United States District Court, E.D. Missouri, Northern Division
DONALD L. U., JR., Plaintiff,
ANDREW M. SAUL,  Commissioner of Social Social Security Administration, Defendant.
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE.
action is before the Court pursuant to the Social Security
Act, 42 U.S.C. §§ 401, et seq. (“the
Act”). The Act authorizes judicial review of the final
decision of the Social Security Administration denying
Plaintiff Donald U.'s (“Plaintiff”)
application for disability benefits under Title II of the
Social Security Act, see 42 U.S.C. §§ 401
et seq. and supplemental security income under Title
XVI, see 42 U.S.C. §§ 1381 et
seq. All matters are pending before the undersigned
United States Magistrate Judge with the consent of the
parties, pursuant to 28 U.S.C. § 636(c). Substantial
evidence supports the Commissioner's decision, and
therefore it is affirmed. See 42 U.S.C. §
22, 2015, Plaintiff filed applications for disability
benefits, arguing that his disability began on May 9, 2015,
as a result of diabetes, back injury, arthritis, right
shoulder pain, blockage in artery of left leg, and immobility
of hip. (Tr. 196, 269-75) On August 31, 2015, Plaintiff's
claims were denied upon initial consideration. (Tr. 196-99)
Plaintiff then requested a hearing before an Administrative
Law Judge (“ALJ”). Plaintiff appeared at the
hearing (with counsel) on February 14, 2017, and testified
concerning the nature of his disability, his functional
limitations, and his past work. (Tr. 143-65) The ALJ also
heard testimony from Dan Zumalt, a vocational expert
(“VE”). (Tr. 165-75, 383-87) The VE opined as to
Plaintiff's ability to perform his past relevant work and
to secure other work in the national economy, based upon
Plaintiff's functional limitations, age, and education.
(Id.) After taking Plaintiff's testimony,
considering the VE's testimony, and reviewing the rest of
the evidence of record, the ALJ issued a decision on July 19,
2017, finding that Plaintiff was not disabled, and therefore
denying benefits. (Tr. 8-19)
sought review of the ALJ's decision before the Appeals
Council of the Social Security Administration
(“SSA”). (Tr. 1-7) On May 17, 2018, the Appeals
Council denied review of Plaintiff's claims, making the
July 19, 2017, decision of the ALJ the final decision of the
Commissioner. Plaintiff has therefore exhausted his
administrative remedies, and his appeal is properly before
this Court. See 42 U.S.C. § 405(g).
brief to this Court, Plaintiff raises two related issues.
First, Plaintiff argues that the ALJ failed to give more
weight to Dr. Samaritoni's opinions in the MSS as his
treating doctor. Second, he argues that the ALJ's
Residual Function Capacity (“RFC”) determination
is not supported by substantial evidence. The Commissioner
filed a detailed brief in opposition. In his Reply brief,
Plaintiff argues that the ALJ erred by finding he could
perform other work at step 5 because the ALJ failed to
support the RFC with medical opinions.
explained below, the Court has considered the entire record
in this matter. Because the decision of the Commissioner is
supported by substantial evidence, it will be affirmed.
administrative record before this Court includes medical
records concerning Plaintiff's health treatment from May
12, 2014, through September 6, 2017. The Court has considered the
entire record. The following is a summary of pertinent
portions of the medical records relevant to the matters at
issue in this case.
Hannibal Free Clinic (433-34, 435-54,
May 12, 2014, and October 10, 2016, a number of doctors on
staff at Hannibal Free Clinic treated Plaintiff.
treatment on May 12, 2014, for diabetes mellitus, Dr. Adam
Samaritoni noted that Plaintiff was not taking his prescribed
medications. Plaintiff reported no chief complaint except
follow-up treatment. Plaintiff returned on June 27, 2014, and
Dr. Samaritoni continued Plaintiff's medication regimen.
On August 29, 2014, Plaintiff returned for a routine follow
up and reported no chief complaint.
January 30, 2015, Plaintiff returned for follow-up treatment
and medication refills. Plaintiff admitted that he had not
been taking his prescribed medications for two to three weeks
and reported no chief compliant.
treatment on May 30, 2015, Dr. Lawrence Nichols completed a
musculoskeletal examination noting as follows:
“Literally, when I asked him to move his arm, his whole
body would tremor and he would act as though he could not
lift his arm, he could not even lift his arm up to shake my
hand, but I was passively able to move his arm through pretty
much a full range of motion. Of course, he did lots of facial
grimacing, reporting severe pain.” (Tr. 433) Dr.
Nichols “explained to [Plaintiff] if the symptoms are
that severe and he truly cannot move his arm, he may have
something significant going on within the vertebral column,
with the spinal cord, I explained to him that things like
diskitis can be present, and recommended that they go
immediately over to the emergency room for further evaluation
including possible MRI of that area.” (Tr. 457) Dr.
Nichols commented that he thought Plaintiff was malingering
and upset that he did not prescribe narcotics.
follow-up treatment on July 13, 2015 with Dr. Samaritoni,
Plaintiff reported having pain in his feet. On October 12,
2015, Plaintiff reported not taking his medications and being
unable to do much of anything because of severe back and
right shoulder pain. In follow-up visit on January 11, 2016,
Plaintiff reported having palpitations. On April 11, 2016,
Plaintiff returned for a routine visit and Dr. Samaritoni
continued his medication regimen. Plaintiff returned on July
11and October 10, 2016, for medication refills, and Plaintiff
reported having no chief complaint.
January 9, 2017, Dr. Samaritoni completed a Medical Source
Statement of Ability to do Work-Related Activities (Physical)
(“MSS”) in a checklist format and answered
questions regarding Plaintiff's impairments at the behest
of counsel. Dr. Samaritoni opined that Plaintiff could lift
less than ten pounds occasionally; sit less than two hours;
stand less than two hours; and walk less than two hours in an
eight-hour workday. Dr. Samaritoni indicated that Plaintiff
could sit and/or stand for ten minutes before changing
position, and he must walk around every fifteen to twenty
minutes for five minutes in an eight-hour workday. Next, Dr.
Samaritoni indicated that Plaintiff would have to lie down
every hour during the workday. In support of these
limitations, Dr. Samaritoni listed Plaintiff's medical
conditions including frozen shoulder, cervical radiculopathy,
and diabetic peripheral neuropathy. Dr. Samaritoni further
opined that Plaintiff can never stoop, crouch, or climb
stairs or ladders. As to his manipulative functions, Dr.
Samaritoni opined that Plaintiff can never reach, handle,
finger, or push/pull. Dr. Samaritoni further noted that
Plaintiff “has very little mobility because of his
conditions.” (Tr. 453) Next, Dr. Samaritoni noted that
Plaintiff would miss more than four days of work each month;
he would be off task 25% or more each workday; and he would
need to take an unscheduled break every sixty to ninety
minutes for thirty minutes due to his muscle weakness and
Hannibal Regional Hospital (Tr.49-58,
109-14, 135-42, 396-430)
30, 2015, Plaintiff presented in the emergency room at
Hannibal Regional Hospital, complaining of severe back pain
and numbness and difficulty moving his right arm. Plaintiff
reported not taking any medications and being a daily smoker.
Plaintiff reported being hit in the back a month earlier and
experiencing progressive pain since that time. Examination
showed normal strength and his strength 5/5 to proximal and
distal muscle groups of the upper and lower extremities
bilaterally. An MRI of his thoracic spine showed degenerative
disk disease and spondylosis without evidence of acute
fracture or subluxation. In the diagnostic interpretation,
Dr. Phillip Rohde opined that Plaintiff had “no
weakness that would be concerned for radiculopathy as
dermatomal distribution not consistent with location of
pain” and diagnosed Plaintiff with back contusion. (Tr.
406) Dr. Rohde prescribed muscle relaxants and provided a
physical therapy regimen of back exercises.
January 9, 2017, MRI of Plaintiff's cervical spine showed
degenerative changes in disc protrusion.
21, 2017, Plaintiff received follow-up treatment in the
emergency room at Hannibal Regional Hospital for an infection
after femoral bypass surgery. Plaintiff reported having no
back, neck, or limb pain. The treating doctor transferred
Plaintiff to University of Missouri Health Care for treatment
of his acute cellulitis.
Midwest Orthopedic Specialists (Tr. 105-08)
April 24, 2017, Dr. Curtis Burton treated Plaintiff's
chronic right shoulder pain. Dr. Burton noted that an x-ray
showed no specific abnormality and diagnosed Plaintiff with
chronic adhesive capsulitis. Plaintiff reported smoking one
to two packages of cigarettes a day. Examination showed no
significant tenderness with palpation of his neck and limited
external rotation of his right shoulder. Dr. Burton told
Plaintiff to quit smoking.
Hannibal Regional Medical Group (Tr.
January 9, 2017, Plaintiff established care with Dr.
Samaritoni with a chief complaint of diabetes. In follow-up
treatment on March 21, 2017, Plaintiff reported not taking
Lantus for several months as prescribed. Plaintiff
experienced pain when Dr. Samaritoni examined his right
shoulder. On March 29, 2017, Plaintiff presented for a
follow-up appointment, and Dr. Shaybu Harruna strongly
encouraged Plaintiff to stop smoking. Examination showed no
joint pain or stiffness.
April 20, 2017, Plaintiff returned for a one month follow up
for his diabetes type 2 and although he was supposed to start
Lyrica, he had not picked up the medication from the
pharmacy. On April 24, 2017, Dr. Luvell Glanton treated
Plaintiff's pain. Plaintiff reported his pain interfering
with his driving, walking, bathing, vacuuming, leisure
activities, work duties, and cooking. Musculoskeletal
examination of his upper and lower extremity was normal. Dr.
Glanton recommended a cervical epidural injection.
University of Missouri Health Care (Tr.
1, 2017, Plaintiff had elective bilateral leg angiogram and
right femoral sheath placement to treat his severe peripheral
vascular disease. Plaintiff returned on June 26, 2017,
complaining of left leg and foot pain. Dr. Paul Humphrey
performed a left femoral bypass. Examination showed good
range of motion of all major joints.
22, 2017, Plaintiff received follow-up treatment at the
University of Missouri Health Care for an infection.
Plaintiff reported smoking a pack of cigarettes daily and a
history of hypertension and diabetes mellitus.
Musculoskeletal examination showed Plaintiff had a normal
range of motion of all joints and normal strength and no
pain. The treating doctor noted that Plaintiff had no
Columbia Surgical Associates (Tr. 42-48)
September 6, 2017, Plaintiff returned for treatment at Health
Care Columbia Surgical Associates. Examination showed
Plaintiff was able to ...