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Shields v. Saul

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

September 5, 2019

ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff 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.

         Procedural History

         On May 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.[2] 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).

         In this 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.

         For the reasons that follow, I will remand the matter to the Commissioner for further proceedings.

         Medical Records and Other Evidence Before the ALJ

         In 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.

         Shields 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.

         Throughout 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.

         The ALJ denied Shields' applications for benefits on August 11, 2017.

         With 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' arguments.


         A. Legal Standard

         To be 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), 1382c(a)(3)(B).

         The 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.

         The 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).

         I must 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).

         I must 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.

         B. The ALJ's Decision

         The ALJ 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.)[3] 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 the public.

(Tr. 24.)

         The ALJ 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.)

         C. Opinion Evidence re Mental Impairments

         The 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 determinations.

         In her 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. ...

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