Skiver v. Social Security Administration, Commissioner
Filing
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MEMORANDUM OPINION - For the reasons stated above, this court concludes that the decision of the Commissioner is due to be REVERSED AND REMANDED for further consideration consistent with this Memorandum Opinion. The court will enter a separate Order in accordance with the Memorandum Opinion. Signed by Chief Judge Karon O Bowdre on 9/21/2018. (KEK)
FILED
2018 Sep-21 AM 09:40
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION
HELEN MAY SKIVER,
Claimant,
v.
NANCY A. BERRYHILL,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Respondent.
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CIVIL ACTION NO.
7:17-CV-00861-KOB
MEMORANDUM OPINION
I. INTRODUCTION
On July 29, 2014, the claimant, Helen May Skiver, applied for disability insurance
benefits under Title II of the Social Security Act and Supplemental Security Income benefits
under Title XVI of the Social Security Act. (R. 97-98). The claimant alleged disability,
commencing on July 14, 2014, because of diabetes mellitus with neuropathy, degenerative disc
disease, carpal tunnel syndrome, right arm nerve damage, depression, avoidant personality
disorder, borderline personality disorder, and anxiety. (R. 39, 207, 792). The Commissioner
denied the claims on September 3, 2014, and the claimant filed a timely request for a hearing
before an Administrative Law Judge (ALJ). (R. 134-35). The ALJ held the hearing on January
11, 2016. (R. 30-62).
In a decision dated May 6, 2016, the ALJ denied disability benefits to the claimant. The
ALJ held that the claimant was not disabled, as defined by the Social Security Act, and,
therefore, was ineligible for Social Security benefits. (R. 11). On April 14, 2017, the Appeals
1
Council declined to grant review of the ALJ’s decision. (R. 1-6). The claimant has now appealed
her decision to this court, which has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
For the reasons stated below, this court REVERSES and REMANDS the decision of the
Commissioner.
II. ISSUE PRESENTED
Whether the ALJ erred in giving consultative examiner Dr. Storjohann’s opinion only
some weight. 1
III. STANDARD OF REVIEW
The standard for reviewing the Commissioner’s decision is limited. This court must
affirm the ALJ’s decision if he applied the correct legal standards and if substantial evidence
supports his factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422
(11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
“No . . . presumption of validity attaches to the [Commissioner’s] legal conclusions,
including determination of the proper standards to be applied in evaluating claims.” Walker, 826
F.2d at 999. This court does not review the Commissioner’s factual determinations de novo. The
court will affirm those factual determinations that are supported by substantial evidence.
“Substantial evidence” is “more than a mere scintilla. It means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402
U.S. 389, 402 (1971).
The court must keep in mind that opinions, such as whether a claimant is disabled, the
nature and extent of a claimant’s residual functional capacity, and the application of vocational
factors “are not medical opinions, . . . but are, instead, opinions on issues reserved to the
1
The claimant raised other issues; however, because the court is reversing and remanding on the issue of the level
of weight attributed to Dr. Storjohann’s medical opinion, the court will not address the other issues.
2
Commissioner because they are administrative findings that are dispositive of a case; i.e., that
would direct the determination or decision of disability.” 20 C.F.R. §§ 404.1527(d), 416.927(d).
Whether the claimant meets the listing and is qualified for Social Security disability benefits is a
question reserved for the ALJ, and the court “may not decide facts anew, reweigh the evidence,
or substitute [its] judgment for that of the Commissioner.” Dyer v. Barnhart, 395 F.3d 1206,
1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ about the
significance of certain facts, the court has no power to reverse that finding as long as substantial
evidence in the record supports it.
The court must “scrutinize the record in its entirety to determine the reasonableness of the
[Commissioner]’s factual findings.” Walker, 826 F.2d at 999. A reviewing court must not only
look to those parts of the record that support the decision of the ALJ, but also must view the
record in its entirety and take account of evidence that detracts from the evidence relied on by
the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).
IV. LEGAL STANDARD
This court has a duty to ensure that the Secretary “exercised reasoned decision-making”
in his fact finding and policy judgments. Owens v. Heckler, 748 F.2d 1511, 1514 (11th Cir.
1984). In determining the level of weight to provide a medical opinion, including an examining
physician, “[t]he ALJ is to consider a number of factors in determining how much weight to give
to each medical opinion: (1) whether the doctor has examined the claimant; (2) the length,
nature, and extent of a treating doctor’s relationship with the claimant; (3) the medical evidence
and explanation supporting the doctor’s opinion; (4) how consistent the doctor’s ‘opinion is with
the record as a whole’; and (5) the doctor’s specialization.” Brown v. Comm’r of Soc. Sec., 442
F. App’x 507, 511 (11th Cir. 2011). Refusal by the ALJ to accord proper weight to the opinion of
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a consultative examining physician is cause for reversal. Henry v. Comm’r of Soc. Sec., 802 F.3d
1264, 1268 (11th Cir. 2015).
V. FACTS
The claimant was thirty-six years old at the time of the ALJ’s final decision; has a high
school education and two years of college; has past work experience as a cashier and a part-time
housekeeper; and alleges disability based on diabetes mellitus with neuropathy, carpal tunnel
syndrome, right arm nerve damage, degenerative disc disease, depression, avoidant personality
disorder, borderline personality disorder, and anxiety. (R. 11, 39, 54, 105, 207, 792).
Physical and Mental Impairments
In 2006, while the claimant was a student at the University of Alabama, Jacalyn Tippey,
Ph.D. diagnosed the claimant with a math and reading disorder. The claimant indicated to Dr.
Tippey that she had dyslexia, which impaired her academic performance. After meeting with and
assessing the claimant, Dr. Tippey wrote that the claimant seemed pleasant, cooperative, and
forthcoming. Dr. Tippey recommended that the claimant be allowed to tape class lectures, use a
calculator for simple calculations, use her laptop in class to take notes, and be given additional
time to complete class assignments. (R. 655-56).
On January 20, 2011, the claimant presented to the emergency department at DCH
Regional Medical Center complaining of lower back pain. She had experienced the pain for two
days prior, and indicated her pain was an eight out of ten on the pain scale. Dr. Alan Heins
assessed that the claimant had acute lower back pain, particularly a lumbar strain. Dr. Heins
prescribed the claimant Naproxen 500 mg and Tramadol and discharged her in stable condition
later the same day. (R. 560-67).
4
The claimant again went to the emergency department at DCH Regional Medical Center
on October 19, 2011, because she feared she had taken too much insulin. The claimant reported
that, around 12:45 a.m., she took eleven units of Humilin insulin, sixty units of Lantus insulin,
and also ate an ice cream sandwich. The claimant stated that she came to the emergency
department because her glucose level dropped too quickly, and she suddenly felt shaky,
nauseated, and lightheaded. Dr. Jeremy Pepper assessed that the claimant had nausea and
hyperglycemia. Dr. Pepper instructed the claimant to drink plenty of no-sugar liquids and to take
her insulin as ordered. Dr. Pepper discharged the claimant approximately one hour after her
arrival at the emergency department. (549, 554, 558).
On November 19, 2012, the claimant returned to the emergency department at DCH
Regional Medical Center for upper back and neck pain, numbness, and tingling. The claimant
assessed her pain as a seven out of ten on the pain scale, and she indicated that she heard a “pop”
in her neck earlier in the day. Dr. Cristi Vaughn ordered an x-ray of the claimant’s spine that
revealed cervical disc disease that caused the numbness and tingling in her arms. However, the
x-ray showed no evidence of fracture, dislocation, or significant arthritis, and Dr. Vaughn
discharged the claimant approximately three-and-a-half hours after her arrival at the medical
center. (R. 467, 478).
Dr. James Geyer of Northport Medical Center completed a nerve conduction study on the
claimant, at the request of Dr. James Robinson at the Good Samaritan Clinic, on March 27, 2013.
Dr. Geyer indicated that nerve conduction velocities were slow in the left sural sensory nerve and
in the left peroneal motor nerve. However, he concluded that nerve conduction velocities in the
right sural sensory nerve, the right peroneal motor nerve, and bilateral posterior tibial motor
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nerves were within normal limits. The findings of the study were consistent with neuropathy,
particularly involving the left lower extremity. (R. 652).
The claimant visited Dr. Fred Graham of West Alabama Spine & Pain Specialists on July
31, 2013, complaining of pain in her neck, right arm and lower back. Dr. Graham examined the
claimant and ordered an MRI of her cervical spine. On September 5, 2013, Dr. Elizabeth
Caldwell of the Radiology Clinic, LLC completed the MRI that showed cervical degeneration.
Dr. Caldwell compared the MRI results to a previous 2007 MRI2 and reported a slight worsening
in mild annular disc bulging and spondylosis at C5-C6, with an additional small central inferior
disc extrusion. She also reported minimal ventral cord surface molding; possible right C6
impingement; and mild bilateral degenerative disc disease at C3-C4 and C4-C5 without
impingement. Ultimately, however, Dr. Caldwell concluded that the changes between the two
MRIs were minimal. (R. 570-75).
The claimant sought treatment at DCH Regional Medical Center on January 24, 2014,
complaining of a panic attack and a psychiatric disorder. The claimant reported feeling dizzy and
admitted to drinking too much alcohol the night before. Dr. Russell Scholl ordered a chest x-ray
that showed no pulmonary filtrate; stabilized the claimant’s condition; and discharged her on
January 25, 2014. (R. 308-09, 332-33).
The claimant received two selective nerve root block injections from Dr. Graham at the
Tuscaloosa Surgical Center to relieve back and neck pain in 2014. The first injection occurred on
March 18, 2014, and the last injection happened on July 15, 2014. (R. 101, 596).
On June 11, 2014, Dr. Angella Woodward ordered an MRI of the claimant’s cervical
spine at the DCH Regional Medical Center Department of Imaging Services. Dr. David Smith
reported, by way of comparison with the September 13, 2013, MRI, the presence of a broad2
The record does not provide any details or results of the September 7, 2007 MRI.
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based disc osteophytic bulge with mild central disc protrusion. Dr. Smith also reported the
development of endplate edema; however, the MRI ultimately showed no abnormality and no
obvious impingement. (R. 637-38).
Dr. Robert Slaughter completed a nerve conduction study on the claimant’s upper
extremities on June 26, 2014. Dr. Slaughter found a slowing of sensory nerve conduction
velocities in the median nerves bilaterally and prolonged terminal latency in the right median
nerve, indicating bilateral carpal tunnel syndrome. Dr. Slaughter’s other findings were normal.
(R. 641).
On September 3, 2014, Dr. Robert Estock, a state agency physician, conducted a
telephone interview with the claimant. He opined that the claimant did not allege any mental
issues on her initial application or during the interview with him, and she did not show
difficulties with understanding, coherency, concentrating, talking, or answering questions. Dr.
Estock concluded, based upon his telephone interview and review of the medical evidence, that
the claimant did not have any severe mental issues that would prevent her from working. (R.
101-02).
The claimant was involved in a motor vehicle accident in late September 2014. Following
the accident, the claimant complained of neck pain. On October 7, 2014, Dr. Graham treated the
claimant with epidural steroids. The following month, on November 26, 2014, Dr. Graham
ordered an MRI of the claimant’s cervical and lumbar spine at the Radiology Clinic, LLC. Dr.
Hugh Borak compared the cervical spine MRI to the claimant’s June 11, 2014, MRI and found
diffuse disc bulging; mild uncovertebral osteophytic change; and a small central protrusion.
However, Dr. Borak concluded that the findings were unchanged since the previous MRI with no
neural impingement. Dr. Borak noted the claimant’s October of 2006 lumbar spine MRI and
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reported that the 2014 MRI showed some crowding of the descending right L5-S1 nerve root but
no definite impingement. (R. 671-79, 698-701).
On October 15, 2014, the claimant visited Dr. Stephen Ikard of the University
Orthopaedic Clinic and Spine Center. 3 Dr. Ikard diagnosed the claimant with bilateral carpal
tunnel syndrome, with the right hand worse than the left. On October 27, 2014, the claimant
underwent endoscopic carpal tunnel release on the right wrist. The claimant followed up with Dr.
Ikard on November 5 and November 19, 2014. After the last visit, Dr. Ikard reported significant
improvement. He wrote that the claimant had good range of motion, an expected amount of mild
soreness, and no significant paresthesia. (R. 659-67).
The claimant visited the Good Samaritan Clinic to discuss her diabetes, neuropathy and
depression on December 9, 2014. The doctor 4 instructed the claimant to cut back on her evening
mealtime insulin and start taking low-dose Neurontin for her neuropathy. The claimant told the
doctor that she felt depressed, that she “doesn’t feel like doing anything,” and sometimes sits on
the couch for days at a time. She denied suicidal ideation at the time of the appointment. The
doctor prescribed the claimant Prozac for her depression and referred her to Indian Rivers Mental
Health Center for mental treatment. (R. 689).
On January 13, 2015, at her Good Samaritan Clinic follow-up appointment, the claimant
indicated that her depression was still a concern but that the Prozac was helping. On February 24,
2015, the claimant visited the Good Samaritan Clinic and had her Prozac prescription refilled.
The claimant also had other prescriptions filled between May 2014 and February 2015.
According to the claimant’s Wal-Mart pharmacy medical expense summary, the claimant last
filled her prescription for Meloxicam on May 20, 2014; Cyclobenzapr on June 11, 2014;
3
The record does not state who referred the claimant to Dr. Ikard. However, the visit comes four months after Dr.
Slaughter’s nerve conduction study that indicated that the claimant had bilateral carpal tunnel syndrome.
4
The doctor’s signature on the Good Samaritan Clinic report is illegible.
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Centirizine on February 2, 2015; Permethrin on February 2, 2015; and Prednisone on February 2,
2015. (R. 258, 687-88).
On June 16, 2015, the claimant visited Good Samaritan Clinic complaining of depression.
The claimant said she “was in a dark place a few months ago and went off all [her] medication.”
The claimant reported that she has experienced mood swings and episodes of severe anxiety. The
claimant denied suicidal ideation at the time of the appointment. Diagnoses included major
depressive disorder and anxious distress. Stephanie Wynn, a certified registered nurse
practitioner, increased the claimant’s daily Prozac dosage and instructed her to return for a
follow-up appointment with the clinic in a few months. (R. 685).
On November 3 and December 1, 2015, at her routine follow-up appointments at Good
Samaritan Clinic, the claimant reported elbow pain and asked that her Prozac be reduced from 40
mg to 20 mg because she could not sleep. The medical record discussed the claimant’s diabetes,
neuropathy, carpal tunnel syndrome, depression and anxiety. As of December 1, 2015, the
claimant was taking Humilin insulin and Lantus insulin for her diabetes, Neurontin for her
neuropathy, Prozac for her depression, and Ibuprofen and Tylenol for her pain. (R. 780-82).
At the Good Samaritan Clinic for a follow-up appointment on January 5, 2016, the
claimant complained of hip pain, muscle weakness, and knee pain. A physical examination
showed full range of hip motion but weakness in her thigh. 5 The medical record discussed the
claimant’s diabetes, neuropathy, and depression, with no new or additional concerns. (R. 778).
The ALJ Hearing
After the Commissioner denied the claimant’s request for disability insured benefits, the
claimant requested and received a hearing before an ALJ on January 11, 2016. At the hearing,
the claimant testified that she had a part-time job working as a housekeeper between two and five
5
The record did not indicate which thigh was weak.
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days per week. As a housekeeper, she makes beds, dusts, and cleans windows and mirrors in the
hotel rooms. However, she testified that other housekeepers helped her complete tasks that
required a lot of bending down or getting on her knees, such as taking out the trash. The claimant
stated that the work was difficult for her, and that she would not be capable of sustaining fulltime employment. She testified that she could not stand for more than twenty minutes at a time;
that she tried not to lift anything above five pounds; and that she tripped constantly when she
walked because of her neuropathy. (R. 32, 41-43, 58).
In addition to working a part-time job, the claimant testified that she spends the majority
of days she is not working lying in her bed or sitting in her rocking recliner because of pain and
depression. The claimant stated that she is able to drive, dress herself, go grocery shopping, cook
with the assistance of her son, watch television, socialize on Facebook, pay bills, handle money,
spend time with her son and attend church. The claimant expressed difficulty driving for more
than twenty minutes at a time. (R. 17, 58).
The claimant further testified that a doctor diagnosed her with diabetes when she was
twenty-seven. She testified that she currently takes insulin at night and Humulin R at every meal.
In addition, she stated that she checks her blood sugar at least six times a day; however, the
medicine does not control her diabetes. She testified that her diabetes has manifested itself
through the neuropathy; has affected her eyesight; and has caused her to constantly have to use
the restroom, particularly at night. (R. 54-57).
The claimant also testified that she experiences depression. When she is depressed, she
does not want to do anything. She stated that as an adult she considered killing herself on one
occasion, but her son helped to bring her out of her suicidal depression. 6 She testified that the
suicidal depression incident lasted a couple of days and required no hospitalization. The claimant
6
The record does not indicate exactly when the suicidal episode happened.
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stated that she has tried to get treatment at Indian Rivers Mental Health Center but has been
unable to because an appointment at the facility is “three years down the line.” The claimant
testified that she is currently taking Prozac to help treat her depression. (R. 49, 56-58).
At the conclusion of the hearing, the ALJ told the claimant that he was going to have two
doctors who contract with the Social Security Administration examine her and submit written
reports on their findings. (R. 61).
Post-Hearing Evaluations with Dr. Storjohann and Dr. Todorov
After the ALJ hearing, Dr. Storjohann conducted a psychological evaluation of the
claimant on February 19, 2016, and Dr. Todorov conducted a physical evaluation of the claimant
on February 29, 2016.
Dr. Storjohann completed an evaluation of the claimant’s psychological capabilities. The
claimant reported to Dr. Storjohann that she struggled with serious depression since she was in
her early teens; that she experienced multiple panic attacks daily before she was on medication;
and that even on medication she still experiences multiple panic attacks every week. As a fifteenyear-old, the claimant attempted suicide by slitting her wrist. The claimant stated that she has
never been psychiatrically hospitalized; attended a woman’s support group for about six months
after being raped when she was twenty-two; and takes psychotropic medication prescribed by her
personal physician. (R. 789-90).
Dr. Storjohann assessed that the claimant has moderate difficulty understanding and
remembering simple instructions; carrying out simple instructions; making judgments on simple
work-related decisions; and interacting appropriately with the public. Dr. Storjohann indicated
that the claimant has marked difficulty understanding and remembering complex instructions;
carrying out complex instructions; making judgments on complex work-related decisions;
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interacting appropriately with supervisor(s); interacting appropriately with co-workers; and
responding appropriately to usual work situations and to changes in a routine work setting. (R.
785-86).
Dr. Storjohann indicated that the claimant was cooperative with the evaluation process
and appeared to make the best effort at answering all questions to the best of her ability. Dr.
Storjohann observed that the claimant was depressed, anxious, and tense. Based on his
evaluation and the claimant’s psychological history, Dr. Storjohann diagnosed the claimant as
having significant mental health difficulties and wrote that her prognosis was poor. He concluded
that she was in need of mental health treatment. (R. 792).
On February 29, 2016, Dr. Todorov conducted a physical examination of the claimant.
The examination included a review of the claimant’s records and past medical history, in
addition to a physical examination. Dr. Todorov found that the claimant could continuously lift
or carry up to ten pounds; frequently lift or carry between eleven and twenty pounds;
occasionally lift or carry between twenty-one and fifty pounds; sit for up to two hours without
interruption; stand for one hour at a time; walk for up to thirty minutes at a time; sit for a total of
four hours in an eight-hour workday; stand for two hours and walk for one hour in an eight-hour
workday; continuously reach and finger on the job; frequently handle, feel, push and pull;
continuously operate foot controls; frequently climb stairs and ramps as well as balance;
occasionally climb ladders or scaffolds, stoop, kneel, crouch or crawl; and had no environmental
limitations. (R. 799-804).
Dr. Todorov concluded that the claimant can do all aspects of daily life but not for long
periods of time; she can do work-related activities in a sitting position and stand and walk for a
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short period of time; her ability to lift and carry is limited; and she can handle objects for short
periods of time. (R. 798).
The ALJ’s Decision
On May 6, 2016, the ALJ issued a decision finding that the claimant was not disabled
under the Social Security Act. First, the ALJ found that the claimant met the insured status
requirements of the Social Security Act through March 31, 2019, and had not engaged in
substantial gainful activity since her alleged onset date of July 14, 2014. (R. 11, 16, 24).
Next, the ALJ found that the claimant had the severe impairments of diabetes mellitus II
(DM2); neuropathy; right carpal tunnel, status post release surgery (CTS); and lumbar
degenerative disc disease (DDD). The ALJ also discussed the claimant’s medically determinable
mental impairments of anxiety, avoidant personality disorder, borderline personality disorder and
depression. The ALJ found that the claimant had no limitation in activities of daily living; mild
limitation in social functioning; no limitation in concentration; and no episodes of
decompensation for an extended duration because she has not been hospitalized for any type of
mental issue. The ALJ supported his findings by pointing to her ability to work as a housekeeper
part-time, care for her son, drive her car, pay bills, and attend church. The ALJ found that the
claimant’s mental impairments, considered singly and in combination, did not cause more than a
minimal limitation in the claimant’s ability to perform basic mental work activities and were
non-severe. (R. 16-19).
The ALJ next found that the claimant did not have an impairment or combination of
impairments that met or medically equaled the severity of one of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1. The ALJ considered whether the claimant met the
criteria of Listing 1.04, related to disorders of the spine. The ALJ determined that the evidence
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failed to show any compromise of the nerve root, which is required to meet the criteria of the
section. In making his determination, the ALJ relied on evidence of an MRI of the lumbar spine
taken on November 26, 2014. The MRI showed a small central disc protrusion at L5-S1 with
crowding of the descending right S1 root, but without definite impingement. Therefore, the ALJ
held that the claimant’s degenerative disc disease did not meet the criteria of Listing 1.04. (R.
19-20).
The ALJ then discussed Dr. Storjohann’s mental examination of the claimant, to which
he gave “some weight.” The ALJ expressed his opinion that the claimant “is certainly not as
limited as opined by Dr. Storjohann.” The ALJ explained that he only gave “some weight” to Dr.
Storjohann’s opinion because the claimant has previous work experience; she currently works as
a part-time housekeeper “with no problems”; she has never received any professional mental
health treatment; her doctors have noted no significant mental limitations; she has only been
treated in the emergency room once for a panic attack after consuming alcohol; she is not
currently taking her Prozac according to a printout of her medications; she has not reported
ongoing mental issues to any doctor; and she had no complaints at her January 2016 follow-up
appointment at Good Samaritan Clinic. (R. 19).
The ALJ also gave “some weight” to Dr. Estock’s opinion that the claimant did not have
any mental impairment. The ALJ noted that the claimant had not alleged any mental impairment
in her application or during her telephone interview with Dr. Estock. However, because of Dr.
Storjohann’s diagnoses and the claimant’s treatment for depression at the Good Samaritan
Clinic, the ALJ found the claimant had depression and other mental impairments, but he listed
them as non-severe. (Id.).
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The ALJ next considered that the claimant has the residual functional capacity to perform
unskilled sedentary work, but not her past relevant work. In making his determination, the ALJ
considered the claimant’s subjective allegations and residual functional capacity and pointed to
discrepancies between medications the claimant testified she took and a Wal-Mart pharmacy
printout indicating prescriptions she has filled. Further, he argued that despite the claimant’s
medical conditions, objective medical evidence did not support the claimant’s complete inability
to work. Additionally, the ALJ pointed to evidence that the claimant’s carpal tunnel syndrome
had healed and that the MRIs showed that the claimant’s degenerative disc disease was not
severe enough to prevent her from performing unskilled sedentary work on a full-time basis. (R.
20, 23).
The ALJ also discussed the claimant’s consultative examination with Dr. Todorov.
Although the ALJ disagreed with Dr. Todorov’s opinion of the length of time the claimant could
sit, he gave “good weight” to the doctor’s opinion. The ALJ concluded by pointing out that the
claimant is currently working on a part-time basis. He reasoned that, if she was truly
experiencing debilitating back and foot pain, she would be unable to work at all. (R. 20-23).
Based on the record as a whole, the ALJ found that the claimant had the residual
functional capacity to perform unskilled sedentary work. Therefore, the ALJ concluded that the
claimant was not disabled as defined in the Social Security Act.
VI. DISCUSSION
The claimant argues that the ALJ erred in the weight he gave to the opinion of
consultating physician Dr. Storjohann because substantial evidence does not support his findings.
This court agrees.
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The ALJ has a responsibility to “consider a number of factors in determining how much
weight to give to each medical opinion: (1) whether the doctor has examined the claimant; (2)
the length, nature, and extent of a treating doctor's relationship with the claimant; (3) the medical
evidence and explanation supporting the doctor's opinion; (4) how consistent the doctor’s
‘opinion is with the record as a whole’; and (5) the doctor’s specialization.” Brown, 442 F.
App’x at 511.
In the present case, Dr. Storjohann professionally examined the claimant. See id. The
ALJ only gave Dr. Storjohann’s post-examination opinion “some weight” because “the claimant
is certainly not as limited as opined by Dr. Storjohann.” The ALJ noted that the claimant worked
in the past and currently works as a housekeeper “with no problems, in particularly [sic]
mentally.” However, the existence of past work experience and the claimant’s ability to dust and
make beds on a part-time basis does not negate the existence of a mental impairment that would
prevent the claimant from working a full-time job.
The ALJ further argued that the claimant was not taking her Prozac, and he relied on the
claimant’s Wal-Mart medication printout from November 5, 2015. The printout appeared to
indicate that the claimant had not filled a prescription since February 2, 2015. However, the ALJ
did not take into account the February 24, 2015, Good Samaritan Clinic appointment at which
the claimant received a prescription refill for Prozac. Furthermore, at her Good Samaritan Clinic
follow-up appointment on November 3, 2015, the report discussed the decrease of the claimant’s
Prozac dosage because she was experiencing sleep problems while taking Prozac. The ALJ also
failed to account for the medication record from Good Samaritan Clinic that included Prozac on
the list of the claimant’s current medications as of December 1, 2015. (See R. 687, 781-82).
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Furthermore, the ALJ contradicted himself in his analysis of the claimant’s lack of mental
impairment. He first stated, “She has not reported ongoing mental issues to any doctor.”
However, in the following paragraph he adds, “However, in light of Dr. Storjohann’s diagnoses
and the fact that claimant has been treated for depression by his [sic] primary care physician at
GSC, the undersigned finds the claimant does have mental impairments.” It cannot be true both
that the claimant has reported no mental issues to any doctor and that the claimant has been
treated for depression by her primary care physician. Furthermore, the ALJ wrote “At her most
recent follow-up with GSC in January 2016 she had no complaints.” However, that statement is
wrong. A Good Samaritan Clinic nurse 7 reported discussing depression, along with three other
issues, with the claimant on January 5, 2016. (R. 19, 778).
Additionally, the ALJ gave “some weight” to the opinions of both Dr. Storjohann and Dr.
Estock. However, these two doctors had diametrically opposite opinions. In Dr. Storjohann’s
opinion, the claimant is severely mentally impaired, whereas Dr. Estock who only had a phone
call with the claimant found that the claimant does not have any mental impairment whatsoever.
The ALJ accorded both opinions “some weight.” Given their completely opposing viewpoints,
the court finds curious that the ALJ could find both equally relevant. The weight of the
substantial evidence in the record appears to support Dr. Storjohann’s opinion more than Dr.
Estock’s opinion.
Although the claimant sought treatment in the emergency room only once for a panic
attack following a night of alcohol consumption, she testified under oath that she suffers from
multiple panic attacks on a weekly basis even while taking her medication. The ALJ noted that
the claimant has never had any professional mental health treatment. But, the ALJ ignored the
fact that the Good Samaritan Clinic referred the claimant to a professional mental health facility,
7
The nurse’s signature on the Good Samaritan Clinic report is illegible.
17
and that the claimant testified that she could not get an appointment because the facility is full. 8
(R. 49).
The ALJ also never addressed the consistent and serious nature of the claimant’s
depression, and the ALJ has a responsibility to view the doctor’s opinion in light of the evidence
as a whole. See Brown, 442 F. App’x at 511. Dr. Storjohann reported that the claimant suffers
from serious depression and attempted suicide at fifteen by cutting her wrists. Furthermore,
Good Samaritan Clinic records between 2014 and 2016 consistently listed depression as an
ongoing, serious issue for the claimant. The ALJ only mentioned the Good Samaritan Clinic
reports and never stated with particularity any level of weight accorded to them or addressed
their discussion of the claimant’s mental concerns. The December 9, 2014, Good Samaritan
Clinic report stated that the claimant’s depression was serious enough that she should be treated
at Indian Rivers Mental Health Center. The ALJ also failed to mention that the claimant testified
under oath that she experienced suicidal depression as an adult. (R. 689, 778-81, 789).
The reasons the ALJ gave to discount Dr. Storjohann’s diagnosis and opinion regarding
the claimant’s mental limitations lack merit and substantial evidence does not support them,
which constitutes reversible error. See Henry, 802 F.3d at 1268 (Because substantial evidence
did not support the ALJ’s determination to give a consulting opinion less weight, the court
reversed.) Furthermore, the ALJ failed to seriously consider or address a significant portion of
the claimant’s mental health record. For these reasons, the court finds that substantial evidence
does not support the ALJ’s disregard of Dr. Storjohann’s opinion regarding the claimant’s mental
limitations.
VII. CONCLUSION
8
The claimant testified under oath that she has been unable to get mental treatment because an appointment at
Indian Rivers Mental Health Center where she was referred is “three years down the line.”
18
For the reasons stated above, this court concludes that the decision of the Commissioner
is due to be REVERSED AND REMANDED for further consideration consistent with this
Memorandum Opinion.
The court will enter a separate Order in accordance with the Memorandum Opinion.
DONE and ORDERED this 21st day of September, 2018.
____________________________________
KARON OWEN BOWDRE
CHIEF UNITED STATES DISTRICT JUDGE
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