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Martinez v. Commissioner of Social Security Administration

United States District Court, W.D. Missouri, Southern Division

January 3, 2020




         Before the Court is Plaintiff's appeal brought under 42 U.S.C. § 405(g) seeking review of Defendant Commissioner of Social Security Administration's (“SSA”) denial of disability benefits as rendered in a decision by an Administrative Law Judge (“ALJ”). For the reasons below, the decision of the ALJ is REVERSED, and the case is REMANDED.

         Standard of Review

         The Court's review of the ALJ's decision to deny disability benefits is limited to determining if the decision “complies with the relevant legal requirements and is supported by substantial evidence in the record as a whole.” Halverson v. Astrue, 600 F.3d 922, 929 (8th Cir. 2010) (quoting Ford v. Astrue, 518 F.3d 979, 981 (8th Cir. 2008)). “Substantial evidence is less than a preponderance of the evidence, but is ‘such relevant evidence as a reasonable mind would find adequate to support the [ALJ's] conclusion.'” Grable v. Colvin, 770 F.3d 1196, 1201 (8th Cir. 2014) (quoting Davis v. Apfel, 239 F.3d 962, 966 (8th Cir. 2001)). In determining whether existing evidence is substantial, the Court takes into account “evidence that detracts from the [ALJ's] decision as well as evidence that supports it.” Cline v. Colvin, 771 F.3d 1098, 1102 (8th Cir. 2014) (citation omitted). “If the ALJ's decision is supported by substantial evidence, [the Court] may not reverse even if substantial evidence would support the opposite outcome or [the Court] would have decided differently.” Smith v. Colvin, 756 F.3d 621, 625 (8th Cir. 2014) (citing Davis v. Apfel, 239 F.3d 962, 966 (8th Cir. 2001)). The Court does not “re-weigh the evidence presented to the ALJ.” Guilliams v. Barnhart, 393 F.3d 798, 801 (8th Cir. 2005) (citing Baldwin v. Barnhart, 349 F.3d 549, 555 (8th Cir. 2003)). The Court must “defer heavily to the findings and conclusions of the [ALJ].” Hurd v. Astrue, 621 F.3d 734, 738 (8th Cir. 2010) (citation omitted).


         By way of overview, the ALJ determined that Plaintiff has the following severe impairments: “degenerative disc disease of the cervical spine status post fusion; left cervical dystonia and torticollis; depression; generalized anxiety disorder; obsessive compulsive disorder; and personality disorder.” However, the ALJ found that none of Plaintiff's impairments, whether considered alone or in combination, meet or medically equal the criteria of one of the listed impairments in 20 CFR Pt. 404, Subpt. P, App. 1 (“Listing”). Additionally, the ALJ found that despite his limitations, Plaintiff retained the residual functional capacity (“RFC”) to perform a range of sedentary work[1] with the following limitations:

the claimant can occasionally push or pull levers with the upper left extremity; no climbing ladders, ropes, or scaffolds; can occasionally climb ramps or stairs; can occasionally balance, stoop, crouch, kneel, and crawl; can occasionally reach at shoulder level and above in all directions with the left upper extremity; can occasionally reach overhead with the bilateral upper extremities; should avoid concentrated exposure to extreme cold, extreme heat, excessive vibration, unprotected heights, and the use of hazardous machinery which does not include a motor vehicle; can make simple, work-related decisions; can maintain concentration, persistence, and pace for two hours at a time for simple tasks; can understand, carry out, and remember simple work instructions and procedures; can adapt to changes in the work setting that are simple, predictable, and can be easily explained; where there is occasional and superficial interaction with co-workers, supervisors, and the general public.

(Tr. 16-17.) The ALJ then found that, considering Plaintiff's age, education, work experience, and RFC, he can perform jobs that exist in significant numbers in the national economy, such as the jobs of final assembler and patcher. Consequently, the ALJ concluded that Plaintiff was not disabled.

         On appeal, Plaintiff argues that the RFC is not supported by substantial evidence. Specifically, he argues that the ALJ (1) improperly discounted the opinion of Plaintiff's treating physician; (2) improperly discounted Plaintiff's subjective reports about his symptoms; and (3) failed to support the RFC with medical evidence. The Court agrees that the ALJ improperly discounted the opinion of Plaintiff's treating psychiatrist (Maria Mendez, M.D.) and will remand the case for reconsideration of Dr. Mendez's opinion and Plaintiff's subjective complaints about his mental condition. However, the Court affirms the ALJ's decision regarding Plaintiff's subjective complaints about his neck injury and rejects Plaintiff's suggestion that an RFC cannot be supported by a non-examining physician's opinion.

         I. Treating Physician's Opinion

         “A treating physician's opinion is given controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence.” Goff v. Barnhart, 421 F.3d 785, 790 (8th Cir. 2005) (cleaned up). “A treating physician's opinion does not automatically control, since the record must be evaluated as a whole.” Id. (cleaned up). However, an ALJ must “give good reasons” to discount a treating physician's opinion. Anderson v. Astrue, 696 F.3d 790, 793 (8th Cir. 2012).

         Here, the ALJ failed to give good reasons to disregard Dr. Mendez's opinion. Dr. Mendez was of the opinion that Plaintiff would likely miss four or more workdays a month; that he would likely be off task at least 25% of the time; and that he had moderate, marked, and severe limitations in various areas of mental functioning due to his mental conditions (major depression with psychotic features, obsessive compulsive personality trait disorder, and generalized anxiety disorder). (Tr. 349-50.)

         The ALJ gave five reasons to discount Dr. Mendez's opinion. (Tr. 19.) The ALJ's first reason was that the opinion “is inconsistent with the objective medical evidence” because Plaintiff's “mental status examinations are routinely within normal limits.” (Id.) Most of the ALJ's record citations, however, simply show that Plaintiff was alert, oriented, cognitively intact, and acting appropriately during treatment visits for his physical ailments. (Tr. 294, 296, 297, 300, 311, 320, 354, 401, 412, 424, 448.) The rest of the citations either do not address Plaintiff's mental status (Tr. 305, 434) or show that he was “stuporous” from his medication (Tr. 367, 379, 390). Although these mental status reports suggest Plaintiff was capable of acting appropriately at particular moments in time, they do not speak to Plaintiff's ability to consistently appear for work, stay on task, and perform appropriately. Accordingly, this is an insufficient justification to disregard Dr. Mendez's opinion. See Wenell v. Berryhill, No. 4:18-CV-00098-NKL, 2018 WL 4219427, at *2 (W.D. Mo. Sept. 5, 2018) (ALJ must sufficiently identify inconsistencies in the record).

         The ALJ's second reason for disregarding Dr. Mendez's opinion was that she “sees the claimant only infrequently as the record shows only ten appointments over the past two years.” (Tr. 19.) However, the ALJ did not explain how often a patient with the mental impairments noted by Dr. Mendez would be expected to see a psychiatrist or how many visits would be needed for Dr. Mendez to form a persuasive opinion. The ALJ's logic also ...

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