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Western v. Saul

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

September 6, 2019

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



         This action is before this Court for judicial review of the final decision of the Commissioner of Social Security finding that Plaintiff Ronda Western was not disabled, and thus not entitled to disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434, or supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381-1383f. For the reasons set forth below, the decision of the Commissioner will be affirmed.


         The Court adopts the statement of facts set forth in Plaintiff's Statement of Uncontroverted Facts (ECF No. 13-1) and Defendant's Statement of Additional Facts (ECF No. 22-2).[2] Together, these statements provide a fair description of the record before the Court. Specific facts will be discussed as needed to address the parties' arguments.

         Plaintiff, who was born on April 9, 1966, originally filed an application for disability insurance benefits on April 8, 2013, alleging a disability beginning March 16, 2013, due to fibromyalgia, depression, anxiety, and post-traumatic stress disorder (PTSD). Her application was denied at the administrative level, and she thereafter requested a hearing before an Administrative Law Judge (ALJ). On October 21, 2014, the ALJ heard testimony from Plaintiff, who was represented by counsel, and from a vocational expert (VE). On December 10, 2014, the ALJ issued a decision finding that Plaintiff had the residual functional capacity (RFC) to perform certain jobs that exist in significant numbers in the national economy and was thus not disabled under the Act. Upon judicial review, this Court remanded the case for further consideration and development of the record with respect to opinions of Plaintiff's treating physician, Dr. Jones. Western v. Berryhill, 1:16-CV-00048 JAR, 2017 WL 1407118, at *1 (E.D. Mo. Apr. 20, 2017).

         The Appeals Council consolidated that case with Plaintiff's parallel SSI case and sent the consolidated case back to the ALJ for a supplemental hearing, which was held December 12, 2017. By decision dated April 16, 2018, the ALJ found that Plaintiff had the RFC to perform light work as defined by the Commissioner's regulations, except for the following limitations:

She can occasionally climb ramps and stairs, but never climb ladders, ropes, or scaffolds. She can occasionally balance, stoop, kneel, crouch, and crawl. She can tolerate occasional exposure to extreme cold and extreme heat; however, she should avoid all hazards, including use of moving machinery and exposure to unprotected heights. Secondary to symptoms of fatigue and mental impairments, she is able to understand, remember, and carry out simple, routine and repetitive tasks in a work environment free of fast paced production requirements, involving only simple work-related decisions, with few if any workplace changes. She can tolerate no interaction with the public, but she may have frequent interaction with co-workers and supervisors. Tr. 787.

         The ALJ next found that Plaintiff could perform certain light unskilled jobs listed in the Dictionary of Occupational Titles (DOT) (e.g., router, copy machine operator, collator operator), which the VE had testified a hypothetical person with Plaintiff's RFC and vocational factors (age, education, work experience) could perform and that were available in significant numbers in the national economy. Accordingly, the ALJ found that Plaintiff was not disabled under the Act.[3]

         Plaintiff argues that the ALJ's decision is not supported by substantial evidence on the whole record because the ALJ failed to allocate the proper amount of weight to certain aspects of the evidence, as further discussed below.

         The ALJ's Decision (Tr. 781-796)

         The ALJ found that Plaintiff has the following severe impairments: fibromyalgia, depressive disorder, anxiety disorder with panic attacks, PTSD, and insomnia. However, he found that none of these impairments, alone or in combination, met or medically equaled the severity of impairments listed in the Commissioner's regulations.[4]

         In applying “paragraph B” criteria, the ALJ found that Plaintiff had only moderate limitations in understanding, remembering, or applying information, in interacting with others, in concentrating, persisting, or maintaining pace, or in adapting or managing herself. As such, the ALJ found that the paragraph B criteria were not satisfied.

         In applying “paragraph C” criteria, the ALJ found that, despite Plaintiff's mental health issues, there was no evidence of marginal adjustment in that Plaintiff had not been hospitalized for psychiatric reasons and was able to adapt to her medical treatment schedule and appeared appropriately dressed and groomed at all appointments.

         In determining Plaintiff's RFC and limitations, the ALJ reviewed the following evidence.

         Plaintiff testified that she lived alone and could drive except when her fibromyalgia required extra medication, which was about once a month. She could not drive on the medication. She took Klonopin, Hydrocodone, and Cymbalta. She had insomnia and took medication to help her sleep. She could stand for 30 minutes, walk and sit for 30-45 minutes, and lift 5 pounds. She saw a therapist every two weeks. She spent her days watching television and sleeping. She could dress and bathe and do light housework. She did not have any social activities. She got headaches when stressed or anxious.

         Plaintiff submitted function reports indicating that she had difficulty getting out of bed due to stiffness. She cried and had panic attacks. She was depressed. She had difficulty bathing and dressing due to pain. She hired help to do housework. She could shop and manage her money. She saw family and friends monthly. She had trouble getting along with others. She had difficulty with physical movement and with memory and concentration. She could not lift more than 10 to 15 pounds. She could follow instructions. She felt overwhelmed and could not work.

         The ALJ found that, although Plaintiff's impairments could reasonably be expected to cause her symptoms, Plaintiff's statements concerning the intensity, persistence, and limiting effects of her symptoms were not entirely consistent with the medical evidence and other evidence in the record.

         The ALJ noted that Plaintiff's treatment for fibromyalgia, depression, and anxiety was conservative and routine. In April 2013, Plaintiff underwent a psychiatric evaluation with Dr. Caruso, revealing severe childhood trauma for which Plaintiff had never received therapy. Although she had difficulty coping, Plaintiff was cooperative and fully oriented, she had good hygiene, and she had logical and linear thought. She had a Global Assessment of Functioning (GAF) of 65, indicating mild symptoms. She was prescribed Klonopin and Cymbalta. Plaintiff received follow-up counseling therapy with Shari Boxdorfer in April through June of 2013. Tr. 649-659. At that time, she had a GAF of 55, indicating moderate symptoms. She was prescribed Abilify and Ambien. She continued therapy roughly every two weeks in 2013 and monthly 2014, continuing to struggle with depression but maintaining GAF scores in the moderate range. The ALJ noted that Plaintiff's treatment remained unremarkable in 2014 insofar as Plaintiff's fibromyalgia, depression, and insomnia were managed with medication.

         Plaintiff underwent a consultative medical examination by Dr. Barry Burchett in November 2014. Tr. 748-760. Plaintiff reported pain, fatigue, and stress urinary incontinence. She had normal gait, a stable appearance, full orientation, and a good memory. She had a full range of motion in her hands, with a grip strength of 4/5. She exhibited 16 of 18 fibromyalgia trigger points and 9 of 10 random control points. She had a full range of motion in her extremities, no tenderness in the spine, and normal sensation throughout. She could stand on one leg and walk unassisted. Dr. Burchett diagnosed Plaintiff with possible fibromyalgia and stress urinary incontinence. Dr. Burchett opined that Plaintiff could lift and carry 10 pounds, sit for 2 hours at a time and 8 hours in a day, stand or walk for 1 hour at a time and 3 hours in a day, reach, push, pull, and operate foot controls. She could never climb ladders, kneel, crouch, or crawl but could occasionally climb stairs and stoop and have exposure to environmental conditions. The ALJ assigned little weight to Dr. Burchett's opinion because he only examined Plaintiff once and because his opinion limiting Plaintiff to sedentary work contradicted Dr. Burchett's own examination findings and also did not correlate with her medical records, which showed good range of motion, strength and sensation, and only routine treatment with medication.

         The ALJ noted that Plaintiff's treatment notes were routine throughout 2015 to 2017. She regularly refilled her medications for pain and insomnia. She reported increased pain in 2017, but her physical examinations remained unchanged. As such, the ALJ found that the medical evidence was not consistent with, and did not support, Plaintiff's subjective complaints. While acknowledging that fibromyalgia is inherently subjective, the ALJ found it noteworthy that Plaintiff tested positive for 9 of 10 controls, indicating that her symptoms were not fully reliable. He further noted that examinations of Plaintiff's hands and spine were consistently normal. Additionally, the ALJ reasoned that Plaintiff's complaints were belied by the fact that ...

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