United States District Court, E.D. Missouri, Eastern Division
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 Cindy W.'s ("Plaintiff) application for
disability benefits under Title II of the Social Security
Act, see 42 U.S.C. §§ 401 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).
December 14, 2015, Plaintiff filed an application for
disability benefits, arguing that her disability began on
February 1, 2015,  as a result of bipolar disorder,
depression, anxiety, total knee replacement, high blood
pressure, high cholesterol, underactive thyroid, insomnia,
sleep apnea, and neuropathy. (Tr. 91, 168-71, 191) Plaintiffs
date of last insured is December 31, 2019. (Tr.192) On April
4, 2016, Plaintiffs claims were denied upon initial
consideration. (Tr. 91-95) Plaintiff then requested a hearing
before an Administrative Law Judge ("ALJ").
Plaintiff appeared at the hearing (with counsel) on October
3, 2017, and testified concerning the nature of her
disability, her functional limitations, and her past work.
(Tr. 28-74) The ALJ also heard testimony from Debra Determan,
a vocational expert ("VE"). (Tr. 65-74, 316-18) The
VE opined as to Plaintiffs ability to perform her past
relevant work and to secure other work in the national
economy, based upon Plaintiffs functional limitations, age,
and education. (Id.) After taking Plaintiffs
testimony, considering the VE's testimony, and reviewing
the rest of the evidence of record, the ALJ issued a decision
on December 1, 2017, finding that Plaintiff was not disabled,
and therefore denying benefits. (Tr. 8-22)
sought review of the ALJ's decision before the Appeals
Council of the Social Security Administration
("SSA"). (Tr. 1-5) On February 13, 2018, the
Appeals Council denied review of Plaintiff s claims, making
the December 1, 2017, decision of the ALJ the final decision
of the Commissioner. Plaintiff has therefore exhausted her
administrative remedies, and her appeal is properly before
this Court. See 42 U.S.C. § 405(g).
brief to this Court, Plaintiff raises five related issues.
First, Plaintiff argues that the ALJ erred by giving partial
weight to the opinions of Dr. Mattingly regarding her mental
impairments. Plaintiff also challenges the ALJ's
evaluation of her subjective complaints. Plaintiff argues
that the ALJ erred by not finding her migraine headaches to
be a severe impairment. Next, Plaintiff challenges the
ALJ's determination that she retained the Residual
Functional Capacity ("RFC") to perform light work.
Lastly, Plaintiff requests that if the Court remands this
case for further proceedings, the case be assigned to a
different ALJ. Because the Court finds that remand is not
appropriate, it does address the allegations of ALJ bias. The
Commissioner filed a detailed brief in opposition. In her
Reply brief, Plaintiff raises for the first time an
additional argument regarding the weight accorded to Dr.
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 Plaintiffs health treatment from September
26, 2013, through September 28, 2017. The Court has reviewed
the entire record. The following is a summary of pertinent
portions of the medical records relevant to the matters at
issue in this case.
Mid County Orthopedics - Dr. Jason Rabenold
(Tr. 367-93, 412-20, 428-36, 443-77)
February 16, 2015, Dr. Jason Rabenold treated Plaintiff for a
right shoulder cuff tear. Plaintiff reported pain and
difficulty with her daily activities and working as a school
bus driver. After finding conservative treatment, including
injections, therapy, anti-inflammatories, and activity
modification, had not alleviated Plaintiffs pain, Dr.
Rabenold performed surgery.
March 3, 2015, Dr. Rabenold performed right shoulder
arthroscopy with rotator cuff repair and debridement surgery.
In post-surgery follow up on March 9, 2015, Plaintiff
reported that her pain was under control and she was
exercising. Dr. Rabenold ordered physical therapy. Plaintiff
indicated that she had lost her job so she would no longer
have insurance as of April 1, 2015. Dr. Rabenold contacted
Advanced Physical Therapy about a payment plan for Plaintiff.
Plaintiff returned on April 6, 2015, and reported doing well
and doing her physical therapy exercises. In follow-up
treatment on May 18, 2015, Plaintiff reported her pain being
under control and completing her home exercises. Dr. Rabenold
continued Plaintiffs physical therapy treatment to improve
her strengthening and conditioning.
September 17, 2015, Advanced Training and Rehab discharged
Plaintiff and noted that Plaintiff had met 100% of her goals
and achieved the maximum benefit of therapy.
St. Charles Psychiatric Associates - Dr. Gregory
Mattingly (Tr. 360-62, 395-402, 886-92)
September 26, 2013, and April 6, 2017, Dr. Gregory Mattingly
treated Plaintiffs bipolar disorder and attention deficit
hyperactivity disorder ("ADHD"). Many of Dr.
Mattingly's treatment notes tend to be illegible.
September 26, 2013, Dr. Mattingly's mental status
examination showed Plaintiff was active, alert and oriented
in person, time and place ("AAOX3"), with no
suicidal or homicidal ideations. During treatment on January
28, 2014, Dr. Mattingly noted that Plaintiffs therapy goals
included finding life balance and addressing stress and money
management. Plaintiff reported that she had two minor school
bus accidents so far this year. Mental status examination
showed Plaintiff was AAOX3, with no suicidal or homicidal
ideations, and decreased focus.
16, 2014, Plaintiff reported that she had moved in with her
father because of issues with her son. Dr. Mattingly noted
the same mental status examination findings. On September 19,
2014, Plaintiff reported that she had moved back home after
telling her husband to deal with her son. Mental status
examination showed Plaintiff was AAOX3, with no suicidal or
homicidal ideations or hallucinations, and fair
judgment/insight. The November 10, 2014, mental status
examination showed the same mental status findings.
February 18, 2015, Plaintiff reported being very depressed
and having problems at work and at home with her son. Mental
status examination showed Plaintiff was AAOX3, with no
suicidal or homicidal ideations or hallucinations, and fair
judgment/insight. Dr. Mattingly increased Plaintiffs Latuda
dosage. Dr. Mattingly also completed a form for medical leave
under the Family Medical Leave Act ("FMLA"). In the
FMLA form, Dr. Mattingly indicated that Plaintiffs recurrent
bipolar depression episode started on February 1, 2015, with
a probable duration of two months, and prevented her from
performing job functions such as focus and concentration. Dr.
Mattingly also indicated that Plaintiffs mental impairment
would cause flare-ups that would prevent Plaintiff from
working one day every two months. On February 26, 2015,
Plaintiff reported being fired from her job. Dr. Mattingly
adjusted Plaintiffs medication regimen. During treatment on
March 12, 2015, Plaintiff reported that she was having
problems at home with her son and problems after being fired.
Dr. Mattingly noted the same mental status examination
findings. Dr. Mattingly adjusted her medication regimen.
January 26, 2016, Plaintiff reported that she "filed for
disability for other problems" and being in a car
accident. (Tr. 890) Mental status examination showed AAOX3,
no suicidal or homicidal ideations or hallucinations, and
fair judgment/insight. Dr. Mattingly refilled her medication
regimen. Plaintiff returned on June 22, 2016, and Dr.
Mattingly continued her medication regimen. Dr. Mattingly
noted the same mental status examination findings. On August
15, 2016, Plaintiff reported being in a lot of physical pain
and feeling down. Dr. Mattingly noted the same mental status
examination findings. Dr. Mattingly adjusted Plaintiffs
medication regimen. On October 3, 2016, Plaintiff reported
continued stress caused by her son and having a restraining
order against him and considering moving to Sikeston to live
with her niece. Mental status examination showed Plaintiff
was AAOX3, moderately stressed with no suicidal or homicidal
ideations and fair judgment/insight. Dr. Mattingly continued
Plaintiffs medication regimen, On January 3, 2017, Plaintiff
reported that her son was living at his girlfriend's
house and Plaintiff had a restraining order against him. Dr.
Mattingly noted the same mental status examination findings.
In treatment on April 18, 2017, Plaintiff reported continued
family conflicts. Mental status examination showed Plaintiff
was AAOX3, with no suicidal or homicidal ideations, improved
mood, and fair judgment/insight.
CenterPointe Hospital (Tr. 928-81)
9, 2016, Plaintiff presented for general medical management
at CenterPointe Hospital and reported having a suicide plan.
Dr. Mattingly admitted Plaintiff for treatment for her active
thoughts of suicide and crisis stabilization and placed her
on suicide precautions. Dr. Mattingly noted that Plaintiffs
prior psychiatric history included office treatment and
hospital-based treatment and that Plaintiff "has been
under a great deal of stress in taking care of a father who
is medically ill, [and] her son who has bipolar disorder and
substance abuse." (Tr. 980) Mental status examination
showed Plaintiffs mood was down, her affect constricted, her
speech slowed, and she had limited judgment and insight with
an average overall level of intellect.
time of discharge on May 17, 2016, Dr. Richard Anderson noted
that Plaintiff had received adjustments to her medications,
and Plaintiff had attended group and social worker
counseling. Dr. Anderson noted that Plaintiff was no longer
suicidal or psychotic, and her judgment, insight, and mood
19, 2016, Plaintiff presented for an outpatient psych
evaluation and for stabilization. Plaintiff reported being
unemployed and taking care of her demanding father and being
overwhelmed by her environment. Plaintiff denied any suicidal
ideations or impulsivity but she had anxiety and was unable
to accomplish tasks. Dr. Roomana Arain's mental
examination showed Plaintiffs thought processes to be logical
and goal directed, her mood to be depressed, her orientation
intact x4, her memory intact, her judgment moderately
impaired, and her attention/concentration were distracted.
Dr. Arain admitted Plaintiff for stabilization and
therapeutic treatment and continued her medication regimen.
In the discharge summary, Plaintiff noted that she had
regained the stress of her home life, including being
financially strained with some concern of having to file
bankruptcy. Plaintiff reported that being the care taker of
her alcoholic and verbally abusive father had put her over
the edge and that she was no longer taking care of him.
Plaintiff reported symptoms including irritability, poor
concentration and motivation, anxiety, sadness, feeling of
loss, low self-esteem, increased anger and appetite, and
decreased daily activities. Plaintiff listed her stressors
included taking care of her father, finances, chronic pain,
conflict with her spouse, son's polysubstance abuse, and
denial of Social Security benefits. Dr. Arain diagnosed
Plaintiff with major depressive disorder and generalized
anxiety disorder. Dr. Arain noted that Plaintiff was
motivated for and cooperative with treatment.
3, 2016, Plaintiff was readmitted to the inpatient program
because she reported feeling suicidal again and for
evaluation and treatment for her problems with bipolar
disorder and depression. Plaintiff listed her medically ill
father, her son's bipolar disorder and behavior, and her
difficult relationship with her unsupportive husband as her
stressors. Mental status examination showed Plaintiff to be
alert and oriented x3, depressed mood, constricted affect,
limited judgment and insight, and positive thoughts of
suicide. Dr. Anderson increased her dosage of medications and
directed Plaintiff to participate in the therapy. In the
discharge summary, Dr. Mattingly noted that Plaintiffs
medication regimen had been adjusted while in the hospital,
and her depressive symptoms and suicidal ideations had
gradually improved. Her diagnoses were major depressive
disorder, generalized anxiety disorder, and ADHD. Plaintiffs
discharge follow-up included scheduling an appointment with
Dr. Mattingly and transcranial magnetic stimulation treatment
June 13 and July 15, 2016, Plaintiff received frequent
outpatient TMS treatment. During treatment, Plaintiff noted
that her main stressor was her son who had been kicked out of
the house by her husband. Plaintiff questioned whether she
was depressed or worried about her family situation.
Plaintiff did not report any side effects from the TMS
treatment. Plaintiff reported 100% improvement for her
depression with no crying episodes and feeling like she can
handle situations. On June 27, 2016, Plaintiff reported that
she felt like she had almost made "a complete turn
around." (Tr. 949) Plaintiff also reported being excited
for the future "for the first time in forever, "
communicating better with her family, and enjoying life.
During treatment on July 1, 2106, Plaintiff reported
completing tasks around the house and socializing with
friends and family and denied having any depression or
anxiety. The treatment notes showed that Plaintiff had
experienced improvement in her energy, motivation,
depression, anxiety, and communications with her family.
Plaintiff reported feeling the best she had felt in years.
After her last TMS treatment, the therapist noted that
Plaintiff would continue follow-up treatment with Dr.
March 8 and March 20, 2017, Plaintiff received daily,
outpatient TMS treatment. Plaintiff reported being estranged
from her son and interested in pursuing volunteer
opportunities. Plaintiff reported looking for a part time job
and being in an unhealthy relationship with her husband.
Plaintiff reported no negative side effects from the TMS
treatment and the treatment really helped her symptoms.
Mercy Clinic Pulmonology - Dr. Michael
Brischetto (Tr.486-92, 894-924)
November 11, 2015, Dr. Michael Brischetto evaluated Plaintiff
for possible sleep apnea and noted in his impression, sleep
onset insomnia due to anxiety, anxiety, depression, and
snoring. Dr. Brischetto recommended doing a sleep study and
adjusted Plaintiffs medication regimen. Plaintiff reported
stress from having her son live with her but her stress level
had improved since her son was in treatment at a rehab
facility. Examination showed no back, neck, or joint pain.
Plaintiff indicated that she has problems due to her
finances, husband, and son. Dr. Brischetto observed that
Plaintiff had a normal gait.
December 11, 2015, sleep study showed mild-to-moderate
obstructive sleep apnea, and the doctor recommended that
Plaintiff return for CPAP titration.
August 19, 2016, Plaintiff reported being under a lot of
stress from caring for her alcoholic father, placing her son
in rehab, and being fired. Dr. Brischetto directed Plaintiff
to continue using a CPAP and to exercise three to four hours
prior to bed time.
follow-up treatment for sleep apnea and insomnia on January
16, 2017, Plaintiff indicated that she had filed for
disability due to her bipolar disorder. Plaintiff reported
spending a lot of time in bed playing on her computer or
SSM Health St. Joseph Lake St. Louis (Tr.
December 22, 2105, Plaintiff presented in the emergency room
at SSM Health St. Joseph for treatment for a sternal fracture
caused by a car accident. Plaintiff reported having knee and
back pain. A MRI of Plaintiff s cervical spine showed no
fracture and minor degenerative changes. The MRI of Plaintiff
s cervical and lumbar spine was normal, and a bilateral knee
x-ray was normal.
Mercy Services O'Fallon Family Medicine - Dr. Alyssa
Keller (Tr 552-700, 726-846)
Alyssa Keller treated Plaintiff between December 16, 2014,
and April 24, 2017.
December 16, 2014, Dr. Keller diagnosed Plaintiff with
bronchitis. Plaintiffs Problem List included the notation,
"mgrn with aura wo ntrc mgrn" with treatment from
March 24, 2006, though January 17, 2011, with Dr. Thomas
Sommers. Plaintiff reported having weekly migraine headaches
with relpax providing relief. On February 23, 2015, Plaintiff
returned for a preoperative examination and released
Plaintiff for surgery. In follow-up treatment on April 13,
2015, Plaintiff reported having back pain and a rash.
Plaintiff also reported crying spells and stress caused by
her son's recent suicide attempt and being terminated
from school bus driver job. Plaintiff indicated that Dr.
Mattingly prescribed lithium for her psychiatric care, and
she felt lithium and prozac helped her.
16, 2015, Plaintiff returned, complaining of back and
abdominal pain. Dr. Keller noted that Plaintiffs blood
pressure was well controlled on her current medication.
Plaintiff returned on May 20, 2015, for a routine general
medical examination with no complaints on review. Plaintiff
reported previously using relpax for intermittent headaches
with good relief, but she stopped taking relpax because it
was not covered by her insurance. Plaintiff denied having any
current headaches. Plaintiff reported starting a progressive
daily aerobic exercise program and following a low-fat diet
to lose weight.
23, 2015, Dr. Keller noted that Plaintiffs blood pressure was
within a normal range. In follow-up treatment on August 26,
2015, Plaintiff received treatment for shingles and reported
being under a great deal of stress caused by her family
situation. Plaintiff explained that her son had been abusing
multiple drugs and was recently released from a psychiatric
treatment on December 1, 2015, Plaintiff returned for a
medication review. Plaintiff indicated that she was applying
for a new job as a driver for a packaging company and
requested Dr. Keller complete the necessary paperwork.
Plaintiff reported that she had a restraining order against
her son because of his violent behavior and denied having any
suicidal ideation or homicidal ideation. Dr. Keller observed
Plaintiff had a normal gait and normal strength. Dr. Keller
completed Plaintiffs paperwork for her new employer and
explained how her new depression medication prescribed in the
emergency room might have side effects including suicidal
ideations. Plaintiff returned on December 8, 2015, to discuss
restarting her psychiatric medications. Plaintiff explained
that she thought she could get off some of her medications so
that she could start a new job but her bipolar episodes
interrupt her sleep. Dr. Keller referred Plaintiff back to
Dr. Mattingly for psychiatric treatment. On December 16,
2015, Plaintiff reported "a history of bipolar disorder
managed by psychiatry (Dr. Mattingly) on Latuda, adderall XR,
and prozac." (Tr. 665) Plaintiff requested evaluation
for burning discomfort in her feet with some numbness. In her
assessment, Dr. Keller listed neuropathy and referred
Plaintiff for nerve conduction testing. Plaintiff returned on
December 29, 2015, for treatment after a car accident.
Plaintiff reported lower back and left knee pain, severe
chest pain, abdominal pain, and no severe headaches or loss
of balance. An x-ray of Plaintiff s ribs showed a fracture of
her fifth and sixth right lateral ribs. Dr. Keller instructed
Plaintiff to rest, to apply ice as needed, and to use
extra-strength Tylenol. A nerve conduction study of Plaintiff
s bilateral lower extremities showed no denervation in the
distal muscles on either side.
returned on February 24, 2016, for follow-up treatment after
a car accident. Plaintiff reported that her knee pain had
improved and requested a referral for physical therapy for
her back pain. On March 15, 2016, Plaintiff presented with
radiating lower back pain. Examination of Plaintiff s back
showed a normal range of motion and no tenderness. In
treatment on March 28, 2016, Plaintiff reported that she had
been seeing an orthopedic doctor and completed four weeks of
physical therapy relieving her symptoms with overall
improvement. Dr. Keller approved Plaintiff for medical
returned on August 4, 2016, and reported feeling well with no
complaints. Dr. Keller directed Plaintiff to begin a
progressive daily aerobic exercise program and reduce
exposure to stress. On September 27, 2016, Plaintiff reported
abdominal pain possibly caused by the multiple medications
follow-up treatment on March 3, 2017, Plaintiff reported
ongoing problems with bilateral ankle pain and swelling, a
history of plantar fasciitis, and neuropathy in her feet. On
April 24, 2017, Plaintiff reported left hip joint pain,
swelling of right middle finger, hypertension, and bilateral
swelling of her feet and ankles. Dr. Keller provided home
exercises for her hip pain and continued her hypertension
Dr. David Lipsitz (Tr 706-10)
March 25, 2016, Dr. David Lipsitz, Ph.D., completed a
psychological consultation after reviewing Plaintiffs medical
records. Dr. Lipsitz observed that Plaintiff exhibited no
difficulty with her posture or gait, and she drove herself to
the consultation. As her chief complaint, Plaintiff stated
that she drove a school bus for over seven years, and her
bipolar disorder resulted in her not being able to deal with
students so the school district fired her. Plaintiff reported
a thirty-year history of psychiatric treatment. Plaintiff
indicated that Dr. Mattingly diagnosed her with bipolar
disorder ten years earlier. Plaintiff reported being
depressed but her energy level is good. Dr. Mattingly also
diagnosed Plaintiff with ADHD. Plaintiff reported
"spending a lot of time taking care of her father"
usually half the week Plaintiff goes to shows and plays poker
once a week. Plaintiff spends most of her time playing
computer games, taking care of her father, doing some
housework, and preparing meals. Plaintiff indicated that she
had a lot of stress caused by her son resulting in financial
stress. Mental status examination showed no active psychotic
functioning, depressed mood, intellectual functioning within
the average range, good concentration, fair insight and
judgment, and preoccupied thought processes with physical and
emotional problems. Dr. Lipsitz found that Plaintiff did not
have any impairment in concentration, but due to volatility
factors, anxiety, and depression, Plaintiff had difficulty
persisting with tasks and a somewhat slow pace.
Mercy Orthopedic Clinic - Dr. Keith ...