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Jones v. Berryhill

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

April 15, 2019

SALLY A. JONES, Plaintiff,
v.
NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration, Defendant.

          MEMORANDUM AND ORDER

          PATRICIA L. COHEN UNITED STATES MAGISTRATE JUDGE.

         Plaintiff Sally Jones seeks review of the decision of the Social Security Administration (SSA) denying her applications for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act.[1] The Court has reviewed the parties' briefs and the administrative record, including the hearing transcript and medical evidence. For the reasons set forth below, the case is reversed and remanded.

         I. Background and Procedural History

         Plaintiff, who was then forty-five years old, filed applications for Disability Insurance Benefits and Supplemental Security Income in June 2015, alleging she was disabled as of March 15, 2007.[2] (Tr. 15) The SSA denied Plaintiff's applications, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 133, 145-46)

         The SSA granted Plaintiff's request for review, and an ALJ conducted a hearing in January 2016. (Tr. 161) In a decision dated June 25, 2017, the ALJ determined that Plaintiff “has not been under a disability, as defined in the Social Security Act from March 15, 2007, through the date of this decision[.] (Tr. 25).

         In her decision, the ALJ applied the five-step evaluation set forth in 20 C.F.R. §§ 404.1520, 416.920 and determined that Plaintiff had the severe impairments of: “degenerative disc disease with mild spondylosis that is slightly eccentric with the right greater than the left at ¶ 4-L5 and L5-S1, obesity, chronic obstructive pulmonary disease (COPD), and major depressive disorder.” (Tr. 17) Additionally, the ALJ found that Plaintiff had the non-severe impairments of diabetes mellitus, gastro esophageal reflux disease (GERD), and hypertension. (Tr. 18)

         After reviewing the record, the ALJ determined that Plaintiff had the residual functioning capacity (RFC) to:

Perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except that she can never climb ladders, ropes or scaffolds; can occasionally climb ramps or stairs; and she can occasionally stoop, kneel, crouch and crawl. She must avoid concentrated exposure to excessive vibration, pulmonary irritants such as fumes, odors, dust and gases, extreme cold, extreme heat, moving factory-type machinery and unprotected heights. She can perform work limited to simple repetitive tasks. She can have occasional contact with the public, co-workers and supervisors.

(Tr. 20) Finally, the ALJ concluded: “Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform.” (Tr. 24)

         Plaintiff requested review of the ALJ's decision with the SSA Appeals Council, which denied review in January 2018. (Tr. 1) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         With respect to the medical records and other evidence of record, the Court adopts Plaintiff's recitation of facts set forth in her Statement of Material Facts [ECF No. 22-1], to the extent admitted by Defendant [ECF No. 28-1]. The Court also adopts the additional facts set forth in Defendant's Statement of Additional Facts [ECF No. 28-2] and notes that Plaintiff did not refute them. Together, these statements provide a fair and accurate description of the relevant record before the Court. The Court will address specific facts related to the issues raised by Plaintiff as needed in the discussion below.

         II. Standards for Determining Disability Under the Act

         Eligibility for disability benefits under the Act requires a claimant to demonstrate that he or she suffers from a physical or mental disability. 42 U.S.C. § 423(a)(1). The Act defines disability as “the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period not less than 12 months.” 20 C.F.R. §§ 404.1505(a), 416.905(a). The impairment must be “of such severity that [the claimant] is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy ....” 42 U.S.C. § 1382c(a)(3)(B).

         To determine whether a claimant is disabled, the Commissioner engages in a five-step evaluation process. See 20 C.F.R. §§ 404.1520, 416.920. Those steps require a claimant to show that he or she: (1) is not engaged in substantial gainful activity; (2) has a severe impairment or combination of impairments which significantly limits his or her physical or mental ability to do basic work activities or (3) has an impairment which meets or exceeds one of the impairments listed in 20 C.F.R., Subpart P, Appendix 1; (4) is unable to return to his or her past relevant work; and (5) the impairments prevent him or her from doing any other work. Id.

         III. Discussion

         Plaintiff claims substantial evidence does not support the ALJ's decision because the ALJ failed to: (1) properly evaluate and provide “good reasons” for discrediting the opinion of Plaintiff's treating physician; and (2) find that Plaintiff's borderline intellectual functioning was a severe impairment. [ECF No. 22] Defendant counters that: (1) substantial evidence supported the ALJ's evaluation of Plaintiff's subjective complaints, including her evaluation of the medical opinion evidence; and (2) the failure to find Plaintiff's borderline intellectual functioning was a severe impairment did not constitute reversible error.

         A. Standard of Judicial Review

         A court must affirm an ALJ's decision if it is supported by substantial evidence. 42 U.S.C. § 405(g). “Substantial evidence ‘is less than a preponderance, but enough so that a reasonable mind might find it adequate to support the conclusion.'” Cruze v. Chater, 85 F.3d 1320, 1323 (8th Cir. 1996) (quoting Boerst v. Shalala, 2 F.3d 249, 250 (8th Cir. 1993)). In determining whether the evidence is substantial, a court considers evidence that both supports and detracts from the Commissioner's decision. Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th Cir. 2009). However, a court “do[es] not reweigh the evidence presented to the ALJ and [it] defer[s] to the ALJ's determinations regarding the credibility of testimony, as long as those determinations are supported by good reason and substantial evidence.” Renstrom v. Astrue, 680 F.3d 1057, 1064 (8th Cir. 2012) (quoting Gonzales v. Barnhart, 465 F.3d 890, 894 (8th Cir. 2006)).

         B. Treating physician

         Plaintiff contends the ALJ's RFC determination is not supported by substantial evidence because the ALJ improperly discredited the medical opinion of Plaintiff's primary care physician, Dr. Heather Gessling. [ECF No. 22] More specifically, Plaintiff argues that the ALJ did not provide “good reasons” for discrediting Dr. Gessling's medical source statement (MSS) because the ALJ cited only one treatment note and appeared to disregard the treatment notes of Plaintiff's pain management physician, Dr. Miranda Reed. In response, Defendant asserts that the ALJ properly cited Dr. Gessling's most recent treatment note and discussed other evidence in the record that conflicted with Dr. Gessling's MSS.

         “A treating physician's opinion regarding an applicant's impairment will be granted controlling weight, provided the opinion is well supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the record.”[3] Hamilton v. Astrue, 518 F.3d 607, 610 (8th Cir. 2008) (quoting Singh v. Apfel, 222 F.3d 448, 452 (8th Cir. 2000)). “The ALJ may discount or disregard such an opinion if other medical assessments are supported by superior medical evidence, or if the treating physician has offered inconsistent opinions.” Id. (quoting Hogan v. Apfel, 239 F.3d 958, 961 (8th Cir. 2001)). See also Prosch v. Apfel, 201 F.3d 1010, 1013 (8th Cir. 2000).

         “Whether the ALJ gives the opinion of a treating physician great or little weight, the ALJ must give good reasons for doing so.” Walker v. Comm'r, 911 F.3d 551, 553 (8th Cir. 2018) (quoting Reece v. Colvin, 834 F.3d 904, 909 (8th Cir. 2016)). ‚ÄúThis requires the ALJ to explain in his written decision, with some specificity, why he has rejected the treating physician's ...


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