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Burris-Willis v. Berryhill

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

April 30, 2019

NANCY A. BERRYHILL, Deputy Commissioner Operations, Social Security Administration Defendant.



         Plaintiff Gay Burris-Willis seeks review of the decision by Defendant Nancy A. Berryhill, Deputy Commissioner of Operations, Social Security Administration, denying her applications for Disability Insurance Benefits under the Social Security Act.[1] For the reasons set forth below, the case is reversed and remanded.

         I. Background & Procedural History

         In October 2014, Plaintiff, then fifty years old, filed an application for Disability Insurance Benefits alleging that she was disabled as of September 10, 2014 due to: asthma, arthritis, De Quervain's tenosynovitis, depression, chronic bronchitis, chronic fatigue, constant pain, and stress. (Tr. 147, 152) The Social Security Administration (SSA) denied Plaintiff's claims, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 69-73; 74-76). The SSA granted Plaintiff's request for review and conducted a hearing on October 20, 2016, at which Plaintiff appeared and testified. (Tr. 30-54)

         In a decision dated March 17, 2017, the ALJ applied the five-step evaluation set forth in 20 C.F.R. Section 404.1520(a) and concluded that Plaintiff “has not been under a disability within the meaning of the Social Security Act from September 10, 2014, through the date of this decision.” (Tr. 17) Plaintiff timely filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review in November 2017. (Tr. 103-04, 1-6) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the Commissioner's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000) (citing 20 C.F.R. §§ 404.900(a) (4)-(5), 404.955, 404.981, and 422.210(a)).

         II. Evidence before the ALJ

         A. Testimony at the ALJ Hearing

         Plaintiff, who appeared at the hearing without counsel, testified that she was fifty-two years old and had completed one year of college. (Tr. 40) Plaintiff had previously worked as a home healthcare aide and as an administrative assistant for a correspondence school and the Census Bureau. (Tr. 41-42)

         Plaintiff testified that she stopped working because “when the COPD thing hit me it was like I could barely do anything.” (Tr. 42) In addition to COPD, Plaintiff's back problems, which included “a tear, ” “a pinched nerve, ” and “two bulging discs, ” and weakness and arthritis in her hands prevented her from working. (Tr. 42, 49) Plaintiff also believed she was depressed “because I haven't been able to work, ” but she was not receiving treatment. (Tr. 50)

         Plaintiff explained that she had difficulty completing household chores and required help from her daughters. (Tr. 43) Plaintiff was able to dress herself and take care of her personal hygiene, but her daughters helped her wash her hair. (Tr. 44-45) Plaintiff was unable to lift “heavier things like laundry” and “even sometimes…dishes.” (Tr. 45) Plaintiff testified that she needed help grocery shopping, particularly lifting items, such as milk or a pack of ground beef, into the cart. (Tr. 45-46) Plaintiff stated she was able to drive unless “I don't feel well or I'm taking medication[.]” (Tr. 41)

         The ALJ asked if Plaintiff could stoop, kneel, or pick something up from the floor. (Tr. 46) Plaintiff replied that “[i]t is challenging, but you know, I try working it out. I mean, even like walking is a chore.” (Tr. 46) She estimated that she could walk for one half of a block or stand fifteen to thirty minutes before needing to rest. (Tr. 48-49) Plaintiff also had difficulty sitting and needed to change positions often. (Tr. 48)

         Plaintiff's treatment for COPD included “three inhalers and the medicine for the nebulizer machine.” (Tr. 46) She testified that she was not taking any pain medication because “the doctor has refused to write a prescription” because “she don't like writing narcotic prescription[s].” (Tr. 47) Plaintiff took Aleve, which “work[ed]…somewhat for the pain, ” used heating pads, and occasionally took her husband's pain medications. (Tr. 48)

         A vocational expert also testified at the hearing regarding the work Plaintiff had performed in the last fifteen years. (Tr. 52-54) The vocational expert classified: home health attendant as a semi-skilled, medium-exertion job; fast food worker as an unskilled, medium-exertion job; and housekeeper as an unskilled, light-exertion job. (Tr. 52)

         B. Relevant Medical Evidence[2]

         In June 2013, Plaintiff injured her left wrist at work. (Tr. 261-63) Later that month, Dr. Strecker, a hand surgeon, diagnosed Plaintiff's with de Quervain's tenosynovitis. (Tr. 285) Dr. Strecker performed surgery in September 2013 and cleared Plaintiff for work in December 2013.[3] (Tr. 245, 247)

         On May 13, 2014, Plaintiff visited her primary care physician, Dr. Barbara Lutey, for treatment of her asthma and shortness of breath. (Tr. 301-08) Dr. Lutey referred Plaintiff to the pulmonology department for further evaluation. (Tr. 305) A subsequent Pulmonary Function Test (PFT) revealed “a mild obstructive ventilator defect, ” “significant improvement after the administration of aerosolized bronchodilator, ” and “air trapping.” (Tr. 322)

         Plaintiff followed up with Dr. Lutey in June 2014 to review the results of the PFT. (Tr. 394) In addition to her asthma symptoms, Plaintiff complained of coughing at night and chest tightness. (Tr. 394) Dr. Lutey noted that Plaintiff had not filled her Flovent prescription because of its cost. (Tr. 394) Dr. Lutey advised Plaintiff that “the most important thing to improve [her quality of life]” would be twice daily use of the Flovent inhaler. (Tr. 394) Dr. Lutey also encouraged Plaintiff to stop smoking, but noted that Plaintiff “has several barriers to quitting including stress[.]” (Tr. 394)

         Later in June 2014, Plaintiff presented to the emergency room with shortness of breath, chest pain, and a painful cough, which she rated as a severity of seven out of ten. (Tr. 363) The hospital's notes list Plaintiff's diagnoses as: asthma exacerbation, chest pain, hypokalemia, gastroesophageal reflux disease (GERD), osteoarthritis, generalized anxiety disorder, depression, and nicotine dependence. (Tr. 353-54) The emergency room physician noted moderate respiratory distress and bilateral wheezing, which was greater in her left lung. (Tr.365) The doctor treated Plaintiff for asthma exacerbation and discharged her the next day. (Tr. 368, 358- 62)

         Plaintiff returned to the emergency room in November 2014, complaining of shortness of breath and chest pain. (Tr. 422) On examination, the emergency room doctor found that Plaintiff had decreased breath and wheezing and he admitted her to the hospital for further evaluation and treatment. (Tr. 427, 429) A chest x-ray revealed no acute cardiopulmonary diseases. (Tr. 431) Two days later, a doctor diagnosed Plaintiff with COPD exacerbation, determined her condition had stabilized, and discharged her from the hospital. (Tr. 421, 424)

         In early December 2014, Plaintiff presented to the emergency room with bilateral leg and hip pain that prevented her from walking. (Tr. 441) A nurse practitioner examined Plaintiff and noted tenderness in her lower spine and a positive straight leg raise on the left at forty-five degrees. (Tr. 438-39) A doctor's examination found “tenderness in hip, knees, ” “pain with internal and external rotation, ” “tenderness to palpation on lumbar region; no back pain in ROS, only on exam.” (Tr. 443-44) An x-ray of Plaintiff's lumbar spine revealed a mild levoconvex curvature in her thoracic spine, mild disc space narrowing at ¶ 5-S1 without significant facet arthropathy, and no acute fracture. (Tr. 447-48) Hospital staff discharged Plaintiff the following day. (Tr. 437)

         Plaintiff followed up with Dr. Lutey a few days later to discuss her recent hospitalizations for asthma, COPD, and leg weakness. (Tr. 670-74) Plaintiff complained of continued pain that “is always in the hips and extends down to her legs, ” as well as “tingling and numbness extending down legs into feet.” (Tr. 670) Dr. Lutey opined that the “likely etiology seems to be ...

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