Schumacher v. Colvin

Filing 27

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the decision of the Commissioner is REVERSED, and this cause is REMANDED for further proceedings. A separate Judgment in accordance with this Memorandum and Order is entered this same date. Signed by Magistrate Judge Terry I. Adelman on 8/21/2014. (KMS)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION

LINDA W. SCHUMACHER,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

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No. 4:13CV351 TIA

MEMORANDUM AND ORDER
This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial
review of the Commissioner’s final decision denying Linda W. Schumacher’s
application for disability insurance benefits under Title II of the Social Security
Act, 42 U.S.C. §§ 401, et seq., and application for supplemental security income
under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. All matters are pending
before the undersigned United States Magistrate Judge, with consent of the parties,
pursuant to 28 U.S.C. § 636(c). Because the Commissioner’s final decision is not
supported by substantial evidence on the record as a whole, it is reversed.
I. Procedural History
On July 28, 2010, plaintiff Linda W. Schumacher applied for disability
insurance benefits (DIB) and supplemental security income (SSI), claiming she

became disabled on December 31, 2004, because of chronic asthma. (Tr. 126-32,
133-36, 174.) Upon initial consideration, the Social Security Administration
denied plaintiff’s claims for benefits. (Tr. 69-76.) On October 5, 2011, a hearing
was held before an administrative law judge (ALJ) at which plaintiff and a
vocational expert testified. (Tr. 28-62.) On January 20, 2012, the ALJ issued a
decision denying plaintiff’s claims for benefits, finding plaintiff able to perform
work as it exists in significant numbers in the national economy. (Tr. 10-24.) On
December 21, 2012, the Appeals Council denied plaintiff’s request to review the
ALJ’s decision. (Tr. 1-5.) The ALJ’s decision thus stands as the final decision of
the Commissioner. 42 U.S.C. § 405(g).
In the instant action for judicial review, plaintiff raises numerous claims that
the ALJ’s decision is not supported by substantial evidence on the record as a
whole. Specifically, plaintiff challenges the ALJ’s determination regarding her
residual functional capacity (RFC), arguing that the ALJ failed to accord proper
weight to the opinion of her treating physician, Dr. Robins, and failed to include
limitations in the RFC that were supported by the medical records as well as by Dr.
Robins’ opinion. Plaintiff also contends that the ALJ failed to cite medical
evidence to support her RFC determination. Plaintiff also argues that the ALJ
should have ordered a consultative examination regarding the extent to which
plaintiff’s mental impairment affected her ability to work. Finally, plaintiff claims
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that the ALJ erred in finding her subjective complaints not to be credible. Plaintiff
requests that the final decision be reversed and that she be awarded benefits, or that
the matter be remanded for further proceedings. For the following reasons, the
matter will be remanded for further consideration.
II. Testimonial Evidence Before the ALJ
A.

Plaintiff’s Testimony
At the hearing on October 5, 2011, plaintiff testified in response to questions

posed by the ALJ and counsel.
At the time of the hearing, plaintiff was fifty-two years of age. Plaintiff
stands five feet, one inch tall and weighs 127 pounds. (Tr. 35.) Plaintiff left high
school in the ninth grade and never obtained her GED. Plaintiff has received no
vocational or other training. (Tr. 38.) Plaintiff currently receives unemployment
benefits. (Tr. 37.)
Plaintiff’s Work History Report shows that plaintiff worked as a school bus
driver from June 1999 to approximately November 2004. From March to July
2005, plaintiff worked as a bartender and stocker at an Elks Lodge, as well as
performed some clerical work. In 2006 and 2007, plaintiff worked as a
housecleaner. From August 2007 to October 2009, plaintiff again worked as a
school bus driver. (Tr. 205.) Plaintiff testified that she was placed on medical
leave from this last job because of pain, pulmonary irritation, and an inability to
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take her medication on account of the driving requirements of the job. (Tr. 39.)
Plaintiff testified that she was ultimately fired because of her long period of
medical leave. (Tr. 36-37.) Plaintiff testified to other short-term or temporary
employment positions previously held and, further, that she was terminated from
all positions for reasons related to her medical impairments. (Tr. 35, 40-43.)
Plaintiff testified that she was currently unable to work because of
significant breathing difficulties. Plaintiff testified that she frequently is out of
breath with climbing stairs, walking from her car to the grocery store, and walking
through a building. Plaintiff testified that, while at the grocery store, she must lean
on a cart for support. Plaintiff testified that temperature extremes also negatively
affect her breathing. (Tr. 44.) Plaintiff testified that she uses a nebulizer and takes
Albuterol, Singulair, Benadryl, Uniphyl, and Spiriva for her breathing
impairments. (Tr. 47-48.)
Plaintiff testified that she also experiences headaches every day and has
since her childhood. Plaintiff testified that the headaches sometimes make her
sick. (Tr. 44.) Plaintiff testified that she takes Imitrex or Relpax for the condition.
(Tr. 50.)
Plaintiff testified that she also has arthritis in her tailbone that sometimes
feels like a knife or needle going through her back. Plaintiff testified that the pain
sometimes prevents her from standing. Plaintiff testified that she also has pain in
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her right hip that radiates to her knee, which her doctor suggested may be her ACL.
Plaintiff testified that pain in her ankles causes difficulty with standing and
walking, and that fibromyalgia pain in her upper back causes pain and twitching in
her arms and hands. (Tr. 44-45.) Plaintiff testified that she takes Oxycodone and
prescription strength Advil for pain. Plaintiff testified that she also takes Cymbalta
for pain, but that it does not help her condition. Plaintiff testified that she takes
Valium for restless legs. (Tr. 48-49.)
Plaintiff testified that she has kidney stones and scar tissue in her neck, but
no testimony appears in the record that she is affected by these conditions. (Tr. 4647.)
Plaintiff testified that she has depression and anxiety for which she takes
Lexapro. (Tr. 50.) Plaintiff testified that she is uncomfortable in big crowds and
does not go anywhere other than the grocery store, drug store, the doctor’s office,
and the library. Plaintiff testified that she has lost friends and has broken up
relationships. Plaintiff testified that she has what she considers “normal” memory
problems in that she sometimes forgets words or sometimes forgets where she
placed things. (Tr. 52-53.)
As to her exertional abilities, plaintiff testified that she cannot sit for very
long because of a “poking” sensation she feels in her hip and buttocks. Plaintiff
testified that she must shift from side-to-side while sitting. Plaintiff testified that
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she can lift a gallon of milk but must use both hands. (Tr. 51-52.)
As to her daily activities, plaintiff testified that she reads books. Plaintiff
testified that she goes to the library and to the grocery store but gets help with
taking things to the car. Plaintiff testified that she tries to help her sister, who is
seventy years of age, and that she able to do some chores for her while sitting, such
as vacuuming. (Tr. 53-54.) Plaintiff testified that she has a driver’s license and is
able to drive. (Tr. 38.)
B.

Vocational Expert Testimony
Gary Weinholdt, a vocational expert, testified at the hearing in response to

questions posed by the ALJ.
Mr. Weinholdt classified plaintiff’s past relevant work as a school bus driver
as semi-skilled and medium; as a license clerk and a food order expediter as semiskilled and light; and as a telephone solicitor as semi-skilled and sedentary. (Tr.
57-58.)
The ALJ asked Mr. Weinholdt to consider an individual of plaintiff’s age,
education, and past work experience and who could perform work at the light
exertional level. The ALJ asked Mr. Weinholdt to consider the person to be
limited to semi-skilled work and that she must avoid concentrated exposure to
extreme heat, extreme cold, humidity, fumes, odors, dust, gases, and poor
ventilation. Mr. Weinholdt testified that such a person could perform plaintiff’s
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past work as a license clerk, telephone solicitor, and food expediter. (Tr. 58.)
The ALJ then asked Mr. Weinholdt to consider the individual to have the
same exertional and environmental limitations but that she was also limited to
unskilled work and could have only occasional contact with supervisors,
coworkers, and the public and no transactional interaction with the public. Mr.
Weinholdt testified that such a person could not perform the jobs to which he
previously testified, but could perform other work such as an electronic accessory
assembler, of which 1,500 such jobs exist in the State of Missouri and 75,000
nationally; and inspector and hand packager, of which 2,500 such jobs exist in the
State of Missouri and 125,000 nationally. (Tr. 59-60.)
The ALJ then asked Mr. Weinholdt to assume that, in addition to the
limitations set out in the second hypothetical, the person was unable to complete an
eight-hour workday at least twice a week because of her physical problems, to
which Mr. Weinholdt testified that no work would be available for such a person.
(Tr. 60-61.)
III. Medical Evidence Before the ALJ
In December 2003 and January 2004, Dr. D. Helton, D.O., prescribed
Vicodin (hydrocodone) for plaintiff’s chronic headache pain. Plaintiff was also
diagnosed with acute bronchitis; chronic obstructive pulmonary disease (COPD);
and cervical, thoracic, lumbar, and sacral somatic dysfunction. (Tr. 236-38.)
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In February 2004, Dr. Helton noted that plaintiff continued to smoke, but
plaintiff reported that she had not had any recent respiratory problems. Physical
examination was unremarkable. Plaintiff was continued in her diagnoses of
somatic dysfunction, COPD, and chronic headaches. Plaintiff was prescribed
Vicodin and BuSpar and was given samples of Lexapro. (Tr. 235.)
In April 2004, plaintiff reported to Dr. Helton that she experienced shortness
of breath with exertion. Plaintiff continued to smoke and reported that she was not
ready to quit. Plaintiff was diagnosed with bronchitis and was instructed to avoid
smoke, dust, and fumes. (Tr. 232-34.) On April 27, plaintiff requested a refill of
pain medication, reporting that the medication helped but that the pain continued to
be constant. Plaintiff reported the pain not to prevent her from engaging in daily
activities or from working. Plaintiff also reported occasional depressed mood and
diminished energy. It was noted that plaintiff stopped taking Lexapro but
continued to take BuSpar, which helped her anxiety. Psychiatric examination
showed plaintiff to exhibit normal judgment and insight. Memory was intact. No
abnormalities of mood or affect were noted. Physical examination was
unremarkable except for swollen nasal membranes. Dr. Helton diagnosed plaintiff
with somatic dysfunction, chronic headaches, allergic rhinosinusitis, anxiety/
depression, and nicotine addiction. Plaintiff was instructed to restart Lexapro.
BuSpar and Lortab (hydrocodone) were prescribed. (Tr. 232-33.)
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On May 24, 2004, plaintiff reported doing well on her medication.
Plaintiff’s prescriptions for Lortab, BuSpar, and Albuterol were refilled. (Tr. 231.)
On July 6, plaintiff reported to Dr. Helton that she recently had an asthma attack
for which Albuterol provided minimal relief. Scattered expiratory wheezes were
noted upon examination. Loratidine was prescribed. (Tr. 230.) Plaintiff’s
prescriptions for Lortab and BuSpar were refilled in August. (Tr. 229.)
Plaintiff returned to Dr. Helton on November 15, 2004, for medication
refills. Plaintiff complained of lumbar pain. Plaintiff also reported that she injured
her right ankle when she stepped off of some bleachers. Physical examination was
unremarkable. Dr. Helton diagnosed plaintiff with somatic dysfunction, chronic
headaches, COPD, generalized anxiety disorder, and depression. Plaintiff’s
prescriptions for Lortab and BuSpar were refilled. Plaintiff was given samples of
Lexapro. (Tr. 226.) Plaintiff’s medications were again refilled in April 2005, with
samples of Advair given at that time. (Tr. 225.)
Plaintiff’s medications were refilled in July 2005, at which time plaintiff was
also diagnosed with hypertension. Lopressor was prescribed. Physical
examination otherwise was unremarkable. (Tr. 224.) Plaintiff’s prescriptions for
Advair, Albuterol, Lortab, and Lopressor were refilled in October 2005 and again
in February 2006. (Tr. 222-23.)
Plaintiff returned to Dr. Helton’s office on March 10, 2006, and complained
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of dizziness. Plaintiff also reported having difficulty getting her medication refills.
Physical examination was unremarkable. Plaintiff was continued in her diagnoses
of somatic dysfunction, chronic headaches, COPD, generalized anxiety disorder,
depression, and hypertension. Plaintiff’s prescriptions were refilled. (Tr. 221.)
On June 5, 2006, plaintiff visited Dr. Helton for follow up and reported that
her depression was well controlled with Lexapro. Physical examination was
unremarkable. Plaintiff’s prescription for Lortab was refilled, and samples of
Lexapro were given. (Tr. 218.) Physical examination in August continued to be
unremarkable. Plaintiff’s prescriptions for Lortab, Lopressor, Advair, and
Albuterol were refilled. Samples of Lexapro were given. (Tr. 217.)
In October 2006, plaintiff reported to Dr. Helton that she had increased
shortness of breath and wheezing associated with a cold. Dr. Helton diagnosed
plaintiff with pneumonia. Dr. Helton prescribed valproic acid and Tramadol for
headaches. On December 9, plaintiff reported that the Tramadol did not help.
Valproic acid and Vicodin were prescribed. (Tr. 215-16.)
Plaintiff visited Dr. David L. Pittenger, D.O., on January 24, 2007, for pain
management regarding her headaches and back pain. It was noted that plaintiff
was “now able to hold down a job.” Dr. Pittenger diagnosed plaintiff with
migraine and tension headaches, as well as unstable low back. Plaintiff was
prescribed Lopressor, Wellbutrin, and Lorcet (hydrocodone). (Tr. 291.) In
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February, Dr. Pittenger noted plaintiff to wheeze. Plaintiff continued to complain
of headaches. Plaintiff was diagnosed with depression, hypertension, cervical
dysfunction, and headaches. Plaintiff was instructed to discontinue Lopressor
because of wheezing, and Diltiazem was prescribed. Wellbutrin and Albuterol
were also prescribed. (Tr. 290.)
Plaintiff visited Dr. Pittenger on April 3, 2007, for medication refills and
continued to complain of headaches. Plaintiff also complained of cough and
fatigue. Plaintiff was diagnosed with bronchiolitis, migraine headaches, and
cervical dysfunction. Lexapro, Diltiazem, and Lorcet were prescribed. (Tr. 289.)
Plaintiff returned to Dr. Pittenger on April 27 after having twisted her ankle. Dr.
Pittenger also noted plaintiff’s chronic low back pain. Plaintiff was prescribed
Advil, Lorcet, and Advair. Plaintiff was instructed to rest, ice, and elevate her
ankle. (Tr. 288.)
On May 21, 2007, plaintiff reported to Dr. Pittenger that her pain was
controlled with Lorcet. It was noted that plaintiff was not using Advair. Wheezing
was noted with expiration. Plaintiff was diagnosed with chronic lower back pain
and asthma and was prescribed Lorcet and Advair. In June, plaintiff reported to
Dr. Pittenger that her medication was stolen. Dr. Pittenger had a long discussion
with plaintiff regarding her pain medication. Plaintiff’s medications were refilled,
including Lorcet. In July, plaintiff returned to Dr. Pittenger for an adjustment to
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her back and for medication refills. Plaintiff’s prescriptions were again refilled in
August. (Tr. 284-87.)
Plaintiff visited Dr. Pittenger on October 3, 2007, and reported having
shortness of breath. Wheezing was noted upon inspiration and expiration.
Plaintiff was diagnosed with bronchiolitis and was prescribed medication,
including Albuterol and Advair. In November, Dr. Pittenger noted continued
wheezing and headaches. Lorcet, Symbicort, and Singulair were prescribed. It
was noted that plaintiff had been off of Lexapro for two weeks. On December 1,
plaintiff’s Lorcet was refilled for lumbosacral dysfunction. On December 31,
plaintiff’s prescriptions were refilled for reactive depression and chronic low back
pain. (Tr. 280-83.)
Between January and May 2008, plaintiff visited Dr. Pettinger on five
occasions for medication refills for her back, headache, and bronchiolitis
conditions. (Tr. 275-79.) On June 2, plaintiff complained of continued coughing,
and Dr. Pettinger noted wheezing and coughing upon examination. Symbicort,
Zyrtec, and Chantix were prescribed. (Tr. 274.) Dr. Pettinger also determined to
discontinue plaintiff’s narcotic medication (id.); but on July 7, he prescribed Lorcet
for sciatica pain and sacroiliac pain. Plaintiff also reported having cramps in her
feet at that time. (Tr. 273.) Plaintiff’s prescriptions for Lorcet, Singulair, and
Symbicort were refilled on July 29. (Tr. 272.)
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Between August and December 2008, plaintiff visited Dr. Pettinger on six
occasions for medication management of chronic low back pain, allergic rhinitis,
sciatica, bronchiolitis, and asthma. Plaintiff’s prescriptions were repeatedly
refilled during this period, including for Lorcet, Symbicort, and Albuterol. (Tr.
266-71.) Between January and March 2009, plaintiff visited Dr. Pettinger on four
occasions for medication refills. (Tr. 262-65.)
On March 25, 2009, plaintiff reported to Dr. Pettinger that her lower back
had not been okay since fall. Plaintiff reported the pain to be in her tailbone, low
back, and right leg. Plaintiff reported that her hips “stopped.” Cough and mucous
production was also noted. Plaintiff was diagnosed with degenerative joint disease
of the low back and asthmatic bronchiolitis, and medication was prescribed. (Tr.
262.)
On April 20, 2009, Dr. Pettinger refilled plaintiff’s prescription for Lorcet,
and Wellbutrin and Paxil were added to plaintiff’s medication regimen for reactive
depression. On May 4, Dr. Pettinger noted increased wheezing and prescribed
Prednisone. Plaintiff was instructed to discontinue her tobacco use. On May 13,
plaintiff complained of headache pain, and Dr. Pettinger refilled her prescription
for Lorcet. (Tr. 259-61.)
On June 9, 2009, plaintiff continued to complain of headaches and of
wheezing. Dr. Pettinger counseled plaintiff on discontinuing tobacco and
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“codone.” Dr. Pettinger diagnosed plaintiff with uncontrolled hypertension,
chronic pain, and bronchial asthma. Plaintiff was instructed to discontinue Paxil.
Wellbutrin and Lorcet were prescribed. (Tr. 258.)
Between July and December 2009, plaintiff visited Dr. Pettinger on seven
occasions for medication refills for her conditions of asthma, low back and hip
pain, and hypertension. (Tr. 250-57.) On December 23, plaintiff reported to Dr.
Pettinger that she was having crying and panic episodes. Dr. Pettinger restarted
plaintiff on Lexapro. Plaintiff also reported that her headaches and wheezing had
not improved. Symbicort and Singulair were prescribed. (Tr. 250.) Prednisone
and Tramadol were prescribed on January 4, 2010, and plaintiff was referred to a
neurologist. (Tr. 249.) On January 13, Dr. Pettinger diagnosed plaintiff with TMJ
dysfunction, asthma, and reactive depression. Lexapro, Singulair, Symbicort, and
Lorcet were prescribed. (Tr. 248.)
On February 26, 2010, plaintiff complained of increased pain to Dr.
Pettinger but reported that her muscle weakness and fatigue had improved.
Plaintiff also reported being happy with Lexapro and Wellbutrin. Physical
examination showed no wheezing. Dr. Pettinger noted plaintiff’s depression to be
controlled. Dr. Pettinger continued to diagnose plaintiff with asthma, chronic
headaches and back pain, several allergies, and possible viral syndrome.
Medication was prescribed, including Lorcet and Wellbutrin. (Tr. 312.)
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An x-ray taken of the lumbar spine on March 8, 2010, yielded negative
results. (Tr. 293.) Pulmonary function tests performed in March 2010 showed
moderately severe obstruction prior to the administration of medication, with
significant improvement after medication. (Tr. 296-97.)
On March 25, 2010, plaintiff complained to Dr. Pettinger of increased
wheezing. Plaintiff was continued on her medications. (Tr. 311.) On April 21,
plaintiff reported that she experiences difficulty breathing when walking more than
thirty feet. Plaintiff also continued to complain of chronic low back pain. Plaintiff
was continued on her medications, and a nebulizer was prescribed. Nebulizer
treatment was provided at the appointment for shortness of breath. (Tr. 309.) On
May 18, plaintiff’s medications were refilled for her diagnosed conditions of
bronchiolitis and headaches. Celexa was also prescribed. (Tr. 308.) Plaintiff’s
prescriptions for Lorcet, Celexa, and Wellbutrin were refilled in June (Tr. 305);
and on July 27, plaintiff was switched from Lexapro to Cymbalta. (Tr. 303.)
Plaintiff visited Dr. Pettinger on August 5, 2010, and reported having pain in
her low back and neck. Plaintiff also reported that she experiences numbness in
her buttocks and has problems standing. Plaintiff’s prescriptions were refilled.
(Tr. 302.) Plaintiff’s prescription for Lorcet was refilled again on August 30. (Tr.
301.) On September 27, plaintiff’s prescriptions were refilled for her diagnosed
conditions of lumbosacral dysfunction, sciatica, and hypertension. (Tr. 325.)
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On September 28, 2010, James Morgan, Ph.D, a psychological consultant
with disability determinations, completed a Psychiatric Review Technique Form in
which he opined that plaintiff’s mental impairments were not severe, finding
plaintiff to have no limitations in activities of daily functioning and in
concentration, persistence, or pace; mild limitations in maintaining social
functioning; and no repeated episodes of decompensation of extended duration.
(Tr. 313-23.)
On October 21, 2010, plaintiff reported to Dr. Pettinger that she cannot sleep
when taking Cymbalta and that she feels “whacked out.” Dr. Pettinger continued
in his diagnoses of chronic low back pain and migraine headaches. Dr. Pettinger
instructed plaintiff to discontinue Singulair and to double her dosage of Nasonex.
Plaintiff’s prescriptions for Cymbalta and Lorcet were refilled. (Tr. 324.)
Plaintiff visited Patients First Health Care (Patients First) on November 16,
2010, who noted plaintiff’s history of uncontrolled asthma. It was noted that
plaintiff stopped smoking one month prior. It was noted that plaintiff’s chronic
lumbar back pain was stable and controlled with her current medication. No
depression was noted. Plaintiff was instructed to restart Singulair and to continue
with Ventolin, Symbicort, and Spiriva for her asthma and COPD conditions.
Plaintiff was also prescribed Uniphyl. Plaintiff was instructed to continue with
Lorcet for her chronic back pain. (Tr. 326.)
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Plaintiff returned to Patients First on December 14, 2010, and reported that
her motivation, interest, and irritability had improved with Cymbalta but that
taking an increased dose made her “feel funny.” Plaintiff denied any depression or
anxiety. Plaintiff reported having persistent shortness of breath with exertion less
than fifty feet. It was noted that plaintiff’s chronic lumbar back pain and
depression were stable, and plaintiff was continued on Lorcet and Cymbalta.
Plaintiff was instructed to return in one month. (Tr. 351.)
On January 11, 2011, plaintiff visited Dr. Christina A. Robins at Patients
First for medication refills and for evaluation of a cough. Physical examination
was unremarkable. Dr. Robins refilled plaintiff’s prescription for hydrocodone for
lumbago and Cymbalta for depression, which Dr. Robins noted to be controlled.
Dr. Robins also noted plaintiff’s asthma to be controlled. Dr. Robins’ other
diagnoses included cough, hypertension, and general osteoarthritis. (Tr. 348-50.)
Plaintiff returned to Dr. Robins on February 8, 2011, and reported her back
pain to be relieved with pain medication. Dr. Robins noted the condition to be
under fair control, and plaintiff’s prescription for Lorcet was refilled. Plaintiff
complained of muscle pain, however, and specifically in her right thigh and
shoulder area when sitting too long or if she moves her arm too far. Physical
examination was normal. Dr. Robins determined plaintiff’s cough and depression
to be improved and that plaintiff’s asthma was under fair control. Plaintiff’s
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hypertension was noted to be under good control. (Tr. 345-47.) On March 3, Dr.
Robins noted plaintiff’s conditions to be under fair control. Plaintiff was doing
well with her depression, but she reported irritable mood and loss of energy and
was having some difficulties meeting home, work, or social obligations. Physical
examination was normal. Plaintiff’s prescriptions for Lorcet, Cymbalta, Uniphyl,
Singulair, and Proair were refilled. (Tr. 342-44.)
Plaintiff returned to Dr. Robins on March 24, 2011, for follow up of mixed
hyperlipidemia, fibromyalgia, generalized osteoarthritis, and benign hypertension.
Dr. Robins noted plaintiff’s chronic problems to also include depression, lumbago,
and asthma. Plaintiff reported her pain to be in her low back and that it was
aggravated by daily activities and by changing positions, but relieved by her
medication. Dr. Robins noted plaintiff’s fibromyalgia and osteoarthritis pain to be
controlled with Vicodin and Cymbalta. Dr. Robins also noted plaintiff’s
hypertension and hyperlipidemia to be fairly controlled. (Tr. 340-41.)
Plaintiff returned to Dr. Robins for medication refills on April 19, 2011, and
reported increased anxiety because of a friend having a stroke. Dr. Robins also
noted an acute asthma exacerbation, and a nebulizer was ordered with instruction
for nebulizer treatment two to four times every day. (Tr. 337-39.)
Plaintiff was admitted to Urgent Care on April 29, 2011, with increased
symptoms of anxiety and depression. Dr. Amy Couch noted the exacerbation of
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symptoms to be related to the recent death of a friend and to marital discord.
Mental status examination showed plaintiff to be anxious and tearful but was
otherwise unremarkable. Plaintiff was instructed to continue with her medications
and a prescription for Valium was given. Plaintiff was also instructed to continue
with her asthma medications for her increased cough. (Tr. 334-36.)
Plaintiff returned to Dr. Robins on May 31, 2011, who noted plaintiff’s
depression to be under poor control and not to have improved with Lexapro.
Plaintiff reported irritable mood and loss of energy on most days. Dr. Robins
instructed plaintiff to continue with Cymbalta and Lexapro, and Abilify was
prescribed. Plaintiff was also advised to seek counseling. (Tr. 331-33.)
On June 20, 2011, Dr. Robins noted plaintiff’s depression to be mild and
that it had improved with the addition of Abilify. Plaintiff’s dosage was increased.
Dr. Robins also noted plaintiff’s lumbago and asthma to be improved and stable,
and that plaintiff’s fibromyalgia had improved. Plaintiff reported having
intermittent migraine headaches and a recent onset of right knee pain, aggravated
by bending. Physical examination was unremarkable. Plaintiff was continued on
her pain medications. (Tr. 328-30.)
Plaintiff was admitted to the emergency room at Jefferson Regional Medical
Center on July 14, 2011, with complaints of having paranoid thoughts for six
weeks that people are in her house and she is being followed. Plaintiff reported
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that she hears people speaking to her when she is alone, telling her to harm herself.
Plaintiff reported having called the authorities on numerous occasions to report that
she is being stalked. Plaintiff denied any suicidal thoughts. Physical examination
was normal in all respects. Plaintiff was uncooperative for a mental status
examination. Plaintiff’s mood was noted to be depressed and her thought process
was illogical. Plaintiff’s insight was noted to be poor and her judgment was
impaired. Plaintiff’s memory was intact. Plaintiff was admitted to the hospital
with an admitting diagnosis of psychosis. (Tr. 354-75.)
Upon admission to Jefferson Regional Medical Center, plaintiff underwent a
psychiatric evaluation from which she was diagnosed with schizoaffective
disorder, panic, and anxiety. Plaintiff was assigned a Global Assessment of
Functioning score of 40, and Dr. Ahmad Ardekani determined to place plaintiff on
antipsychotic medication. Plaintiff likewise underwent a physical examination and
complained of knee pain and muscle pain but denied any other complaints. It was
noted that plaintiff smoked. Physical examination was normal in all respects.
Baclofen was given for muscle pain and Motrin for knee pain. On July 18,
plaintiff had no physical complaints. Plaintiff was discharged on July 19 with a
discharge diagnosis of bipolar, mixed. Dr. Ardekani noted plaintiff’s condition to
stabilize during hospitalization, and plaintiff was discharged in improved condition
with a prescription for Seroquel. Plaintiff also requested that she be given a
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prescription for Baclofen inasmuch as it helped her fibromyalgia pain. (Tr. 376403.)
Plaintiff visited Dr. Robins on August 1, 2011, and reported that her
depression had improved but that she stopped taking Abilify because of paranoia.
Dr. Robins noted plaintiff’s condition to be improving slowly and instructed her to
continue with Valium, Cymbalta, and Lexapro. Plaintiff also complained of back
pain with numbness as well as a recent onset of dizziness. Plaintiff reported her
low back, tailbone, and hips to be aching worse than usual. Dr. Robins opined that
plaintiff’s fibromyalgia pain was slightly worse because of increased activity.
Plaintiff was instructed to continue to use her arms and work in the yard in order to
work on strength. Physical examination showed mild arthralgia and myalgia in the
upper and lower extremities, bilaterally. No focal signs or symptoms were noted.
Dr. Robins noted plaintiff’s strength to be good in the bilateral upper and lower
extremities. Plaintiff’s pain medications were refilled. (Tr. 407-09.)
Plaintiff returned to Dr. Robins on August 30, 2011, and reported
improvement in her conditions. Plaintiff reported that she was seeing a counselor
for her depression. Plaintiff requested samples of medications to better control her
migraines. Physical examination was normal. Plaintiff’s medications were
refilled, and plaintiff was prescribed Asthmanex for an acute exacerbation of her
asthma. (Tr. 411-13.)
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On September 7, 2011, Dr. Robins completed a Medical Source Statement
(MSS) in which she opined that plaintiff could frequently and occasionally lift up
to ten pounds; stand continuously for thirty minutes and for a total of one hour in
an eight-hour workday; sit continuously for thirty minutes and for a total of one
hour in an eight-hour workday; and push and/or pull continuously for thirty to
forty-five minutes and for a total of one hour in an eight-hour workday. Dr.
Robins further opined that plaintiff needed to recline for thirty minutes, three or
four times a day; assume a supine position for thirty minutes, three or four times a
day; and elevate both feet for thirty minutes, three to four times a day. Dr. Robins
opined that plaintiff could occasionally bend, kneel, and reach and could frequently
handle and feel. Dr. Robins opined that plaintiff should never be exposed to
heights, temperature extremes, fumes, or vibration, and could occasionally be
exposed to machinery. Dr. Robins reported that plaintiff experienced these
limitations on account of her uncontrolled fibromyalgia, as demonstrated by pain
in the bilateral upper and lower extremities; her moderately controlled asthma,
which is easily exacerbated with fumes and temperature changes; and her lumbar
disc disease/lumbar strain. Dr. Robins reported that plaintiff’s pain was not fully
controlled with medication and that she was unable to fully retain her job in the
past because of her physical limitations. (Tr. 404-06.)

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IV. The ALJ's Decision
The ALJ found that plaintiff met the insured status requirements of the
Social Security Act through December 31, 2014. The ALJ found that plaintiff had
not engaged in substantial gainful activity since December 31, 2004, the alleged
onset date of disability. The ALJ found plaintiff’s asthma/COPD, fibromyalgia,
and mental disorder to be severe impairments, but that plaintiff did not have an
impairment or combination of impairments that met or medically equaled an
impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 15-18.)1 The
ALJ found that plaintiff had the RFC to perform light work as defined in the
Regulations, with additional limitations that she avoid concentrated exposure to
extreme heat, extreme cold, humidity, fumes, odors, dust, gases, and poor
ventilation; and be limited to performing unskilled work with only occasional
contact with supervisors, co-workers, and the public with no transactional
interaction with the public. (Tr. 18.) The ALJ determined plaintiff unable to
perform any of her past relevant work. Considering plaintiff’s age, education,
work experience, and RFC, the ALJ determined vocational expert testimony to
support a finding that plaintiff could perform other work as it exists in significant
numbers in the national economy, and specifically, electronic accessory assembler
1

Although the ALJ found plaintiff’s headaches and hypertension to be medically determinable
impairments, she determined them to be non-severe. The ALJ further determined plaintiff’s
history of back pain not to be a medically determinable impairment. (Tr. 16.) Plaintiff does not
challenge these findings.
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and inspector/hand packager. The ALJ therefore found that plaintiff was not under
a disability from December 31, 2004, through the date of the decision. (Tr. 22-24.)
V. Discussion
To be eligible for DIB and SSI under the Social Security Act, plaintiff must
prove that she is disabled. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir.
2001); Baker v. Secretary of Health & Human Servs., 955 F.2d 552, 555 (8th Cir.
1992). The Social Security Act defines disability as the "inability to engage in any
substantial gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or which has lasted or
can be expected to last for a continuous period of not less than 12 months." 42
U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). An individual will be declared disabled
"only if [her] physical or mental impairment or impairments are of such severity
that [she] is not only unable to do [her] previous work but cannot, considering [her]
age, education, and work experience, engage in any other kind of substantial
gainful work which exists in the national economy." 42 U.S.C. §§ 423(d)(2)(A),
1382c(a)(3)(B).
To determine whether a claimant is disabled, the Commissioner engages in a
five-step evaluation process. See 20 C.F.R. §§ 404.1520, 416.920; Bowen v.
Yuckert, 482 U.S. 137, 140-42 (1987). The Commissioner begins by deciding
whether the claimant is engaged in substantial gainful activity. If the claimant is
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working, disability benefits are denied. Next, the Commissioner decides whether
the claimant has a “severe” impairment or combination of impairments, meaning
that which significantly limits her ability to do basic work activities. If the
claimant's impairment(s) is not severe, then she is not disabled. The Commissioner
then determines whether claimant's impairment(s) meets or equals one of the
impairments listed in 20 C.F.R., Subpart P, Appendix 1. If claimant's
impairment(s) is equivalent to one of the listed impairments, she is conclusively
disabled. At the fourth step, the Commissioner establishes whether the claimant
can perform her past relevant work. If so, the claimant is not disabled. Finally, the
Commissioner evaluates various factors to determine whether the claimant is
capable of performing any other work in the economy. If not, the claimant is
declared disabled and becomes entitled to disability benefits.
The decision of the Commissioner must be affirmed if it is supported by
substantial evidence on the record as a whole. 42 U.S.C. § 405(g); Richardson v.
Perales, 402 U.S. 389, 401 (1971); Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir.
2002). Substantial evidence is less than a preponderance but enough that a
reasonable person would find it adequate to support the conclusion. Johnson v.
Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001). This “substantial evidence test,”
however, is “more than a mere search of the record for evidence supporting the
Commissioner’s findings.” Coleman v. Astrue, 498 F.3d 767, 770 (8th Cir. 2007)
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(internal quotation marks and citation omitted). “Substantial evidence on the
record as a whole . . . requires a more scrutinizing analysis.” Id. (internal quotation
marks and citations omitted).
To determine whether the Commissioner's decision is supported by
substantial evidence on the record as a whole, the Court must review the entire
administrative record and consider:
1.

The credibility findings made by the ALJ.

2.

The plaintiff's vocational factors.

3.

The medical evidence from treating and consulting physicians.

4.

The plaintiff's subjective complaints relating to exertional and
non-exertional activities and impairments.

5.

Any corroboration by third parties of the plaintiff's
impairments.

6.

The testimony of vocational experts when required which is
based upon a proper hypothetical question which sets forth the
claimant's impairment.

Stewart v. Secretary of Health & Human Servs., 957 F.2d 581, 585-86 (8th Cir.
1992) (internal citations omitted). The Court must also consider any evidence
which fairly detracts from the Commissioner’s decision. Coleman, 498 F.3d at
770; Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir. 1999). However, even
though two inconsistent conclusions may be drawn from the evidence, the
Commissioner's findings may still be supported by substantial evidence on the
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record as a whole. Pearsall, 274 F.3d at 1217 (citing Young v. Apfel, 221 F.3d
1065, 1068 (8th Cir. 2000)). “[I]f there is substantial evidence on the record as a
whole, we must affirm the administrative decision, even if the record could also
have supported an opposite decision.” Weikert v. Sullivan, 977 F.2d 1249, 1252
(8th Cir. 1992) (internal quotation marks and citation omitted); see also Jones ex
rel. Morris v. Barnhart, 315 F.3d 974, 977 (8th Cir. 2003).
In this cause, plaintiff challenges the manner and method by which the ALJ
determined her RFC, arguing that the ALJ improperly weighed the medical
opinion of her treating physician and failed to cite sufficient medical evidence to
support the RFC conclusion. Plaintiff claims the record to demonstrate that she
experiences limitations in addition to those found by the ALJ and that a
consultative psychological evaluation should have been ordered. Plaintiff also
claims that the ALJ erred in her analysis finding plaintiff’s subjective complaints
not to be credible. Because the ALJ’s final decision is not supported by substantial
evidence on the record as a whole, the matter will be remanded for further
proceedings.
A.

Credibility
Before determining a claimant’s RFC, the ALJ must first evaluate the

claimant’s credibility. Wagner v. Astrue, 499 F.3d 842, 851 (8th Cir. 2007); Tellez
v. Barnhart, 403 F.3d 953, 957 (8th Cir. 2005). In so doing, the ALJ must consider
- 27 -

all evidence relating to the claimant’s subjective complaints, including the
claimant’s prior work record and third party observations as to the claimant's daily
activities; the duration, frequency and intensity of the symptoms; any precipitating
and aggravating factors; the dosage, effectiveness and side effects of medication;
and any functional restrictions. Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir.
1984) (subsequent history omitted). When rejecting a claimant's subjective
complaints, the ALJ must make an express credibility determination detailing her
reasons for discrediting the testimony. Renstrom v. Astrue, 680 F.3d 1057, 1066
(8th Cir. 2012); Cline v. Sullivan, 939 F.2d 560, 565 (8th Cir. 1991). “It is not
enough that inconsistencies may be said to exist, the ALJ must set forth the
inconsistencies in the evidence presented and discuss the factors set forth in
Polaski when making credibility determinations.” Cline, 939 F.2d at 565; see also
Renstrom, 680 F.3d at 1066; Beckley v. Apfel, 152 F.3d 1056, 1059-60 (8th Cir.
1998). Where an ALJ explicitly considers the Polaski factors but then discredits a
claimant’s complaints for good reason, the decision should be upheld. Hogan v.
Apfel, 239 F.3d 958, 962 (8th Cir. 2001); see also Casey v. Astrue, 503 F.3d 687,
696 (8th Cir. 2007). The determination of a claimant’s credibility is for the
Commissioner, and not the Court, to make. Tellez, 403 F.3d at 957; Pearsall, 274
F.3d at 1218.
Here, plaintiff claims that the ALJ did not sufficiently discuss her reasons to
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discredit plaintiff’s subjective complaints and failed to cite to evidence in the
record that was inconsistent with her complaints. Plaintiff’s claim is without merit.
In her written decision, the ALJ set out numerous, detailed inconsistencies in
the record to support her determination that plaintiff’s subjective complaints were
not fully credible. The ALJ first noted that plaintiff’s daily activities were
inconsistent with her complaints of disabling physical and mental limitations,
specifically noting that plaintiff’s claimed physical limitations on account of her
shortness of breath and pain were inconsistent with the record that showed that
plaintiff continued to smoke, helped with household chores including vacuuming,
prepared meals, and drove alone to make trips to the grocery store and to the
library. The ALJ also noted that plaintiff manages her own medications, pays her
own bills, and manages her own savings and checking accounts. Plaintiff’s
Function Report also shows her to visit with family and friends, care for her own
needs, watch television, read, crochet, and periodically attend church. (See Tr.
183-90.) Such activities are inconsistent with plaintiff’s allegations of disability
due to physical and mental impairments. Perks v. Astrue, 687 F.3d 1086, 1092-93
(8th Cir. 2012); Halverson v. Astrue, 600 F.3d 922, 932 (8th Cir. 2010). The ALJ
also noted that plaintiff’s receipt of unemployment benefits after her alleged onset
date was inconsistent with her claim of disability inasmuch as the acceptance of
such benefits implies that she is able and available for work. See Barrett v.
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Shalala, 38 F.3d 1019, 1024 (8th Cir. 1994).
The ALJ also noted that plaintiff’s medications effectively controlled her
impairments, see Brace v. Astrue, 578 F.3d 882, 885-86 (8th Cir. 2009) (evidence
showed that, when taken, medication was successful in controlling mental illness);
Perks, 687 F.3d at 1092-93 (conservative treatment for back pain with medication,
coupled with reports that medication worked well to cover pain); Clevenger v.
Social Sec. Admin., 567 F.3d 971, 976 (8th Cir. 2009) (appropriate credibility
determination included finding that claimant was “overall improved” after taking
pain medication); and no evidence in the record shows plaintiff to have
experienced side effects from her medication that were not abated with an
adjustment to the medication. See Ellis v. Barnhart, 392 F.3d 988, 996 (8th Cir.
2005) (no record of adverse side effects from medication). In addition, the ALJ
noted plaintiff’s treatment to be conservative in nature in that plaintiff was never
treated by any specialist nor required frequent hospitalizations. See Perks, 687
F.3d at 1092-93 (conservative treatment for back pain consisted of medication
only, which was effective); Black v. Apfel, 143 F.3d 383, 386 (8th Cir. 1998). But
see Cox v. Apfel, 160 F.3d 1203, 1208 (8th Cir. 1998) (consistent diagnosis of
chronic low back pain coupled with long history of pain management and drug
therapy consistent with subjective complaints of pain).
The ALJ cited to isolated instances of plaintiff’s noncompliance with her
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treatment regimen to support her finding that plaintiff’s complaints were not
entirely credible. While a claimant’s noncompliance with prescribed treatment is a
basis upon which to find subjective complaints not credible, the undersigned finds
the limited circumstances here upon which the ALJ relies, that is, forgetting to pick
up blood pressure medication from the pharmacy in June 2006 (Tr. 218), being
unable to afford to fill a prescription for Medrol Dosepak in November 2009 (Tr.
253), and being out of Singulair in November 2010 (Tr. 326) not to rise to such a
level that plaintiff’s complaints should be discredited on this basis. Cf. Brown v.
Barnhart, 390 F.3d 535, 542 (8th Cir. 2004) (ALJ properly discredited subjective
complaints for, inter alia, claimant’s “continuing failure to comply with prescribed
treatments.”). However, given the ALJ’s numerous other well-supported reasons
to discredit plaintiff’s subjective complaints, this one factor does not serve as a
basis to reverse the ALJ’s credibility decision. Cf. Hepp v. Astrue, 511 F.3d 798,
806 (8th Cir. 2008) (deficiency does not require reversal when it has no bearing on
outcome).
Accordingly, in a manner consistent with and as required by Polaski, the
ALJ considered plaintiff’s subjective complaints on the basis of the entire record
and set out numerous inconsistencies that detracted from her credibility. Because
the ALJ’s determination not to credit plaintiff’s subjective complaints is supported
by good reasons and substantial evidence, this Court must defer to this
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determination. Renstrom, 680 F.3d at 1065; Goff v. Barnhart, 421 F.3d 785, 793
(8th Cir. 2005); Vester v. Barnhart, 416 F.3d 886, 889 (8th Cir. 2005).
B.

Opinion Evidence
Upon concluding that plaintiff’s subjective complaints were not entirely

credible, the ALJ turned to the September 2011 MSS completed by plaintiff’s
treating physician, Dr. Robins, and accorded it little weight, finding it to be
inconsistent with her own treatment notes and with other evidence of record and,
further, that it was based primarily on plaintiff’s subjective complaints rather than
on any diagnostic evidence. For the following reasons, the ALJ did not err in
according little weight to Dr. Robins’ opinion.
In evaluating opinion evidence, the Regulations require the ALJ to explain
in the decision the weight given to any opinions from treating sources, non-treating
sources, and non-examining sources. See 20 C.F.R. §§ 404.1527(f)(2)(ii),
416.927(f)(2)(ii).2 The Regulations require that more weight be given to the
opinions of treating physicians than other sources. 20 C.F.R. §§ 404.1527(d)(2),
416.927(d)(2). A treating physician's assessment of the nature and severity of a
claimant's impairments should be given controlling weight if the opinion is well
supported by medically acceptable clinical and laboratory diagnostic techniques
2

Citations to 20 C.F.R. §§ 404.1527 and 416.927 are to the 2011 version of the Regulations,
which were in effect at the time the ALJ rendered the final decision in this cause. This
Regulation’s most recent amendment, effective March 26, 2012, reorganizes the subparagraphs
relevant to this discussion but does not otherwise change the substance therein.
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and is not inconsistent with other substantial evidence in the record. 20 C.F.R. §§
404.1527(d)(2), 416.927(d)(2); see also Forehand v. Barnhart, 364 F.3d 984, 986
(8th Cir. 2004). This is so because a treating physician has the best opportunity to
observe and evaluate a claimant's condition,
since these sources are likely to be the medical professionals most
able to provide a detailed, longitudinal picture of [a claimant's]
medical impairment(s) and may bring a unique perspective to the
medical evidence that cannot be obtained from the objective medical
findings alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations.
20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2).
When a treating physician's opinion is not given controlling weight, the
Commissioner must look to various factors in determining what weight to accord
the opinion. 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). Such factors include the
length of the treatment relationship and the frequency of examination, the nature
and extent of the treatment relationship, whether the treating physician provides
support for her findings, whether other evidence in the record is consistent with the
treating physician's findings, and the treating physician's area of specialty. 20
C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). The Regulations further provide that the
Commissioner “will always give good reasons in [the] notice of determination or
decision for the weight [given to the] treating source's opinion.” 20 C.F.R. §§
404.1527(d)(2), 416.927(d)(2).
Here, the ALJ properly discounted Dr. Robins’ MSS inasmuch as it was
- 33 -

inconsistent with her own treatment notes. The ALJ specifically noted that Dr.
Robins’ statement in the MSS that plaintiff’s fibromyalgia was uncontrolled was
wholly inconsistent with her treatment notes that consistently noted the impairment
to be controlled or “fairly” controlled. See Martise v. Astrue, 641 F.3d 909, 925
(8th Cir. 2011) (ALJ may justifiably discount treating physician’s opinion when it
is inconsistent with her own clinical treatment notes). The ALJ also noted that
none of Dr. Robins’ treatment records indicate that plaintiff was restricted or
limited in any respect, and especially not to the degree as opined in the MSS
checklist form. An ALJ is permitted to discount a treating physician’s MSS
“where the limitations listed on the form ‘stand alone’ and were ‘never mentioned
in [the physician’s] numerous records of treatment’ nor supported by ‘any
objective testing or reasoning.’” Reed v. Barnhart, 399 F.3d 917, 921 (8th Cir.
2005) (quoting Hogan, 239 F.3d at 961). See also Teague v. Astrue, 638 F.3d 611,
615 (8th Cir. 2011) (little evidentiary weight accorded to functional limitations set
out in MSS check-off form because previous treatment notes did not report any
significant limitations); Halverson, 600 F.3d at 930 (inconsistency between
treating physician’s treatment records and his functional assessment provides good
reason for ALJ to discount physician’s opinion). The ALJ also noted that Dr.
Robins appeared to rely quite heavily on plaintiff’s subjective complaints to render
her opinion inasmuch as there were few, if any, diagnostic examinations upon
- 34 -

which she could base her opinion. Where a physician’s opinions are largely based
on a claimant’s subjective complaints rather than on objective findings, an ALJ
does not err in giving such opinions less than controlling weight. Renstrom, 680
F.3d at 1064.
Because the ALJ’s determination to accord little weight to Dr. Robins’
September 2011 MSS is supported by good reasons and substantial evidence, the
Court defers to this determination.
C.

RFC Determination
Residual functional capacity is the most a claimant can do despite her

physical or mental limitations. Masterson v. Barnhart, 363 F.3d 731, 737 (8th Cir.
2004). The ALJ bears the primary responsibility for assessing a claimant’s RFC
based on all relevant, credible evidence in the record, including medical records,
the observations of treating physicians and others, and the claimant’s own
description of her symptoms and limitations. Goff, 421 F.3d at 793; Eichelberger
v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004); 20 C.F.R. §§ 404.1545(a),
416.945(a). Because a claimant’s RFC is a medical question, some medical
evidence must support the ALJ’s RFC determination. Vossen v. Astrue, 612 F.3d
1011, 1016 (8th Cir. 2010); Eichelberger, 390 F.3d at 591; Hutsell v. Massanari,
259 F.3d 707, 711-12 (8th Cir. 2001). As such, the ALJ must “consider at least
some supporting evidence from a [medical professional]” and should obtain
- 35 -

medical evidence that addresses the claimant’s ability to function in the workplace.
Hutsell, 259 F.3d at 712 (internal quotation marks and citation omitted). An ALJ’s
RFC assessment which is not properly informed and supported by some medical
evidence in the record cannot stand. Id.
Here, a review of the ALJ’s decision shows that upon discrediting plaintiff’s
complaints and Dr. Robins’ opinion, the ALJ simply determined that her RFC
assessment was supported by the evidence of record and was thus warranted. (Tr.
22.) In setting out her RFC assessment, however, the ALJ cited and discussed only
that evidence of record that served to discredit plaintiff’s complaints and Dr.
Robins’ opinion. (See Tr. 18-22.) The ALJ engaged in no discussion or analysis
of the evidence – and, indeed, cited no evidence – as it related to plaintiff’s RFC,
that is, what she is able to do despite her impairments. Drawing a conclusion
regarding credibility is not equivalent to demonstrating by medical evidence that a
claimant has the RFC to perform certain work-related activities. Estabrook v.
Apfel, 14 F. Supp. 2d 1115, 1122 (S.D. Iowa 1998), cited approvingly in Graham
v. Colvin, No. 4:12-cv-00863-SPM, 2013 WL 3820613, at *7 (E.D. Mo. July 23,
2013) (memorandum opinion). Instead, the ALJ’s RFC assessment must discuss
and describe how the evidence supports each conclusion and cite specific medical
facts (e.g., laboratory findings), nonmedical evidence (e.g., daily activities,
observations), and resolution of any material inconsistencies or ambiguities in the
- 36 -

evidence of record. Soc. Sec. Ruling (SSR) 96-8p, 1996 WL 374184, at *7 (Soc.
Sec. Admin. July 2, 1996). The ALJ wholly failed to do so here.
The ALJ determined plaintiff to have the RFC to engage in light exertional
work3 except that she “must avoid concentrated exposure to extreme heat, extreme
cold, humidity, fumes, odors, dust, gasses and poor ventilation” and is “limited to
performing unskilled work with only occasional contact with supervisors, coworkers and the public with no transactional interaction with the public.” (Tr. 18.)
While the medical evidence of record spans from December 2003 to September
2011, no evidence from any medical source refers to plaintiff’s ability to engage in
work-related activities on or after her alleged onset date of disability, other than
Dr. Robins’ September 2011 MSS which was properly accorded little weight.
While there is some record evidence that plaintiff was instructed as early as April
2004 to avoid smoke, dust, and fumes; exhibited good strength and mild arthralgia/
myalgia in August 2011; and showed no abnormalities with examination during
routine appointments for medication refills, there is no credited medical evidence
that addresses plaintiff’s ability to perform work-related activities on a regular and
continuing basis. See SSR 96-8p, 1996 WL 374184, at *7. The ALJ made no
specific findings regarding plaintiff’s ability to lift, carry, stand, walk, or sit, other
3

Light work involves “lifting no more than 20 pounds at a time with frequent lifting or carrying
of objects weighing up to 10 pounds. . . . [A] job is in this category when it requires a good deal
of walking or standing, or when it involves sitting most of the time with some pushing and
pulling of arm or leg controls.” 20 C.F.R. §§ 404.1567(b), 416.967(b).
- 37 -

than that she was generally limited to light work. Nor did she provide any
explanation or refer to any evidence of record to support her finding that plaintiff’s
exposure to pulmonary irritants was limited to only concentrated exposure.
Indeed, the ALJ cites to no medical evidence at all to support any of the limitations
she identified. Lauer v. Apfel, 245 F.3d 700 (8th Cir. 2001) (ALJ’s decision
unclear as to the medical basis for the RFC assessment).
While the Court is mindful that the plaintiff bears the burden to establish her
RFC, the ALJ’s duty to develop the record is independent of this burden. Snead v.
Barnhart, 360 F.3d 834, 838 (8th Cir. 2004). Here, the plaintiff produced
sufficient medical evidence to support the medically determinable impairments as
found by the ALJ. However, none of this evidence addresses the extent to which
these impairments, both severe and non-severe, affect plaintiff’s ability to perform
work-related activities on or after December 31, 2004.4 Nevertheless, without
citing to any medical or other evidence, the ALJ concluded that plaintiff’s
impairments caused a number of limitations, including non-exertional limitations.
Because the ALJ must articulate the medical and other evidence upon which she
bases her RFC determination, and she failed to do so here, it cannot be said that the
RFC determination is supported by substantial evidence on the record as a whole.
4

An RFC assessment must consider the combined effects of a claimant’s severe and non-severe
medically determinable impairments. Ford v. Astrue, 518 F.3d 979, 981 (8th Cir. 2008); 20
C.F.R. §§ 404.1545(a)(2), 416.945(a)(2).
- 38 -

In the absence of any thoughtful discussion or analysis by the ALJ, this Court
would be required to weigh the evidence in the first instance or review the factual
record de novo in order to find the ALJ’s RFC assessment to be supported by
substantial evidence on the record as a whole. This the Court cannot do. See
Naber v. Shalala, 22 F.3d 186, 188 (8th Cir. 1994).
Where records from a claimant’s medical sources do not provide sufficient
medical evidence upon which an ALJ may determine whether a claimant is
disabled, the ALJ is required to order medical examinations and tests in order for
her to make an informed decision. Dozier v. Heckler, 754 F.2d 274, 276 (8th Cir.
1985); 20 C.F.R. §§ 404.1517, 416.917. Given the sufficient medical evidence of
record establishing plaintiff’s medically determinable impairments, but the dearth
of medical evidence addressing plaintiff’s ability to perform work-related
activities, the ALJ upon remand shall further develop the record by ordering
consultative examination(s) to determine the extent to which plaintiff’s physical
and mental impairments, both severe and non-severe, affect her ability to perform
work-related activities. Upon receipt of such additional information, the ALJ shall
reconsider the record as a whole, including the medical and nonmedical evidence
of record as well as plaintiff’s own description of her symptoms and limitations,
and reassess plaintiff’s RFC. Such reassessed RFC shall be based on some
medical evidence in the record and shall be accompanied by a discussion and
- 39 -

description of how the evidence supports each RFC conclusion. Cox v. Astrue, 495
F.3d 614, 619 (8th Cir. 2007); SSR 96-8p, 1996 WL 374184, at *7.
VI. Conclusion
For all of the foregoing reasons, the Commissioner’s decision is not
supported by substantial evidence on the record as a whole and the case shall be
remanded to the Commissioner for further consideration. Inasmuch as a claimant’s
RFC is a medical question and some medical evidence must support the ALJ’s
RFC determination, the Commissioner shall obtain medical evidence upon remand
that addresses plaintiff’s ability to function in the workplace. In view of the
additional evidence to be procured upon remand, which may support or detract
from plaintiff’s subjective complaints, plaintiff’s credibility shall likewise be
reassessed in light of the fully developed record.
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is
REVERSED, and this cause is REMANDED for further proceedings.
A separate Judgment in accordance with this Memorandum and Order is
entered this same date.

__/s/ Terry I. Adelman_________________
UNITED STATES MAGISTRATE JUDGE
Dated this 21st day of __August___, 2014.
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