United States District Court, W.D. Missouri, St. Joseph Division
LISA D. LEEPER, Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.
ORDER AND OPINION REVERSING COMMISSIONER'S FINAL
DECISION DENYING BENEFITS AND REMANDING FOR FURTHER
D. SMITH, SENIOR JUDGE UNITED STATES DISTRICT COURT
is Plaintiff's appeal of the Commissioner of Social
Security's decision denying her application for a period
of disability and disability insurance benefits. For the
following reasons, the Commissioner's decision is
reversed, and the case is remanded for further proceedings.
agency psychological consultant, Dr. Elissa Lewis, provided
her opinion as to Plaintiff's mental limitations.
Regarding affective and anxiety-related disorders, Dr. Lewis
concluded Plaintiff has mild restrictions in daily living
activities, mild difficulties with social functioning, and
moderate difficult with maintaining concentration,
persistence, or pace. R. at 70. Regarding Plaintiff's
mental residual functional capacity (“RFC”), Dr.
Lewis opined Plaintiff is moderately limited in her ability
understand and remember detailed instructions; has sustained
concentration and persistence limitations; can understand,
remember, and carry out simple instructions; can interact
adequately with peers and supervisors; and can adapt to most
changes in a work setting. R. at 76-78.
concedes the Administrative Law Judge (“ALJ”) did
not mention Dr. Lewis's opinion in her decision denying
Plaintiff benefits. Doc. #17, at 18; R. at 11-20. In fact,
there is no reference to Dr. Lewis's opinion.
See R. at 11-20. Plaintiff claims it is reversible
error for the ALJ to fail to consider and weigh Dr.
Lewis's opinion. Doc. #12, at 17 n.3; 20 C.F.R. §
404.157. Defendant claims it is not reversible error,
although does not cite anything in support of this
proposition. Doc. #17, at 18. Instead, Defendant contends the
ALJ considered Dr. Lewis's opinion because the RFC mental
limitations mirror Dr. Lewis's opinion. Doc. #17, at 18.
The ALJ found Plaintiff had the following mental limitations:
The claimant retains the ability to understand and remember
simple instructions. She can carry out simple work
instructions. She can maintain adequate attendance and
sustain an ordinary routine without special supervision. The
claimant can interact adequately with peers and supervisors
in a work setting. She cannot work with the public. She can
adapt to most changes in a competitive work setting.
R. at 15.
Court notes no medical professional, other than Dr. Lewis,
provided an opinion as to Plaintiff's ability to
concentrate and persist. Dr. Lewis found Plaintiff had
“sustained” concentration and persistence
limitations. Although the ALJ found Plaintiff's ability
to concentrate, persist, and maintain pace was
“moderately limited, ” she determined the
“greater limitation is not warranted because
examinations routinely demonstrate no deficits of attention
or concentration.” R. at 14. The ALJ's
determination is contrary to Dr. Lewis's opinion about
Plaintiff's concentration and persistence limitations.
But the ALJ did not discuss or explain why she discounted Dr.
Lewis's opinion. Upon remand, the ALJ must consider Dr.
Lewis's opinion, afford weight to her opinion (or explain
why no weight was afforded to her opinion), and explain the
basis of the weight afforded to her opinion.
ALJ's RFC must be “supported by some medical
evidence of [Plaintiff's] ability to function in the
workplace.” Hensley v. Colvin, 829 f.3d 926,
932 (8th Cir. 2016) (citation omitted); see also McKinney
v. Apfel, 228 F.3d 860, 863 (8th Cir. 2000) (stating an
ALJ must base the RFC on “all of the relevant evidence,
including the medical records, observations of treating
physicians and others, and an individual's own
description of his limitations.”). As set forth
supra, paragraph 1, the mental RFC limitations are
not supported by medical evidence. Upon remand, the ALJ must
set forth mental limitations in the RFC that are supported by
some medical evidence and shall identify the medical evidence
supporting those limitations.
Although the ALJ found Plaintiff's has severe impairments
of anxiety and depression, she determined Plaintiff's
alleged symptoms from these impairments were “not
entirely consistent with the medical evidence and other
evidence in the record.” R. at 13, 18. However, it is
unclear what limitations, if any, Plaintiff's depression
and anxiety have on her ability to work. Upon remand, the ALJ
shall identify the limitations on Plaintiff's ability to
work that are caused by her depression and anxiety. If the
ALJ finds Plaintiff's depression and anxiety do not limit
her ability to work, the ALJ must explain the basis for that
support the physical limitations in the RFC, the ALJ placed
great weight on the opinion of Dr. David Marty. R. at 18. Dr.
Marty, however, did not evaluate limitations associated with
Plaintiff's severe impairments of osteoarthritis of the
right hand and obesity. R. at 72-76. The record does not
appear to contain any medical opinions as to limitations
associated with these severe impairments. Additionally, the
ALJ did not afford any weight to any other medical
professional's opinions as to her physical limitations.
a claimant for benefits has the burden of proving a
disability, the Secretary has the duty to develop the record
fully and fairly, even if…the claimant is represented
by counsel.” Boyd v. Sullivan, 960 F.2d 733,
736 (8th Cir. 1992); 20 C.F.R. § 416.919a(b). When the
medical records do not provide sufficient information to make
an informed decision, the ALJ may order a consultative
examination. Id. (citing 20 C.F.R. § 416.917).
“It is reversible error for an ALJ not to order a
consultative examination when such an evaluation is necessary
for him to make an informed decision.” Id.
(citations omitted). Here, the record does not provide
sufficient evidence to determine whether Plaintiff is
physically disabled. Thus, upon remand, the ALJ is ordered to
obtain a consultative examination to determine the extent of
Plaintiff's physical limitations. Upon receipt of the
consultative examination, the ALJ must re-evaluate
Plaintiff's credibility and reformulate the RFC.
her decision, the ALJ discussed a third-party function report
from Plaintiff's father but did not mention a third-party
function report provided by Plaintiff's spouse. R. at 18.
There is no indication in the ALJ's decision that she
considered the content of Plaintiff's spouse's
report. For example, he stated Plaintiff was unable to
complete household chores on her own and required help from
others. R. at 205-06. Yet, the ALJ found Plaintiff was able
to “complete household chores.” R. at 14, 18.
Also, Plaintiff's spouse reported Plaintiff had
difficulty using her hands and reaching, and experienced
weakness in her hands. ...