United States District Court, E.D. Missouri, Eastern Division
GRACE E. McROBERTS, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration, Defendant.
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE
matter is before the Court for review of an adverse ruling by
the Social Security Administration. The parties have
consented to the jurisdiction of the undersigned United
States Magistrate Judge pursuant to 28 U.S.C. § 636(c).
October 17, 2013, plaintiff Grace E. McRoberts protectively
filed an application for supplemental security income, Title
XVI, 42 U.S.C. §§ 1381 et seq., with an
alleged onset date of November 1, 2009. (Tr. 158-63). A
subsequent application for a period of disability and
disability insurance benefits under Title II, 42 U.S.C.
§§ 401 et seq., is not under consideration
here. After plaintiff's application for
benefits was denied on initial consideration (Tr. 110-16),
she requested a hearing from an Administrative Law Judge
(ALJ). (Tr. 117-19).
and counsel appeared for a hearing on September 2, 2015. (Tr.
45-63). Plaintiff testified concerning her disability, daily
activities, functional limitations, and past work. The ALJ
also received testimony from vocational expert Jenifer
Teixeira, M.Ed., in the form of responses to interrogatories.
(Tr. 410-12). The ALJ issued a decision denying
plaintiff's application on March 2, 2016. (Tr. 28-39).
After reviewing additional evidence plaintiff submitted, the
Appeals Council denied plaintiff's request for review on
March 10, 2017. (Tr. 1-7). Accordingly, the ALJ's
decision stands as the Commissioner's final decision.
Evidence Before the ALJ
Disability and Function Reports and Hearing
was born on August 29, 1978, and was 31 years old on the
alleged onset date. She completed high school and received an
associate's degree in billing and coding. She lived with
her father and eleven-year old daughter. She had been insured
through Medicaid for more than five years and received food
stamps and housing assistance. (Tr. 51-53, 159-60). Plaintiff
previously worked as a child-care provider, a client
relations specialist in the mortgage/banking field, a
customer service representative in telecommunications, a
dietary aide, and a production worker/packer at a printing
company. (Tr. 183).
listed her impairments as depression, anxiety, degenerative
disc disease, asthma, and migraines. (Tr. 182). In 2013 and
2014, plaintiff was prescribed a number of medications for
the treatment of anxiety, depression, insomnia, back pain,
migraine, and asthma. (Tr. 184, 227).
stated in her November 2013 function report (Tr. 192-203)
that her daily activities included getting her daughter off
to school, tending to household chores and grocery shopping
and, on occasion, checking on her sister. She prepared meals
and completed laundry and house cleaning. Her conditions did
not impair her ability to attend to her grooming or personal
hygiene. She was unable to sleep through the night and did
not always have a desire to eat. She lacked the financial
resources to pay her bills on time but was otherwise capable
of managing her finances. Her hobbies included watching
television and relaxing in a tub. She used to be able to sit,
stand, walk, run, and clean without needing breaks. When she
applied for disability, however, she was only able to walk
for a half mile or mile before she needed to take a break for
15 to 20 minutes. In addition, she was no longer able to
concentrate and multitask as she once had. She did well with
written instructions and could follow spoken instructions if
she asked for them to be repeated. She did not always get
along with others because she was easily irritated and
resented being talked down to, and she did not handle changes
in routine well. Plaintiff had difficulties with lifting,
bending, standing, walking, sitting, kneeling, climbing
stairs, memory, completing tasks, concentrating,
understanding, following instructions, and getting along with
others. The Field Office interviewer spoke with plaintiff by
telephone and noted that she did not appear to have any
difficulty comprehending or understanding and did not seem to
be in pain or struggling for breath. (Tr. 179).
testified at the September 2015 hearing that she experienced
pain in the mid-to-low back and found it difficult to remain
seated for long periods of time without rocking or shifting
in her seat. (Tr. 53, 56). In addition, she had swelling on
the left side of her back and pressure on her sciatic nerve
which caused shooting pains in her legs. (Tr. 54). She had
previously been treated with injections, but they were no
longer effective and she had switched to radio frequency
denervation treatments. She also took muscle relaxers to
address spasms. (Tr. 54-55). She had to take her medications
at different times of day in order to reduce
sluggishness. With respect to her mental conditions,
plaintiff testified that she experienced anxiety and racing
thoughts and had sudden crying spells and angry outbursts.
(Tr. 56-58). In addition, depression and pain impaired her
ability to concentrate. For example, she tended not to
complete tasks before moving on to new ones or to leave home
without her grocery list. (Tr. 59-60).
testified her migraine headaches began when she was twelve
years old. (Tr. 60). She recently started taking Gabapentin
which reduced their intensity and duration. Even so, she had
headaches two or three times each week, during which she had
to lie down. (Tr. 60-61). In June 2015, she went to the
hospital after experiencing numbness on the left side of her
body. (Tr. 51). She was told that the numbness was the result
of a migraine. (Tr. 61). She was frightened by the
possibility of this happening while she was driving and so
she no longer drive when she had a headache. (Tr. 61).
Plaintiff estimated that she had four or five “bad
days” every week.
June 2012 and March 2016, plaintiff received extensive
medical treatment for chronic back pain, asthma, and
depression and anxiety, in addition to counseling and
community support services to address ongoing psychosocial
stressors. In this action, however, plaintiff
addresses only those portions of the medical record
addressing her treatment for migraine headaches.
7, 2013, primary care physician Seema Iyer, M.D., noted that
plaintiff had migraine headaches without aura, of moderate
severity, with diffuse pain, nausea, and sensitivity to light
and sound. She stated that the headaches had begun a few
weeks earlier and were of variable frequency. (Tr. 703-07).
Plaintiff was prescribed Maxalt,  to be taken as needed. No.
change in the condition was noted at the next office visit in
July 2013. (Tr. 713-17). In August 2013, plaintiff began
treatment of her back pain with pain specialist Suresh
Krishnan, M.D., who noted that plaintiff complained of
headaches. (Tr. 454-58). In September 2013, plaintiff told
psychiatrist Muhammad Arain, M.D., that Maxalt provided
relief for her headaches. (Tr. 472). On two occasions in
November 2013, plaintiff told pain relief specialist Suresh
Krishnan, M.D., that she had continuous headaches with sharp
pain that was worsened by activity. (Tr. 535, 548).
Medication provided 70% relief. (Tr. 535).
April 9, 2014, plaintiff told Crider Health Center community
support specialist Krishawn Williams, M.Ed., that she was
“having headaches again, ” possibly caused by
stress.(Tr. 1006). She intended to make an
appointment for a cortisone shot to address the headaches. On
June 11, 2014, plaintiff's primary care provider noted
that plaintiff's migraines were “currently resolved
with Dr. trigger point injections, ” and on August 28,
2014, pain specialist Dr. Krishnan noted that plaintiff
denied having headaches. (Tr. 755, 671). In September 2014,
plaintiff reported to Dr. Krishnan that she had occasional
“sharp pains” in the parietal region of her head.
(Tr. 665). By October 2014, they appeared to be resolved,
(see Tr. 660-64), and plaintiff did not complain of
headaches again until February 26, 2015. (Tr. 656). In
April and May 2015, Dr. Krishnan noted that plaintiff
reported having headaches, (Tr. 650-54, 646-49), however, she
was undergoing treatment for sinusitis with facial pressure
and headaches during this time frame. (Tr. 781-85, 820-22).
15, 2015, plaintiff was admitted to St. Joseph's Hospital
for evaluation of numbness in her left arm and the left side
of her face. (Tr. 571-75). An MRI of the brain indicated a
possible Chiari 1 malformation and papilledema. (Tr. 796).
Neurologist Gary Gualberto, M.D., opined that the Chiari 1
malformation was probably not symptomatic and that
plaintiff's presenting symptoms were caused by a
complicated migraine. (Tr. 797). He prescribed Gabapentin and
directed plaintiff to avoid caffeine and nicotine, keep a
headache journal, and complete 40 minutes of aerobic exercise
three times a week. (Tr. 797). In July 2015, plaintiff told
her primary care physician that she had experienced another
episode of tingling in the left side of her face that lasted
for about 10 to 20 minutes, followed by a slight headache.
(Tr. 1074). In August 2015, Dr. Gualberto noted that
plaintiff's numbness had resolved. (Tr. 811). Plaintiff
told him that she “sometimes” had mild, dull
headaches in the late evening but that she did not get severe
headaches as she had in the past. (Tr. 807). This is
consistent with reports she made to community support
specialist Kayla Burton and pain specialist Dr. Krishnan.
(Tr. 893; 863).
treatment notes do not contain any further mention of
headaches until November 2015, when plaintiff was diagnosed
with sinusitis, accompanied by coughing and headaches. (Tr.
December 20, 2013, State agency consultant Elissa Lewis,
Ph.D., completed a Psychiatric Review Technique form based on
a review of the record. (Tr. 99-102). Dr. Lewis concluded
that plaintiff had medically determinable impairments in the
categories of 12.04 (affective disorders) and 12.06
(anxiety-related disorders). Dr. Lewis found that plaintiff
had no restriction in the activities of daily living and had
mild difficulties in maintaining social functioning and
maintaining concentration, persistence and pace. She had no
repeated episodes of decompensation of extended duration. The
ALJ gave limited weight to Dr. Lewis's opinion. (Tr. 37).
Single Decision Maker Holly Abbey completed a Physical
Residual Functional Capacity Assessment. (Tr. 101-04). She
determined that plaintiff could lift or carry up to 20 pounds
occasionally and 10 pounds frequently, stand and/or walk for
6 hours in an ...