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Rice v. Berryhill

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

October 2, 2017

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



         Ricky 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 Act.[2] For the reasons set forth below, the case is reversed and remanded.

         I. Background and Procedural History

         On 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).

         II. The Administrative Proceeding

         A. Testimony at Hearing

         Plaintiff 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).

         Plaintiff 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)

         Plaintiff's 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).

         During 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).

         A 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).

         B. Relevant Medical Records[3]

         In 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).

         Plaintiff 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).

         In 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.).

         In 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).

         Plaintiff 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, ...

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