United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
CATHERINE D. PERRY UNITED STATES DISTRICT JUDGE.
Philana Shields brings this action under 42 U.S.C.
§§ 405 and 1383 seeking judicial review of the
Commissioner's final decision denying her claims for
disability insurance benefits (DIB) under Title II of the
Social Security Act, 42 U.S.C. §§ 401, et
seq., and for supplemental security income (SSI) under
Title XVI of the Act, 42 U.S.C. §§ 1381, et
seq. Because the Commissioner's final decision is
not supported by substantial evidence on the record as a
whole, I will reverse the decision and remand the matter to
the Commissioner for further proceedings.
18, 2015, the Social Security Administration denied
Shields' October 2014 applications for DIB and SSI, in
which she claimed she became disabled on September 1, 2013,
because of pace maker, asthma, spinal arthritis, cervical
cancer, numbness in arms and hands, depression,
dizziness/passing out, and anemia. A hearing was held before an
administrative law judge (ALJ) on May 24, 2017, at which
Shields and a vocational expert testified. On August 11,
2017, the ALJ denied Shields' claims for benefits,
finding the vocational expert's testimony to support a
finding that Shields could perform work that exists in
significant numbers in the national economy. On May 7, 2018,
the Appeals Council denied Shields' request for review of
the ALJ's decision. The ALJ's decision is thus the
final decision of the Commissioner. 42 U.S.C. § 405(g).
action for judicial review, Shields claims that the ALJ's
decision is not supported by substantial evidence on the
record as a whole, arguing that the ALJ improperly evaluated
the opinion evidence of record regarding her mental
impairments and improperly engaged in her own medical
conjecture in reviewing this evidence. Shields asks that I
reverse the ALJ's decision and either award benefits or
remand for further proceedings.
reasons that follow, I will remand the matter to the
Commissioner for further proceedings.
Records and Other Evidence Before the ALJ
September 2012, Shields filed applications for DIB and SSI
alleging that she became disabled in June 2012 because of
asthma, third-degree heart block, headaches, and cervical
pain and leg pain resulting from a motor vehicle accident.
After a hearing, an ALJ denied Shields' claims for
benefits on February 28, 2014, and Shields did not pursue the
claims further. In October 2014, Shields filed new
applications for DIB and SSI, claiming disability as of
September 2013 because of, inter alia, cervical
cancer and depression.
underwent a radical hysterectomy in February 2015 to treat
her cervical cancer. At a follow up appointment after
surgery, Shields complained of having urinary problems, and
examination showed that her bladder was backfilled. She could
not void. She was later diagnosed with neurogenic bladder,
resulting in her having to self-catheterize every six hours.
Shields understood that this was a life-long condition. This
situation, as well as her cancer diagnosis and treatment,
exacerbated Shields' symptoms of depression -
e.g., poor sleep, feelings of helplessness and
hopelessness, thoughts of death, and crying spells - for
which she sought and began receiving regular psychiatric
treatment in May 2015. In June 2015, she began reporting that
she heard unidentified voices calling her name. In December
2015, she began reporting that, in addition to the ongoing
auditory hallucinations, she saw persons or shadows walking
around her house. She also felt that someone else's
thoughts were in her head. She was diagnosed with
schizophrenia at that time, and her medication regimen was
changed to treat the impairment.
2016 and into 2017, Shields continued to have auditory and
visual hallucinations, and her mental health care providers
noted no improvement with medication. In May 2017, Shields
was authorized to receive community support services from the
Community Psychiatric and Rehabilitation Center because of
her persistent and severe mental illness.
denied Shields' applications for benefits on August 11,
respect to additional medical records and other evidence of
record, I adopt Shields' recitation of facts set forth in
her Statement of Uncontroverted Facts (ECF 20) and note that
they are admitted in their entirety by the Commissioner (ECF
25-1). I also adopt the Commissioner's Statement of
Additional Facts (ECF 25-2), which Shields does not dispute.
These statements provide a fair and accurate description of
the relevant record before the Court. Additional specific
facts are discussed as needed to address the parties'
eligible for DIB and SSI under the Social Security Act,
Shields must prove that she is disabled. Pearsall v.
Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001);
Baker v. Secretary of Health & Human Servs., 955
F.2d 552, 555 (8th Cir. 1992). The Social Security Act
defines disability as the 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 which has lasted or can be
expected to last for a continuous period of not less than
twelve months.” 42 U.S.C. §§ 423(d)(1)(A),
1382c(a)(3)(A). An individual will be declared disabled
“only if [her] physical or mental impairment or
impairments are of such severity that [she] is not only
unable to do [her] previous work but cannot, considering
[her] age, education, and work experience, engage in any
other kind of substantial gainful work which exists in the
national economy.” 42 U.S.C. §§ 423(d)(2)(A),
Commissioner engages in a five-step evaluation process to
determine whether a claimant is disabled. See 20
C.F.R. §§ 404.1520, 416.920; Bowen v.
Yuckert, 482 U.S. 137, 140-42 (1987). The first three
steps involve a determination as to whether the claimant is
currently engaged in substantial gainful activity; whether
she has a severe impairment; and whether her severe
impairment(s) meets or medically equals the severity of a
listed impairment. At Step 4 of the process, the ALJ must
assess the claimant's RFC - that is, the most the
claimant is able to do despite her physical and mental
limitations, Martise v. Astrue, 641 F.3d 909, 923
(8th Cir. 2011) - and determine whether the claimant is able
to perform her past relevant work. Goff v. Barnhart,
421 F.3d 785, 790 (8th Cir. 2005) (RFC assessment occurs at
fourth step of process). If the claimant is unable to perform
her past work, the Commissioner continues to Step 5 and
determines whether the claimant can perform other work as it
exists in significant numbers in the national economy. If so,
the claimant is found not to be disabled, and disability
benefits are denied.
claimant bears the burden through Step 4 of the analysis. If
she meets this burden and shows that she is unable to perform
her past relevant work, the burden shifts to the Commissioner
at Step 5 to produce evidence demonstrating that the claimant
has the RFC to perform other jobs in the national economy
that exist in significant numbers and are consistent with her
impairments and vocational factors such as age, education,
and work experience. Phillips v. Astrue, 671 F.3d
699, 702 (8th Cir. 2012). If the claimant has nonexertional
limitations, including those caused by a severe mental
impairment, the Commissioner may satisfy his burden at Step 5
through the testimony of a vocational expert. King v.
Astrue, 564 F.3d 978, 980 (8th Cir. 2009).
affirm the Commissioner's decision if it is supported by
substantial evidence on the record as a whole. 42 U.S.C.
§ 405(g); Richardson v. Perales, 402 U.S. 389,
401 (1971); Jones v. Astrue, 619 F.3d 963, 968 (8th
Cir. 2010). Substantial evidence is less than a preponderance
but enough that a reasonable person would find it adequate to
support the conclusion. Jones, 619 F.3d at 968.
Determining whether there is substantial evidence requires
scrutinizing analysis. Coleman v. Astrue, 498 F.3d
767, 770 (8th Cir. 2007).
consider evidence that supports the Commissioner's
decision as well as any evidence that fairly detracts from
the decision. McNamara v. Astrue, 590 F.3d 607, 610
(8th Cir. 2010). If, after reviewing the entire record, it is
possible to draw two inconsistent positions and the
Commissioner has adopted one of those positions, I must
affirm the Commissioner's decision. Anderson v.
Astrue, 696 F.3d 790, 793 (8th Cir. 2012). I may not
reverse the Commissioner's decision merely because
substantial evidence could also support a contrary outcome.
McNamara, 590 F.3d at 610.
The ALJ's Decision
found that Shields met the requirements of the Social
Security Act through June 30, 2017, and that she had not
engaged in substantial gainful activity since September 1,
2013, the alleged onset date of disability; or since February
28, 2014, the date of the prior unfavorable decision. The ALJ
found that Shields' spinal arthritis, asthma, neurogenic
bladder, schizophrenia, depression, and anxiety were severe
impairments, but that these impairments did not meet or
medically equal a listed impairment in 20 C.F.R. Part 404,
Subpart P, Appendix 1. (Tr. 22-23.) The ALJ found that Shields
had the RFC to perform sedentary work except that she
cannot climb ladders, ropes or scaffolds. He [sic] can
occasionally climb ramps and stairs. He [sic] can engage in
frequent stooping, crouching, crawling and can frequently
engage in handling and fingering. The claimant cannot have
concentrated exposure to extreme heat/cold, dust, fumes, or
other pulmonary irritants. He [sic] is limited to performing
simple, routine tasks but not at a fast pace such as assembly
line. The claimant is limited to occasional interaction with
determined that Shields could not perform her past relevant
work as a nurse's aide. (Tr. 30.) Considering
Shields' RFC and her age, education, and work experience,
the ALJ found vocational expert testimony to support a
conclusion that Shields could perform work as it exists in
significant numbers in the national economy, and
specifically, as a document preparer, administrative support
worker, and final assembler-optical. The ALJ thus found that
Shields was not under a disability from February 28, 2014,
through the date of the decision. (Tr. 31.)
Opinion Evidence re Mental Impairments
record before the ALJ contained treatment notes and medical
source statements from Shields' three mental health care
providers who treated Shields beginning in May 2015. The
record also contained 1) a report from a consulting
psychologist, who conducted a consultative psychological
evaluation of Shields in April 2015 for disability
determinations; and 2) a psychiatric review technique form
(PRTF) completed May 13, 2015, by a state-agency,
non-examining psychological consultant with disability
written decision, the ALJ accorded some weight to the
opinions of the consulting psychologist and non-examining
psychologist. As to Shields' three treating mental health
care providers, PA Branum and Drs. Clarke and Owoso, the ALJ
accorded partial weight to Dr. Clarke's opinion, little
to partial weight to PA Branum's opinion, and little
weight to Dr. Owoso's opinion. ...