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McRoberts v. Berryhill

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

May 23, 2018

GRACE E. McROBERTS, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration, Defendant.



         This 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).

         I. Procedural History

         On 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.[1] 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).

         Plaintiff 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.

         II. Evidence Before the ALJ

         A. Disability and Function Reports and Hearing Testimony

         Plaintiff 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).

         Plaintiff 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).

         Plaintiff 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).

         Plaintiff 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.[2] 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).

         Plaintiff 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.

         B. Medical Evidence

         1. Treatment records

         Between 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.[3] In this action, however, plaintiff addresses only those portions of the medical record addressing her treatment for migraine headaches.

         On June 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.[4] (Tr. 703-07). Plaintiff was prescribed Maxalt, [5] 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).

         On 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.[6](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.[7] (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).

         On June 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[8] and papilledema.[9] (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).

         The 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. 1093, 1099).

         2. Opinion evidence

         On 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 ...

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