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Walsh v. Saul

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

September 13, 2019

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



         This is an action under Title 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying the applications of Philip Walsh (“Plaintiff”) for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq. and Supplemental Security Income (“SSI”) under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. Plaintiff has filed a brief in support of the Complaint (ECF No. 16) and Defendant has filed a brief in support of the Answer (ECF No. 23).

         I. Procedural History

         Plaintiff filed his application for DIB under Title II of the Social Security Act on October 10, 2014 and an application for SSI under Title XVI of the Act on December 4, 2014. (Tr. 12, 186-94) Plaintiff claimed he became disabled on October 1, 2014[2] because of bipolar mood disorder, type I, hypomania; generalized anxiety disorder; hypertension; and high cholesterol. (Tr. 84) Plaintiff was initially denied relief on November 5, 2014.[3] (Tr. 70-87) At Plaintiff's request, a hearing was held before an Administrative Law Judge (“ALJ”) on September 29, 2016, at which Plaintiff and a vocational expert testified. (Tr. 32-43, 89-91) The ALJ requested additional medical evaluations and later held a supplemental hearing on April 26, 2017. (Tr. 44-64) Plaintiff, a vocational expert, and two medical experts testified at the hearing. By decision dated June 19, 2017, the ALJ found Plaintiff was not disabled. (Tr. 12-26) On February 22, 2018, the Appeals Council denied Plaintiff's request for review of the ALJ's decision. (Tr. 1-6) Thus, the ALJ's decision stands as the final decision of the Commissioner.

         In this action for judicial review, Plaintiff claims the ALJ's decision is not supported by substantial evidence on the record as a whole. Specifically, Plaintiff argues: (1) the ALJ erred in determining Plaintiff's RFC by failing to properly consider all the evidence of the record and its consistency; and (2) the hypothetical question to the vocational expert based on the RFC determination was flawed such that the vocational expert testimony did not support the ALJ's decision.

         For the reasons that follow, the Commissioner's final decision is supported by substantial evidence on the record as a whole, and the Court affirms the decision.

         II. Medical Records and Other Evidence before the ALJ

          As stated in his disability application, Plaintiff indicated he last worked as a certified medical technician in April 2008. (Tr. 226) In a disability report, Plaintiff claimed he could not work at a fast food restaurant because the job did not pay enough, and the stress of people was too much to handle. (Tr. 278) Plaintiff completed a function report and stated he could clean the house, take care of his son, prepare meals, and do laundry. (Tr. 258, 259) He further stated he did not perform yard work, but went outside daily, drove, and shopped in stores once a week. (Tr. 260) However, he indicated that he was unable to pay bills because of his tendency to forget. (Tr. 260) As part of Plaintiff's disability application, state agency psychologist, Joan Singer, Ph.D., reviewed the medical records. Dr. Singer stated Plaintiff had mild restrictions of daily living and moderate difficulties in maintaining social functioning, concentration persistence, and pace. (Tr. 73)

         On August 13, 2014, Jhansi Vasireddy, M.D., examined Plaintiff for complaints of anxiety and mood swings. Plaintiff stated he stopped his medication a year earlier. (Tr. 314) Dr. Vasireddy prescribed Depakote and Klonopin. (Tr. 315) On mental status examination, Plaintiff was cooperative with good eye contact, maintained good hygiene, and had fair insight and judgment. (Tr. 315-316) Plaintiff returned to Dr. Vasireddy on September 10, 2014, and he reported the medication was helping and he felt good with no mood swings. (Tr. 312) In July and August 2015, Plaintiff followed up with Dr. Vasireddy. Plaintiff reported having marital problems and stated he cut his throat while intoxicated, which resulted in a five-day hospitalization in the psych unit. He stated he lost his job as medical technician and drug counselor because he “fell off the wagon, ” but he was doing well on medications, which included lithium, Seroquel XR, and Klonopin. (Tr. 343-44, 351) Dr. Vasireddy observed Plaintiff was stable, alert and oriented, pleasant, and cooperative. (Tr. 344)

         Between June 2015 and January 2016, Plaintiff saw Quentin Chambers, a mental health nurse practitioner. Plaintiff explained he had anxiety but wanted to continue his medication because it helped. (Tr. 385-87) Nurse Chambers generally observed Plaintiff was oriented, cooperative, pleasant, and polite, with good eye contact, normal hygiene, logical thought flow, normal energy, and fair memory. His insight and judgment were poor. (Tr. 385, 387, 389, 391, 393, 394) Nurse Chambers increased Plaintiff's lithium prescription but denied requests to increase Clonazepam. (Tr. 396) Plaintiff expressed a desire to find a psychiatrist who would prescribe more Clonazepam. (Tr. 397)

         Between February and May 2016, Plaintiff saw Ivy Alwell, an advanced nurse practitioner. Plaintiff stated his medications helped and that he was happier with a better mood. (Tr. 460) Nurse Alwell reported that Plaintiff was alert, oriented, and cooperative with good focus and concentration. (Tr. 457, 459) She declined Plaintiff's request for an early refill of his Klonopin prescription on May 24, 2016. (Tr. 458) Laboratory tests indicated Plaintiff was positive for some questionable benzodiazepine and opiate levels. (Tr. 464)

         Plaintiff met with his community case manager Patsy Gilbo between June and August 2016 and informed her that he was trying to get disability so he could pay his mother back. He was feeling good, taking regular walks, and attending AA meetings. (Tr. 346, 349, 536) Plaintiff stated he took care of his son and wanted to enjoy every moment. He had some anxiety when there was pressure on him to handle things. (Tr. 331) He reported that his medications and exercise helped, and he felt as though he was gaining control. (Tr. 338, 341, 346, 349) He also attended church and prayer group every week. (Tr. 346, 536)

         In August 2016, Dr. Vasireddy completed a mental residual functional capacity questionnaire. Dr. Vasireddy noted Plaintiff had no side effects from his prescribed medications, displayed slightly pressured speech, and had a fair prognosis. However, Dr. Vasireddy did not check any boxes pertaining to Plaintiff's signs and symptoms, and she did not assess any of Plaintiff's mental abilities to work. (Tr. 379-83)

         Between September 2016 and October 2016, Plaintiff again met with Ms. Gilbo. She noted that Plaintiff went for walks, attended appointments, and shopped in stores. (Tr. 532) Plaintiff stated he “has been doing alright, ” his recent medication adjustments were helping, and he was leading AA meetings. He worried about his disability getting approved because he wanted to start helping his mother. (Tr. 526, 532)

         On October 26, 2016, Jerry Cunningham, Psy.D., performed a consultative mental diagnostic evaluation of Plaintiff at the request of Disability Determinations. (Tr. 408-16) Plaintiff acknowledged his medication helped, and he got along well with people and coworkers. (Tr. 408-09, 411) His visual hallucinations improved in that he used to see mice but currently only saw roaches. (Tr. 408) Plaintiff reported being hospitalized last year for a suicide attempt. (Tr. 409) Mental status examination revealed adequate hygiene, normal eye contact, a “pretty good and decent” mood, and cooperative/adequate effort. (Tr. 411) Plaintiff reported an ability to take care of his personal hygiene, do household chores, cook meals, and go shopping. He was stabilized on medication, and Dr. Cunningham opined Plaintiff may be able to perform work tasks and have sustained concentration on basic tasks. However, Dr. Cunningham suggested Plaintiff did not have the capacity to cope with the cognitive demands of basic work-like tasks, and he could not complete work-like tasks within an acceptable timeframe due to mania and hypomania. (Tr. 415)

         On November 6, 2016, Dr. Cunningham completed a mental medical source statement form. He stated Plaintiff had no restrictions in understanding, remembering, and carrying out simple instructions. He had mild restrictions in his ability to make judgments on simple work-related decisions, as well as understanding, remembering, and carrying out complex instructions. Additionally, Plaintiff had only mild restrictions in his ability to interact appropriately with the public, supervisors, and co-workers. However, Dr. Cunningham opined Plaintiff did have moderate restrictions in his ability to make judgments on complex work-related decisions and his ability to respond appropriately to usual work situations and changes in a routine work setting. Dr. Cunningham qualified his opinion by explaining that these restrictions are only present when Plaintiff was manic or severely depressed. Further, while medications were starting to stabilize Plaintiff's extreme moods, he continued to have some anger issues to work through. (Tr. 417-20)

         Plaintiff followed-up with Dr. Vasireddy on November 22, 2016 and January 23, 2017. Plaintiff reported he was doing very well on his current medication. (Tr. 499-504) Dr. Vasireddy observed Plaintiff was alert, oriented, pleasant, and cooperative, with good hygiene, good eye contact, euthymic mood and affect, goal directed thought process, and fair insight and judgment. He reported seeing roaches off and on. (Tr. 500-03) Between November 2016 and February 2017, Plaintiff again met with Ms. Gilbo. He reported staying busy with his appointments and meetings, including chairing AA meetings, going to church, and taking care of his son. (Tr. 513-524)

         Joseph Carver, Ph.D. testified at the second administrative hearing. Based upon his review of the medical records, Dr. Carver explained Plaintiff's anxiety and alleged hallucinations were more likely associated with medication affect. Reports of mania appeared more consistent with drugs or alcohol, as there were no reports of mania since 2015 when Plaintiff stated he stopped alcohol and drug use. Dr. Carver testified Plaintiff had no impairment in understanding, remembering, and applying information. Plaintiff had a mild impairment in his ability to interact with others, and a moderate impairment in his ability to concentrate, persist, and maintain pace. Plaintiff had no problem in the area of adapting and managing oneself based on his ability to work independently, go to meetings, take extensive walks, and be a home parent. Further, Dr. Carver saw no evidence of an anxiety condition, explaining that while Plaintiff reported anxiety, he still went into the community without difficulty and exhibited no problems commonly associated with high levels of anxiety. Dr. Carver explained, while Dr. Cunningham appeared to restrict Plaintiff to only complex work-related activities, Plaintiff would only have mild issues in understanding instructions in a job setting. (Tr. 55-59)

         During the second administrative hearing the ALJ posed a hypothetical to the vocational expert (“VE”). The ALJ described an individual with the age, education, and work experience as the Plaintiff, an perform work with no exertional restrictions, but with limitations from affective mood disorders that would restrict work activity to simple, routine, and repetitive tasks. Based on this hypothetical, the VE testified that the hypothetical individual could not perform Plaintiff's past relevant work but was able to perform unskilled jobs available in significant numbers in the national economy, including laundry worker, packager, and dining room ...

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