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Gray v. Berryhill

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

March 8, 2018

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



         This action is before this Court for judicial review of the final decision of the Commissioner of Social Security finding that Plaintiff Sonya Gray was not disabled, and thus not entitled to Supplemental Security Income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f For the reasons set forth below, the decision of the Commissioner will be reversed and the case remanded for further consideration.


         Plaintiff, who was born on August 27, 1962, filed her application for SSI benefits on August 9, 2013 (at the age of 51), alleging disability as of that date due primarily to depression, high blood pressure, arthritis, and lower back pain. Plaintiff s application was denied at the initial administrative level, and pursuant to her request, a hearing was held before an Administrative Law Judge ("ALJ") on September 9, 2015. After the hearing, the ALJ ordered an orthopedic consultative examination, which was conducted by Stanley London, M.D. (the "consulting examiner"), on October 13, 2015.

         By decision dated January 22, 2016, the ALJ found that Plaintiff had the residual functional capacity ("RFC") to perform the full range of light work, and based on the Commissioner's Medical-Vocational Guidelines ("Guidelines"), 20 C.F.R. pt. 404, subpt. P, app. 2, § 202.00, rules 202.13-. 15, was not disabled under the Social Security Act. Plaintiffs request for review by the Appeals Council of the Social Security Administration was denied on December 5, 2016. Plaintiff has thus exhausted all administrative remedies and the ALJ's decision stands as the final agency action now under review.

         Plaintiff argues that the ALJ's RFC determination is not supported by substantial evidence in the record as a whole. More specifically, Plaintiff argues that the ALJ erred in not accounting for Plaintiffs nonexertional limitations (such as her limited capacity to stoop, bend, and squat) found by the two medical opinions - the December 2, 2013 opinion of non-examining medical consultant Nancy Ceasar, M.D., and, more significantly, the consulting examiner's opinion to which the ALJ assigned "great weight." Plaintiff further argues that by not requesting a Medical Source Statement from the consulting examiner, the ALJ failed in her responsibility to develop a full and fair record. Plaintiff maintains that these errors were not harmless because they resulted in the ALJ improperly relying on the Guidelines to find that Plaintiff was not disabled. Plaintiff seeks remand for a new hearing and decision based upon a completed record.

         Defendant argues that the ALJ properly weighed the opinion evidence in the record; that the ALJ's decision is supported by substantial evidence, including Plaintiff's daily activities, work history, treatment notes, and "improvement"; that the ALJ fully and fairly developed the record; and that the ALJ properly relied on the Guidelines to determine that Plaintiff was not disabled.

         Agency Records, Medical Records, and ALJ's Decision

         The Court adopts the facts set forth in Plaintiff's Statement in Uncontroverted Facts (ECF No. 16-1), with the exception of If 19 which Defendant disputes as a legal conclusion, and the facts set forth in Defendant's Statement of Additional Material Facts (ECF No. 19-2), accepting Plaintiffs gloss that these facts describe Plaintiff's condition during the relevant time period of 2012 through 2016 and not to the present. Together, these facts provide a fair description of the record before the Court. Specific facts will be discussed as needed to address the parties' arguments.


         Standard of Review and Statutory Framework

         In reviewing the denial of Social Security disability benefits, a court must review the entire administrative record to determine whether the ALJ's findings are supported by substantial evidence on the record as a whole. Johnson v. Astrue, 628 F.3d 991, 992 (8th Cir. 2011). The court "may not reverse . . . merely because substantial evidence would support a contrary outcome. Substantial evidence is that which a reasonable mind might accept as adequate to support a conclusion." Id. (citations omitted). A reviewing court "must consider evidence that both supports and detracts from the ALJ's decision. If, after review, [the court finds] it possible to draw two inconsistent positions from the evidence and one of those positions represents the Commissioner's findings, [the court] must affirm the decision of the Commissioner." Chaney v. Colvin, 812 F.3d 672, 676 (8th Cir. 2016).

         To be entitled to benefits, a claimant must demonstrate an inability to engage in substantial gainful activity which exists in the national economy, by reason of a medically determinable impairment which has lasted or can be expected to last for not less than 12 months. 42 U.S.C. § 423(d)(1)(A). The Commissioner has promulgated regulations, found at 20 C.F.R. § 404.1520, establishing a five-step sequential evaluation process to determine disability. The Commissioner begins by deciding whether the claimant is engaged in substantial gainful activity. If not, the Commissioner decides whether the claimant has a severe impairment or combination of impairments. If an impairment or combination of impairments is severe and meets the duration requirement, the Commissioner determines at step three whether the claimant's impairment meets or is equal to one of the deemed-disabling impairments listed in the Commissioner's regulations. If not, the Commissioner asks at step four whether the claimant has the RFC to perform her past relevant work.

         "An ALJ determines a claimant's RFC based on all the relevant evidence, including the medical records, observations of treating physicians and others, and an individual's own description of her limitations." Combs v. Berryhill,878 F.3d 642, 646 (8th Cir. 2017) (citation omitted). "Because a claimant's RFC is a medical question, an ALJ's assessment of it must be supported by some medical evidence of the claimant's ability to function in the workplace. ...

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