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Donald L. U. v. Saul

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

September 10, 2019

DONALD L. U., JR., Plaintiff,
ANDREW M. SAUL, [1] Commissioner of Social Social Security Administration, Defendant.



         This 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. § 405(g).

         I. Procedural History

         On June 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)

         Plaintiff 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).

         In his 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.

         As 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.

         II. Medical Records

         The administrative record before this Court includes medical records concerning Plaintiff's health treatment from May 12, 2014, through September 6, 2017.[2] 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.

         A. Hannibal Free Clinic (433-34, 435-54, 456-57, 459-78)

         Between May 12, 2014, and October 10, 2016, a number of doctors on staff at Hannibal Free Clinic treated Plaintiff.

         During 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.

         On 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.

         During 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.

         In 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.

         On 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 pain.

         B. Hannibal Regional Hospital (Tr.49-58, 109-14, 135-42, 396-430)

         On May 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.

         The January 9, 2017, MRI of Plaintiff's cervical spine showed degenerative changes in disc protrusion.

         On July 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.

         C. Midwest Orthopedic Specialists (Tr. 105-08)

         On 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.

         D. Hannibal Regional Medical Group (Tr. 115-34)

         On 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.

         On 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.

         E. University of Missouri Health Care (Tr. 29-40, 61-104)

         On May 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.

         On July 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 apparent distress.

         F. Columbia Surgical Associates (Tr. 42-48)

         On September 6, 2017, Plaintiff returned for treatment at Health Care Columbia Surgical Associates. Examination showed Plaintiff was able to ...

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