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Stanley v. Saul

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

September 27, 2019

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 Pamela Stanley (“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. 25).

         I. Procedural History

         Plaintiff filed her applications for DIB under Title II of the Social Security Act and for SSI under Title XVI of the Act on March 30, 2011. (Tr. 11, 100-113) Plaintiff claimed she became disabled on March 22, 2011[2] because of depression, anxiety, and carpal tunnel in both hands. (Tr. 55) Plaintiff was initially denied relief on August 26, 2011. (Tr. 52-59) At Plaintiff’s request, a hearing was held before an Administrative Law Judge (“ALJ”) on January 15, 2013. (Tr. 26-45, 61) By decision dated June 17, 2013, the ALJ found Plaintiff was not disabled. (Tr. 11-21)

         Plaintiff appealed the ALJ’s decision, and on February 12, 2016, District Judge Catherine D. Perry reversed the decision and remanded the case to the Commissioner. (Tr. 673-84) Pursuant to an Order of Remand from the Appeals Council, the ALJ held a second hearing on September 29, 2016, at which Plaintiff and a vocational expert (“VE”) testified. (Tr. 605-45, 685-88) On March 29, 2017, the ALJ issued a decision finding Plaintiff was not under a disability from March 22, 2011 through the date of the decision. (Tr. 558-74) On February 8, 2018, the Appeals Council denied Plaintiff’s request for review of the ALJ’s decision. (Tr. 547-52) 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 support the RFC with “some” medical evidence; (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 that Plaintiff was capable of work; and (3) the ALJ failed to resolve a conflict between the VE testimony and the Dictionary of Occupational Titles (DOT).

         For the reasons that follow, the Court finds the ALJ erred in his evaluation, and the case will be reversed and remanded for further consideration.

         II. Medical Records and Other Evidence before the ALJ

          At the hearing before the ALJ, Plaintiff’s attorney presented an opening statement. Counsel stated Plaintiff was 47 years old with a high school education. She last worked in 2012. She had problems with her back, neck, and right upper extremity, as well as a long history of depression. She was diagnosed with carpal tunnel syndrome, degenerative disc disease of the cervical spine, and bipolar affective disorder. (Tr. 607-11)

         Plaintiff testified she was unable to work because her legs were stiff and weak; her ankles and feet swelled; her back locked up and caused deep throbbing pain; and her neck pain caused sleepless nights. Plaintiff stated her worst problem was her back pain because pain radiated up and down. Plaintiff’s treatment for her back included steroids, Flexeril, lotion, morphine, and Hydrocodone. She visited the emergency room over 20 times in the past few years. Plaintiff further testified the pain from her lower back pulsated to her legs, and her feet felt like they were on fire and stepping on needles. With respect to her neck pain, Plaintiff testified the pain was shooting and went to her back, legs, and arms. In addition, Plaintiff’s right hand locked up. She stated she spent 80 percent of the day laying down. (Tr. 611-29)

         Plaintiff also testified she experienced depression every day since her son was murdered. She had panic attacks daily which made her nervous and shaky and felt like a heart attack. She sometimes heard her son talk to her, and she saw images of him frequently. She experienced crying spells and stopped taking care of her personal needs. Plaintiff did not drive often and only went to doctor appointments, the graveside, or the Family Dollar store. She was able to cook meals in the microwave and make the bed. Her husband did the laundry. (Tr. 629-36)

         In a disability report, Plaintiff listed her conditions as arthritis, depression, back pain, bilateral leg and arm pain, anxiety, panic attacks, Graves Disease, stenosis of the spine, and psychosis. (Tr. 789) Plaintiff also completed a function report and stated she was in pain all the time. She was unable to sleep due to leg cramps and back spasms. She prepared microwave meals but did not perform household chores. She sometimes shopped for food. Plaintiff watched TV when she was able to sit up. She had problems getting along with others. Plaintiff reported her conditions affected her ability to lift, squat, bend, stand, walk, sit, kneel, climb stairs, see, remember, complete tasks, concentrate, understand, use her hands, and get along with others. (Tr. 799-806)

         Plaintiff’s husband also completed a function report. He stated Plaintiff did not cook because she was too depressed. She did not perform any chores but looked at the TV and was depressed all day. She went to the store only to buy a couple of items. Plaintiff was unable to lift more than 15 pounds or walk more than a half block. He further reported Plaintiff did not get along with others and became upset easily. (Tr. 825-32)

         With respect to Plaintiff’s physical impairments, the record shows she saw Elbert H. Cason, M.D., on August 15, 2011 for a consultative examination. Plaintiff complained of carpal tunnel in both wrists. Plaintiff had full range of motion in her back without tenderness or muscle spasms. She could heel and toe walk, stand, and squat. She had normal gait, back motion, straight leg raises, muscle strength in all extremities, and grip strength. Cervical spine, hip, ankle, shoulder, elbow, knee, and wrist motions were all normal. Mental status exam was normal. Dr. Cason assessed history of carpal tunnel syndrome with recurrence of symptoms and hypertension. Dr. Cason opined during an 8-hour workday Plaintiff could occasionally lift/carry less than 10 pounds, stand and/or walk 6 hours, sit about 6 hours, and occasionally climb, stoop, kneel, crouch, and crawl. She had unlimited ability to reach forward and backward and reach overhead. However, she was limited in gross and fine manipulation of both extremities. (Tr. 296-300)

         Plaintiff was treated by Daniel Akwasi Osei, M.D., on April 16, 2012, for complaints of pain in both hands. Physical examination showed no atrophy, with full range of motion in her arms, elbows, and wrists. C-spine exam was positive for spurrowings with radiating symptoms down both arms. (Tr. 359-60) X-rays of the cervical spine revealed mild cervical degenerative disc disease from C3 to C7, mild right foraminal stenosis from C3 to C6, and mild left foraminal stenosis from C2 to C6. (Tr. 361) Nerve conduction studies on May 18, 2012 showed no evidence of carpal tunnel syndrome or right cervical radiculopathy. (Tr. 353) On May 21, 2012, Dr. Osei noted full range of motion, with wrist flexion, extension, and pronosupination being full and intact. Plaintiff’s subjective numbness in bilateral hands was of unknown etiology, and Dr. Osei advised carpal tunnel release surgery was not advised given Plaintiff’s inconsistent symptoms and the lack of objective findings. He advised conservative treatment. (Tr. 346-47)

         On June 14, 2013, Plaintiff was treated by Ivan Stoev, M.D., for complaints of low back pain radiating to her left leg. She also complained of neck pain. Plaintiff advised she was seeking disability. Physical exam revealed full strength throughout 5/5 in all extremities except 4 in the left lower extremity secondary to pain. Her back pain was exacerbated by muscle cramps and spasms in her left leg. Dr. Stoev noted good strength and sensation in Plaintiff’s extremities but would continue to follow her for cervical spine disease. She had a mild compression of the S1 nerve root. Dr. Stoev recommended conservative treatment including pain medication and a nerve root injection. (Tr. 1445-46)

         Hospital records from DePaul Health Center revealed normal range of motion with no tenderness or edema on November 9, 2014. Plaintiff’s mood and affect were normal. (Tr. 1192) On December 11, 2014, Plaintiff appeared uncomfortable. She had normal range of motion in her neck with no tenderness. Musculoskeletal exam showed some tenderness but no edema or deformity. Plaintiff had normal muscle tone. Her mood, affect, and speech were normal, and she was not depressed. (Tr. 1256-57) X-rays taken of Plaintiff’s lumbar spine, sacrum and coccyx, and hip revealed straightening of the normal cervical and lumbar lordosis; mild loss of intervertebral disc height at ¶ 5-C6; and no significant degenerative disease of the lumbar spine, sacrum and coccyx, hip, or pelvis. (Tr. 981)

         Subsequent visits to the emergency room between April and October of 2015 showed normal strength and reflexes, and normal mental status exams. She had some tenderness in her lower back and spine but otherwise normal muscle tone and coordination. X-rays showed mild degenerative disc disease. On September 11, 2015, Plaintiff exhibited bilateral weakness on both sides of her lower back. The examiner noted Plaintiff was not attempting to cooperate with the exam. She was upset and tearful due to pain. (Tr. 1279, 1304, 1311, 1318, 1326, 1380).

         On October 22, 2015, Plaintiff was examined by Yasuo Ishida, M.D., for complaints of pain. Dr Ishida was unable to obtain a good history from Plaintiff, who was sobbing, crying, and complaining of pain. Plaintiff had difficulty walking and was unable to squat or bend. Examination of Plaintiff’s back showed diffuse tenderness. Dr. Ishida was unable to determine Plaintiff’s range of motion. She had difficulty sitting on the exam table and moving around the room. Dr. Ishida assessed stenosis of the spine and sciatica which related to her backache; leg pain; and severe bodily pain, etiology unestablished. Dr. Ishida noted the exam was incomplete, and he was unable to reach any conclusions, as Plaintiff was in pain and unable to cooperate. (Tr. 1181-84)

         Plaintiff underwent a consultative examination with Alan H. Morris, M.D., on December 7, 2016. Dr. Morris noted Plaintiff was a poor historian. Her chief complaint was low back pain. Plaintiff reported an ability to sit 10 minutes, stand 5 minutes, walk 3 minutes, and lift 5 pounds. She had very limited activities and reported sleeping only 2 hours per night. On physical examination, Dr. Morris noted Plaintiff could walk 50 feet without her cane. Her speech was good but reliability poor. Her alignment of the lumbar spine was normal. However, Plaintiff was unable to heel-toe walk, squat, or lie on the examining table due to complaints of pain. Plaintiff had limitations to shoulder rotation with poor effort and limitations in cervical spine motion and lumbar spine flexion. Although testing muscle strength was difficult because of poor effort, Dr. Morris assessed lower extremity strength at ...

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