Paula S. v. Saul, 4:20-CV-04041-VLD

PAULA G.S., Plaintiff, v. ANDREW SAUL, Commissioner of the Social Security Administration, Defendant.

4:20-CV-04041-VLD

UNITED STATES DISTRICT COURT DISTRICT OF SOUTH DAKOTA SOUTHERN DIVISION

April 23, 2021

MEMORANDUM OPINION AND ORDER

INTRODUCTION

Plaintiff, Paula G.S., seeks judicial review of the Commissioner's final decision denying her application for Supplemental Security Income benefits under Title XVI of the Social Security Act.

Ms. G.S. has filed a complaint and motion to reverse the Commissioner's final decision denying her disability benefits and to remand the matter to the Social Security Administration for further proceedings. See Docket Nos. 1, 17. The Commissioner has filed his own motion seeking affirmance of the decision at the agency level. See Docket No. 21.

This appeal of the Commissioner's final decision denying benefits is properly before the court pursuant to 42 U.S.C. § 1383(c)(3).¹ The parties haveconsented to this magistrate judge handling this matter pursuant to 28 U.S.C. § 636(c).

FACTS²

A. Statement of the Case

This action arises from Ms. G.S.'s application for Supplemental Security Income (SSI) with a protected filing date of December 28, 2016, alleging disability starting September 1, 2014, due to diabetes, depression, hypertension, high blood pressure, sclerosis, arthritis, degenerative bones, nerve damage, muscle stiffness, and bone spurs. T267, 311, 323, 328. Ms. G.S. stated in her Function Report, completed with her application process, that her conditions affected her ability to lift, reach, use her hands, squat, bend, stand, walk, sit, kneel, complete tasks, concentrate, and remember things. T328.

Ms. G.S.'s claims were denied at the initial and reconsideration levels, and Ms. G.S. requested an administrative hearing. T200, 207, 214.

Ms. G.S.' administrative law judge (ALJ) hearing was held on November 8, 2018, where a different attorney than her attorney of record in this appeal represented Ms. G.S. T125. The ALJ issued an unfavorable decision on February 4, 2019. T101.

At step one of the evaluation, the ALJ found that Ms. G.S. had not engaged in substantial gainful activity since December 28, 2016, the application date. T106.

At step two, the ALJ found that Ms. G.S. had severe impairments, including diabetes; obesity; chronic bilateral L5 spondylosis with severe lateral recess and neural foraminal stenosis at L5-S1; osteoarthritis of the knees; mild thoracic degenerative disc disease; major depressive disorder; and post-traumatic stress disorder (PTSD). T106. The ALJ found that each of those impairments significantly limited Ms. G.S.'s ability to perform basic work activities. T107. The ALJ found that each of those impairments more than minimally limited Ms. G.S.'s mental and physical abilities to do basic work activities. T107.

The ALJ also found that Ms. G.S. had additional non-severe impairments (hypertension, carpal tunnel syndrome that was moderately severe on the right and mild on the left, and right ulnar neuropathy at the elbow) that caused no more than minimal impact on her ability to carry out work-related activities T107.

The ALJ found that Ms. G.S.'s alleged arthritis in the shoulders was not documented in the medical evidence from an acceptable medical source; therefore, it was not a medically determinable impairment. T107. The ALJ also noted that an MRI had reported multiple sclerosis (MS), but the interpreting neurologist had stated nothing in the record supported a diagnosis of MS. The ALJ asserted in the decision that Ms. G.S. admitted at the hearingthat while the MRI showed abnormal white spots, she knew she did not have MS or a diagnosis of MS. T107. The ALJ then concluded that Ms. G.S.'s alleged MS was not a medically determinable impairment. T107.

In step three, the ALJ found that Ms. G.S. did not have an impairment that meets or medically equals a listing. T107-08. The ALJ found that Ms. G.S. did not meet Listing 1.04A because radiological evidence did not support that the nerve root or spinal cord had been compromised. T107. The ALJ found that Ms. G.S. had mild limitations in understanding, remembering, or applying information; moderate limitations in interacting with others; moderate limitations in concentrating, persisting, or maintaining pace; and, mild limitations in adapting or managing oneself. T108. The ALJ stated that those findings were not a residual functional capacity assessment and the mental residual functional capacity assessment used in steps four and five required a more detailed assessment. T108.

The ALJ determined that Ms. G.S. had residual functional capacity, (RFC), to:

perform less than the full range of light work . . . . Specifically, she can lift and/or carry 20 pounds occasionally and 10 pounds frequently. She can sit for about 6 hours in an 8-hour workday, but would need an opportunity to stand up and/or change position at her workstation for approximately 2-3 minutes after sitting for an hour. After using that opportunity, the claimant can return again to a seated position and continue in that fashion for the remainder of the 8-hour workday. She can stand and/or walk combined for about 6 hours in an 8-hour workday. The claimant can never climb ladders, ropes, or scaffolds, but can occasionally climb ramps and stairs using a handrail. She can occasionally balance, stoop, and crouch, and rarely (defined as 1-5% of a workday) kneel and crawl. She should have noexposure to work around hazards, such as unprotected heights and fast and dangerous moving machinery. Mentally, the claimant can perform simple tasks and maintain concentration, persistence and pace for 2-hour work segments. The claimant can respond appropriately to brief and superficial interactions with co-workers and the general public throughout an 8-hour workday.

T109.

The ALJ found that Ms. G.S.'s impairments could reasonably be expected to cause the symptoms alleged by Ms. G.S., however her statements concerning the intensity, persistence and limiting effects of those symptoms were "not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision." T110.

The ALJ found at step four that Ms. G.S. could not perform her past relevant work as a bus monitor and home health aide. T114.

The ALJ found at step five, relying on the testimony of a vocational expert (VE), that Ms. G.S. could perform the occupations of bench assembler, Dictionary of Occupational Titles (DOT) # 706.687-010; electronics worker, DOT# 726.687-010; and molding machine tender, DOT# 556.685-022, relying on the number of jobs available "nationally"³ for each occupation. T115.

The ALJ considered the opinions of the State agency medical consultants and gave them "some weight" because the ALJ asserted evidence admitted atthe hearing level showed Ms. G.S. was more limited than determined by the agency consultants and required a sit/stand option secondary to chronic back and knee pain. T114. The ALJ stated she afforded the opinions weight to the "extent they support the physical residual capacity assessments as set forth above." T113-14.

The ALJ considered the opinions of the State agency psychological consultants and rejected their finding that Ms. G.S. had no severe mental impairments. T114.

The ALJ considered the statements of Jodi Williams, LPC-MH, and found she was not an acceptable medical source and gave her statements only "partial weight." T113. Ms. Williams identified marked limitations in some areas, and the ALJ asserted the marked limitations were inconsistent with Ms. G.S.'s relatively intact mental status examination observations as well as her intact activities of daily living and sporadic mental health treatment. T113.

The Appeals Council denied Ms. G.S.'s request for review making the ALJ's decision final, and Ms. G.S. timely filed this action. T1-7.

B. Relevant Medical Evidence in Chronological Order:

1. Evidence Before the December 28, 2016, Filing Date

Ms. G.S. was seen at Rosebud Health Care on August 4, 2015, for left knee pain and diabetes check, and she reported a history of bone spurs in her knee with related pain. She said she had been receiving steroid injections, most recently in April 2015. T522. She requested an orthopedic referral. T522. Ms. G.S. received another steroid injection in her left knee. T527.

Barbara J. Howard, N.P., saw Ms. G.S. at Rosebud Health Care on September 1, 2015, when Ms. G.S. sought pain medications, a diabetes check, and an employment physical. T519. She reported having knee problems for 1½ years and said she had not been able to work during that time. T519. N.P. Howard asked Ms. G.S. if "she [had] been released by her physician to work, she told me 'yes.' " T519. However, N.P. Howard could not find the release. T520. Examination revealed Ms. G.S. was disheveled, very controlling, manipulative, and ambulating with a limp due to knee pain. T521. N.P. Howard did not perform a physical because Ms. G.S. was upset because N.P. Howard could not release her to work with a knee injury absent an orthopedist's release. T521. N.P. Howard prescribed hydrocodone for pain. T521.

Madison W. Patrick, M.D., saw Ms. G.S. at Rosebud Emergency Room on October 20, 2015, for severe left knee pain, and a left knee x-ray revealed tricompartmental osteoarthritis greatest in the patellofemoral compartment with severe joint space narrowing and large osteophyte formation. T593, 1009. In the "Subjective" section of the medical note it stated, Ms. G.S.'s "pain was so severe that she was unable to walk without severe pain" and she needed a walker or other assistive device to walk. T1009.

In November 2015, Ms. G.S. went to the Flandreau Clinic to establish care after moving to be closer to her daughter to help her with her new baby T699. N.P. Drago described Ms. G.S. as having a normal mood and affect T700. Ms. G.S. was told she could receive care and medications at the clinic,but since she was not a resident of the county,...