a basic metabolic panel and a colonoscopy
for Plaintiff's rectal pain and muscle spasms. (Tr. 311).
September 2011, Plaintiff saw Dr. Montgomery to discuss his
laboratory results. (Tr. 307-09). Plaintiff's cholesterol
level had “improved some” but his constipation
continued and his abdomen was distended. (Tr. 307-08). Dr.
Montgomery advised Plaintiff to change his diet and
“try a one[-]time dose of mag citrate” to treat
his constipation. (Id.).
December 2011, Plaintiff returned to Dr. Montgomery
complaining of abdominal bloating. (Tr. 305-06). Plaintiff
stated he had no appetite and could go two weeks without
having a bowel movement. (Tr. 305). An exam revealed that
Plaintiff's abdomen was round, tight, and had
“generalized tenderness with no masses[.]” (Tr.
306). Dr. Montgomery ordered an EGD and a colonoscopy.
(Id.). Plaintiff met with Dr. Montgomery to review
laboratory results in March 2012. (Tr. 301-04). Plaintiff
reported he was not eating or taking his medications
properly. (Tr. 301). Dr. Montgomery advised Plaintiff to eat
more healthfully and take his medications as prescribed. (Tr.
302). Dr. Montgomery noted Plaintiff's colonic polyps had
“improved” and diagnosed Plaintiff with
microalbuminuria. (Tr. 303).
saw Dr. Mowaffaq Said in April 2012 for proteinuria and
chronic kidney disease. (Tr. 294-96). Plaintiff reported he
did not have difficulties controlling his blood pressure and
A1c levels but did report right side lower back pain. (Tr.
294). Plaintiff also reported that he was laid-off from his
job the Thursday before the appointment and was going to
school to be a probation officer. (Id.). Dr. Said
noted that Plaintiff was six feet three inches tall and
weighed 258 pounds, “fe[lt] good” physically, and
had no depression or anxiety. (Id.). A renal
ultrasound done in March 2012 “showed no evidence of
obstruction.” (Tr. 295). Dr. Said diagnosed Plaintiff
with hypertension, ...