United States District Court, W.D. Missouri, Western Division
CAROLYN A. MARTINETTE, Plaintiff,
ACTING COMMISSIONER, SOCIAL SECURITY ADMINISTRATION; Defendant.
ROSEANN A. KETCHMARK, JUDGE
the Court is Plaintiff's appeal brought under 42 U.S.C.
§ 405(g) seeking review of Defendant Commissioner of
Social Security Administration's (“SSA”)
denial of disability benefits as rendered in a decision by an
Administrative Law Judge (“ALJ”). For the reasons
below, the decision of the ALJ is REMANDED.
Court's review of the ALJ's decision to deny
disability benefits is limited to determining if the decision
“complies with the relevant legal requirements and is
supported by substantial evidence in the record as a
whole.” Halverson v. Astrue, 600 F.3d 922, 929
(8th Cir. 2010) (quoting Ford v. Astrue, 518 F.3d
979, 981 (8th Cir. 2008)). “Substantial evidence is
less than a preponderance of the evidence, but is ‘such
relevant evidence as a reasonable mind would find adequate to
support the [ALJ's] conclusion.'” Grable v.
Colvin, 770 F.3d 1196, 1201 (8th Cir. 2014) (quoting
Davis v. Apfel, 239 F.3d 962, 966 (8th Cir. 2001)).
In determining whether existing evidence is substantial, the
Court takes into account “evidence that detracts from
the [ALJ's] decision as well as evidence that supports
it.” Cline v. Colvin, 771 F.3d 1098, 1102 (8th
Cir. 2014) (citation omitted). “If the ALJ's
decision is supported by substantial evidence, [the Court]
may not reverse even if substantial evidence would support
the opposite outcome or [the Court] would have decided
differently.” Smith v. Colvin, 756 F.3d 621,
625 (8th Cir. 2014) (citing Davis v. Apfel, 239 F.3d
962, 966 (8th Cir. 2001)). The Court does not “re-weigh
the evidence presented to the ALJ.” Guilliams v.
Barnhart, 393 F.3d 798, 801 (8th Cir. 2005) (citing
Baldwin v. Barnhart, 349 F.3d 549, 555 (8th Cir.
2003)). The Court must “defer heavily to the findings
and conclusions of the [ALJ].” Hurd v. Astrue,
621 F.3d 734, 738 (8th Cir. 2010) (citation omitted).
of overview, the ALJ determined that Plaintiff suffers from
the following severe impairments: degenerative disc disease
of the lumbar spine; asthma; hypertension; diabetes mellitus;
and insomnia. The ALJ also determined that Plaintiff has the
following non-severe impairments: rotator cuff impingement;
anxiety; and depression. However, the ALJ found that none of
Plaintiff's impairments, whether considered alone or in
combination, meet or medically equals the criteria of one of
the listed impairments in 20 CFR Pt. 404, Subpt. P, App. 1
(“Listing”). Additionally, the ALJ found that
despite her limitations, Plaintiff retained the residual
functional capacity (“RFC”) to lift, carry, push,
and pull ten pounds occasionally and less than ten pounds
frequently; stand/walk two hours in an eight-hour day; sit
six hours in an eight-hour day; never climb ladders, ropes or
scaffolds; occasionally climb ramps and stairs; occasionally
balance, stoop, kneel, crouch, and crawl; and must avoid more
than frequent exposure to extreme cold, extreme heat,
wetness, humidity, vibration, fumes, dusts, odors, gases,
poor ventilation, and other hazards such as machinery and
heights. Although the ALJ found that Plaintiff is unable to
perform any past relevant work, the ALJ determined that
considering Plaintiff's age, education, work experience,
and RFC, Plaintiff can perform jobs that exist in significant
numbers in the national economy.
brings the following arguments on appeal: (1) whether there
is substantial evidence to support the ALJ's RFC
determination as to Plaintiff's physical and mental
impairments, and (2) whether the ALJ erred at Step Four of
the sequential evaluation process.
has the responsibility to “develop the record fairly
and fully, independent of the claimant's burden to press
his case.” Cox v. Astrue, 495 F.3d 614, 618
(8th Cir. 2007) (citation omitted). The records are
sufficient as long as they describe the claimant's
“functional limitations with sufficient generalized
clarity to allow for an understanding of how those
limitations function in a work environment.”
Id. at 620 n. 6. Remand is only required where the
claimant “was prejudiced or treated unfairly by how the
ALJ did or did not develop the record[.]” Onstad v.
Shalala, 999 F.2d 1232, 1234 (8th Cir. 1993).
Plaintiff argues there was not substantial evidence in the
record to support the ALJ's RFC determination because
there is no medical opinion evidence in the record regarding
Plaintiff's physical limitations. Defendant does not
argue that there is medical evidence to support the RFC as to
physical limitations; however, Defendant argues there is
sufficient information in the record without a medical
opinion to support the RFC determination.
there is no medical opinion in the record concerning
Plaintiff's functional limitations stemming from her
severe physical impairments. “Because a claimant's
RFC is a medical question, an ALJ's assessment of it must
be supported by some medical evidence of the claimant's
ability to function in the workplace.” Cox,
495 F.3d at 619. An ALJ is “required to consider at
least some supporting evidence from a [medical]
professional.” Lauer v. Apfel, 245 F.3d 700,
704 (8th Cir. 2001). In Hustell v. Massanari, the
Eighth Circuit held that the ALJ's RFC assessment was not
supported by “some medical evidence” in the
record; therefore, remand was proper. 259 F.3d 707, 712 (8th
Cir. 2001). See also Lauer, 245 F.3d at 704 (the
court held some medical evidence “must support the
determination of the claimant's [RFC], and the ALJ should
obtain medical evidence that addresses the claimant's
ability to function in the workplace”); Ellis v.
Barnhart, 392 F.3d 988, 994 (8th Cir. 2005) (where there
is no medical evidence concerning a claimant's ability to
perform light work, the ALJ has a duty to develop the record
on this issue); Chatman v. Astrue, 2007 WL 5110319,
at *8 (E.D. Mo. Mar. 16, 2007) (because no medical evidence
existed to support the RFC attributed to the claimant, the
ALJ had the duty to order a consultative examination to fully
develop the record). On remand, the ALJ is directed to obtain
a consultative medical examination concerning Plaintiff's
severe physical limitations and the RFC determination.
Plaintiff argues the RFC assessment as to Plaintiff's
mental impairments is not supported by substantial evidence
because the ALJ did not include Plaintiff's mild mental
limitations in the RFC, nor explain their omission. The ALJ
determined that Plaintiff had mild limitations in
understanding, remembering, and applying information; mild
limitations in social interaction; mild limitations in
concentration, persistence, or pace; and mild limitations in
adapting and managing oneself. These limitations should have
been incorporated into the RFC determination or a reason
provided for their omission. On remand, the ALJ should either
incorporate these limitations into the RFC or provide
justification for their omission. See Clevenger v.
Colvin, 2016 WL 3911982, at *2 (W.D. Mo. July 15, 2016)
(reversing where the ALJ failed to include his own findings
on social limitations in the RFC determination and did not
explain why they were omitted). See also Ollila v.
Colvin, 2014 WL 7238128, at *3 (W.D. Mo. Dec. 17, 2014)
(the court reversed the decision of the ALJ where the ALJ
failed to include any limitations related to mild
difficulties maintaining social functioning); Richardson
v. Colvin, 2017 WL 6420283, at *2 (W.D. Mo. Dec. 18,
2017) (reversing where the ALJ failed to account for marked,
moderate, and other limitations).
Plaintiff argues the ALJ's RFC determination at Step Four
is not supported by substantial evidence. Because the
ALJ's decision is remanded prior to this step, the Court
need not address this argument.
carefully reviewed the record before the Court and the
parties' submissions on appeal, the Court concludes that
substantial evidence on the record as a whole supports the