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Goolsby v. Berryhill

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

March 25, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This matter is before the Court on Jonathan L. Goolsby's appeal regarding the denial of disability insurance benefits under the Social Security Act. Goolsby alleges disability due to bipolar disorder, mood disorder, and seizures. (Tr. 177.) The Court has jurisdiction over the subject matter of this action under 42 U.S.C. § 405(g). The parties have consented to the exercise of authority by the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). [Doc. 9.] The Court has reviewed the parties' briefs and the entire administrative record, including the transcript and medical evidence. Based on the following, the Court will reverse and remand the Commissioner's decision.

         Standard of Review

          The Social Security Act defines disability as an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

         The Social Security Administration (“SSA”) uses a five-step analysis to determine whether a claimant seeking disability benefits is in fact disabled. 20 C.F.R. § 404.1520(a)(1). First, the claimant must not be engaged in substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). Second, the claimant must establish that he or she has an impairment or combination of impairments that significantly limits his or her ability to perform basic work activities and meets the durational requirements of the Act. 20 C.F.R. § 404.1520(a)(4)(ii). Third, the claimant must establish that his or her impairment meets or equals an impairment listed in the appendix of the applicable regulations. 20 C.F.R. § 404.1520(a)(4)(iii). If the claimant's impairments do not meet or equal a listed impairment, the SSA determines the claimant's RFC to perform past relevant work. 20 C.F.R. § 404.1520(e).

         Fourth, the claimant must establish that the impairment prevents him or her from doing past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant meets this burden, the analysis proceeds to step five. At step five, the burden shifts to the Commissioner to establish the claimant maintains the RFC to perform a significant number of jobs in the national economy. Singh v. Apfel, 222 F.3d 448, 451 (8th Cir. 2000). If the claimant satisfied all of the criteria under the five-step evaluation, the ALJ will find the claimant to be disabled. 20 C.F.R. § 404.1520(a)(4)(v).

         The standard of review is narrow. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001). This Court reviews the decision of the ALJ to determine whether the decision is supported by substantial evidence in the record as a whole. 42 U.S.C. § 405(g). Substantial evidence is less than a preponderance, but enough that a reasonable mind would find adequate support for the ALJ's decision. Smith v. Shalala, 31 F.3d 715, 717 (8th Cir. 1994). The Court determines whether evidence is substantial by considering evidence that detracts from the Commissioner's decision as well as evidence that supports it. Cox v. Barnhart, 471 F.3d 902, 906 (8th Cir. 2006). The Court may not reverse just because substantial evidence exists that would support a contrary outcome or because the Court would have decided the case differently. Id. If, after reviewing the record as a whole, the Court finds it possible to draw two inconsistent positions from the evidence and one of those positions represents the Commissioner's finding, the Commissioner's decision must be affirmed. Masterson v. Barnhart, 363 F.3d 731, 736 (8th Cir. 2004). The Court must affirm the Commissioner's decision so long as it conforms to the law and is supported by substantial evidence on the record as a whole. Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 729 (8th Cir. 2003).


         Goolsby presents three issues for review. First, he states that the administrative law judge (ALJ) improperly gave weight to a medical evaluation that was not in evidence. Second, Goolsby states that the ALJ failed to properly evaluate opinion evidence by failing to give controlling weight to his treating psychiatrist's medical opinion and giving no weight to his counselor's opinion. Third, Goolsby states the ALJ did not properly consider his residual functional capacity (RFC). The Commissioner contends that the ALJ's decision is supported by substantial evidence in the record as a whole and should be affirmed.

         Consideration of Medical Opinion not in Evidence

         First, Goolsby contends that the ALJ committed reversible error by referencing a 2011 consultative examination from licensed psychologist Joseph W. Monolo. Goolsby began receiving disability insurance benefits and supplemental security income in September 2003. (Tr. 20.) Those benefits were discontinued on June 30, 2011. (Tr. 20.) Goolsby did not appeal the termination of benefits. (Tr. 20.) Goolsby filed the current application for disability insurance benefits on March 24, 2014. (Tr. 152-58.) Goolsby alleges an onset date of disability of August 28, 2013. In the ALJ's decision in this case, the ALJ wrote a lengthy two paragraph summary of Manolo's 2011 consultative psychological examination from the previous case and referenced it in another area of his opinion. (Tr. 25, 27.) The ALJ did not provide any citation for Monolo's examination in his opinion and did not include the examination in the List of Exhibits attached to his opinion[1]. (Tr. 25, 27, 33-35.)

         Goolsby contends that the ALJ's inclusion and consideration of medical records outside of the disability time period constitutes reversible error. Goolsby notes that the ALJ gave weight to this opinion and relied upon it to support the decision to deny benefits. The Commissioner states that the ALJ did not rely on the opinion and merely referenced it for background information, because the medical record in this case is sparse. The Commissioner also states that regardless of the ALJ's discussion of Monolo's consultative examination, the final decision is supported by substantial evidence.

         Social Security regulations require the ALJ to develop the claimant's complete medical history for at least the 12 months preceding the month in which the claimant's application was filed. 20 C.F.R. § 404.1512. The ALJ may consider evidence outside the alleged period of disability. “Evidence from outside the insured period can be used in helping to elucidate a medical condition during the time for which benefits may be rewarded.” Cox v. Barnhart, 471 F.3d 902, 907 (8th Cir. 2006). For example, previous medical records may demonstrate the progression of a claimant's medical condition. In the ALJ's discussion of Monolo's examination, he writes that Monolo “did not observe the severity of mental health symptoms that are commonly disabling.” (Tr. 27.) He also wrote “When Joseph Monolo examined the claimant in 2011, he observed no indication of thought disorder or attention problems and that he claimant had intact concentration and persistence and was able to understand, remember, and carry out instructions.” (Tr. 25.) The ALJ's discussion of a medical examination not in the record and outside of the time period at issue is problematic, because it is unclear whether this evidence influenced the ALJ's decision making. The ALJ does not explain why this record is referenced. The Commissioner speculates that the ALJ used Monolo's examination to provide background information regarding Goolsby's claim. However, there is no support for that assumption in the record. Nevertheless, the ALJ's reference to this examination is not reversible error unless it affected the outcome of the ALJ's decision. Because the ALJ leaves the inclusion of this evidence open to speculation, the Court will review whether the ALJ's decision exclusive of Manolo's examination is supported by substantial evidence in the record as a whole.

         Medical Opinion Evidence of Dr. Jenifer Shashek

         Next, Goolsby contends that the ALJ improperly discounted the weight of his treating physician's opinion. “Medical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of a claimant's impairments, including symptoms, diagnosis and prognosis, and what the claimant can still do despite her impairments and her physical or mental restrictions.” 20 C.F.R. § 404.1527(a)(2)[2]. All medical opinions, whether by treating or consultative examiners are weighed based on (1) whether the provider examined the claimant; (2) whether the provider is a treating source; (3) length of treatment relationship and frequency of examination, including nature and extent of the treatment relationship; (4) supportability of opinion with medical signs, laboratory findings, and explanation; (5) consistency with the record as a whole; (6) specialization; and (7) other factors which tend to support or contradict the opinion. 20 C.F.R. § 404.1527(c). Generally, a treating physician's opinion is given controlling weight, but is not inherently entitled to it. Hacker v. Barnhart, 459 F.3d 934, 937 (8th Cir. 2006). A treating physician's opinion “does not automatically control or obviate the need to evaluate the record as a whole.” Leckenby v. Astrue, 487 F.3d 626, 632 (8th Cir. 2007). A treating physician's opinion will be given controlling weight if the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the ...

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