Ingram v. Colvin

Filing 17

MEMORANDUM AND ORDER - THEREFORE, IT IS ORDERED: The Commissioner's decision is affirmed. This case is dismissed;. The parties shall bear their own costs. A separate judgment will be entered. Ordered by Judge John M. Gerrard. (TCL )

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEBRASKA
TERRI SUE INGRAM,
Plaintiff,

4:14-CV-3036

vs.
MEMORANDUM AND ORDER
CAROLYN W. COLVIN, Acting
Commissioner of the Social Security
Administration,
Defendant.
This matter is before the Court on the denial, initially and upon
reconsideration, of plaintiff Terri Sue Ingram's application for disability
insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401 et
seq. The Court has considered the parties' filings and the administrative
record. For the reasons discussed below, the Commissioner's decision is
affirmed.
I. PROCEDURAL BACKGROUND
Ingram applied for disability insurance benefits on January 25, 2011.
T58, 106.1 Her claim was denied initially and on reconsideration. T106–110.
Ingram appealed and requested a hearing from an administrative law judge
(ALJ). T133–34. The ALJ held a hearing on September 19, 2012. T55–105. In
a decision dated September 26, 2012, the ALJ found that Ingram was not
disabled as defined under 42 U.S.C. §§ 416(i) or 423(d), and therefore not
entitled to benefits. T55–74.
Disability, for purposes of the Social Security Act, is defined 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. §§ 416(i) & 423(d).
To determine whether a claimant is entitled to disability benefits, the
ALJ performs a five-step sequential analysis. 20 C.F.R. § 404.1520(a)(4). At
All citations to the administrative record (filings 16 through 16-10) are given as "T
[Transcript]" followed by the page number.
1

step one, the claimant has the burden to establish that she has not engaged
in substantial gainful activity since her alleged disability onset date. Cuthrell
v. Astrue, 702 F.3d 1114, 1116 (8th Cir. 2013). If the claimant has engaged in
substantial gainful activity, she will be found not to be disabled; otherwise, at
step two, she has the burden to prove she has a medically determinable
physical or mental impairment or combination of impairments that
significantly limits her physical or mental ability to perform basic work
activities. Id.
At step three, if the claimant shows that her impairment meets or
equals a presumptively disabling impairment listed in the regulations, she is
automatically found disabled and is entitled to benefits. Id. Otherwise, the
analysis proceeds to step four, but first, the ALJ must determine the
claimant's residual functional capacity (RFC), which is used at steps four and
five. 20 C.F.R. § 404.1520(a)(4). A claimant's RFC is what she can do despite
the limitations caused by any mental or physical impairments. Toland v.
Colvin, 761 F.3d 931, 935 (8th Cir. 2014). At step four, the claimant has the
burden to prove she lacks the RFC to perform her past relevant work.
Cuthrell, 702 F.3d at 1116. If the claimant can still do her past relevant work,
she will be found not to be disabled; otherwise, at step five, the burden shifts
to the Commissioner to prove, considering the claimant's RFC, age,
education, and work experience, that there are other jobs in the national
economy the claimant can perform. Id.; Jones v. Astrue, 619 F.3d 963, 971
(8th Cir. 2010).
Ingram alleged disability primarily as a result of fibromyalgia. T60–61,
77, 106, 109. She alleged a disability onset date of March 1, 2010. T58, 175.
At that time, Ingram was 35 years old. T109. The ALJ found that, based on
her earnings record, Ingram could remain insured through September 30,
2015. T58. Thus, the question before the ALJ was whether Ingram had
demonstrated that she was disabled for some period of not less than 12
months from between March 1, 2010 to September 30, 2015.
At step one, the ALJ found that Ingram had not engaged in substantial
gainful activity following her alleged onset date. Next, at step two, the ALJ
found that Ingram's fibromyalgia was a severe impairment.2 At step three,
the ALJ found that Ingram had no impairment that met or medically equaled
a listed impairment. T60–62. The ALJ then determined that Ingram had the
RFC to perform light work, with the following additional limitations: she was
Ingram also alleged disability as a result of mixed personality disorder, anxiety, and
depression. However, the ALJ found that these conditions imposed no more than minimal
limitations on Ingram's ability to function, and were therefore non-severe. T61. Ingram has
not objected to this finding, and so the Court will not discuss these conditions any further.
2

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limited to occasionally lifting or carrying 20 pounds and frequently lifting or
carrying 10 pounds; she could stand, sit, or walk for 6 hours out of an 8-hour
workday; she could occasionally perform postural activities such as climbing,
balancing, stooping, kneeling, crouching, and crawling; and she should not
work on ladders or with dangerous hazards or equipment. T62.
At step four, the ALJ found, based upon the testimony of a vocational
expert ("VE"), that Ingram retained the ability to perform her past relevant
work as a day care worker, clinical therapist, secretary, and social services
aide. T67, 99. Alternatively, the ALJ went on to find at step five that Ingram
was not disabled under the Medical-Vocational Guidelines (the "Grids"), see
20 C.F.R. pt. 404, subpt. P, app. 2. T67. And as a further alternative at step
five, the ALJ found, based on the VE's testimony, that Ingram could perform
other jobs that existed in significant numbers in the national economy. T67–
68, 100–101. Specifically, the VE testified and the ALJ found that Ingram
could perform the full range of unskilled light and sedentary work. T67–68,
100–101. So, the ALJ found that Ingram was not disabled. T68.
On December 12, 2013, after receiving additional evidence (T6–20, 25–
41, 45–54), the Appeals Council of the Social Security Administration denied
Ingram's request for review. T1–4. Ingram's complaint (filing 1) seeks review
of the ALJ's decision as the final decision of the Commissioner under
sentence four of 42 U.S.C. § 405(g).
II. STANDARD OF REVIEW
The Court reviews a denial of benefits by the Commissioner to
determine whether the denial is supported by substantial evidence on the
record as a whole. Bernard v. Colvin, 774 F.3d 482, 486 (8th Cir. 2014).
Substantial evidence is less than a preponderance but is enough that a
reasonable mind would find it adequate to support the conclusion. Id. The
Court must consider evidence that both supports and detracts from the ALJ's
decision, and will not reverse an administrative decision simply because some
evidence may support the opposite conclusion. Id.; Whitman v. Colvin, 762
F.3d 701, 706 (8th Cir. 2014). If, after reviewing the record, the Court finds it
is possible to draw two inconsistent positions from the evidence and one of
those positions represents the ALJ's findings, the Court must affirm the
ALJ's decision. Bernard, 774 F.3d at 486.
III. FACTUAL BACKGROUND
Ingram has alleged disability as a result of various symptoms
associated with her fibromyalgia. Briefly stated, Ingram claims that she
experiences fatigue, pain, and difficulty concentrating. See, e.g., T89–90, 247–
48. She also alleges that she experiences pain if she sits, stands, or walks for
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any significant period of time, and as a result she must frequently change
positions or rest. See, e.g., T89, 251. Specifically, Ingram claimed that she
could walk for only 10 minutes and stand for only 15 minutes before needing
to sit or lie down, and could only sit for 15 to 20 minutes before needing to
stand up or lie down. T251.
At the time of her alleged onset date of March 1, 2010, Ingram was
working full-time as a mental health therapist. T88, 185, 203. She had
obtained a master's degree in counseling in 2009. T85. Before that Ingram
worked in various positions, including full-time positions as a daycare
provider and as a secretary. T85–88, 98, 203. In March 2010, Ingram was
married, with two children, who were approximately 8 and 10 years old. T84.
Later in 2010, she and her husband separated (and eventually divorced), and
in October 2010 Ingram and her children began residing with Ingram's
parents. Ingram was thus the children's primary caregiver for most of the
period under consideration. T84, 403.
On April 6, 2010, Ingram met with her primary care physician,
Timothy Fischer, M.D., complaining of fatigue and "terrible," diffuse muscle
pain for the past several weeks, as well as fevers and difficulty sleeping. She
became tearful when discussing her work, which was a "very large source of
stress" for her. T265. Fischer referred her for various laboratory tests and
recommended that she remain off work for the time being. T265. In the
following weeks, Ingram continued to report fevers and muscle cramping,
although the cramps improved somewhat when she began taking potassium
supplements. Fischer continued to keep her off work, but did not prescribe
any medication other than probiotics for complaints of diarrhea. On April 26,
Ingram reported that she felt like she was getting better, although she still
had daily muscle cramps. Fischer cleared her to return to work on May 3
without restrictions and planned to recheck her condition in 3 months. T261,
262–65, 443.
Although Ingram was cleared to return to work, there is some
ambiguity in the record as to when she actually ceased working as a
therapist. In a disability report from February 2011, Ingram stated that she
stopped working on March 1, 2010, and that this was due to her conditions.
T202–03. She testified similarly at the hearing, stating that she worked as a
therapist until March 2010, at which time she "became bedridden." T88. But
these claims are contradicted by the contemporaneous notes from Fischer,
which suggest she was still working. See T261, 265, 357. And Ingram later
told another doctor that she worked as a therapist until July 2010, but quit
when they "'got rid of [her] whole department.'" T404. Ingram explained that,
at that time, she was offered an alternative full-time position, but she
declined it because she did not feel well enough to work full-time. T404.
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In any event, after Fischer told Ingram that she could return to work,
Ingram stopped seeing Fischer. Instead, in May 2010 Ingram began
treatment with Catherine Pallas, APRN, MSN.3 T338–39 357. Pallas met
with Ingram on May 21. Ingram complained of experiencing muscle and joint
pain for the past 10 weeks or more, fatigue, mental fogginess, and irritable
bowel syndrome. She rated her pain as an 8 out of 10. T339–340. An
examination revealed tenderness in the arms, legs, and shoulders. T338.
Pallas diagnosed Ingram with fibromyalgia and prescribed Savella.4 On June
3, Ingram telephoned Pallas, reporting adverse side effects, and Pallas
advised her to taper off the Savella. T337.
Beginning in July 2010 and continuing throughout the period under
consideration, Ingram worked part-time as an editor for a company that
produces youth ministry materials. T88–89, 234. The job involved editing and
researching, and using a computer to write and edit, and sitting for a total of
about 2 hours. T234–35. Ingram explained that the job accommodated her
need for frequent breaks and allowed her to choose her hours to accommodate
her symptoms as needed. T235. She generally worked between 2 and 8 hours
a week, averaging about 4 hours a week. See, e.g., T93, 194–97, 403.
Ingram next saw Pallas on September 21, 2010. On examination, her
extremities were not tender, although she moved with a guarded gait and
was observed to be shifting in her chair almost continually. T335. Ingram
reported that she lacked energy and was struggling to keep up with her
housework and working 10 hours a week, that she could not vacuum due to
back pain, and that she even had trouble washing dishes. T335–36. Pallas did
not prescribe any further medication and discussed the possibility of
pursuing disability. T335. Then, on October 22, Pallas drafted a letter in
which she opined that Ingram "cannot do any type of physical labor outside
or even inside the home for at least a full year." T321.
Other than a visit in November 2010 for a sinus infection, T333–34,
Ingram did not meet with Pallas again until March 25, 2011. At her March
visit, Ingram continued to report constant pain; yet she was still not taking
any medications. T471–72. That same day, Pallas filled out a "Fibromyalgia
Impairment Questionnaire" for Ingram. Pallas wrote that Ingram met the
diagnostic criteria for fibromyalgia, and suffered from migraine headaches
Pallas is an advanced practice registered nurse (APRN) with a Master of Science in
Nursing (MSN).
3

Savella (milnacipran) belongs to the same class of medications as many antidepressants
and is used to treat fibromyalgia. U.S. Nat'l Library of Med., Nat'l Insts. of Health,
MedlinePlus, Milnacipran, https://www.nlm.nih.gov/medlineplus/druginfo/meds/a609016.ht
ml (last visited March 19, 2015) [hereinafter "MedlinePlus"].
4

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and irritable bowel syndrome. Pallas opined that Ingram's prognosis was
poor, considering the severity of Ingram's reported symptoms, which Pallas
believed were reasonably consistent with her condition. T350–51.
Among various responses on the questionnaire, Pallas opined that in an
8-hour day, Ingram could only sit, stand, and walk for 0 to 1 hour; that
Ingram could not sit, stand, or walk continuously in a work setting; and that
Ingram would need to get up and move around every 20 minutes. T353.
Pallas wrote that Ingram could occasionally lift up to 10 pounds, but never
more, and could occasionally carry up to 5 pounds, but never more. T353. And
Pallas believed Ingram was "[i]ncapable of even 'low stress' jobs." T353.
Finally, Pallas opined that Ingram would frequently need to take 15-20
minute breaks, and that Ingram's symptoms would cause her to miss work
more than 3 times a month. T354.
Also in March 2011, Ingram completed a form describing her symptoms
and daily activities. T220. Ingram would get her children ready for school and
drive them there. She would take a nap when she returned home, then try to
do laundry or shopping, or if she was not too "foggy," some editing work.
T220. In the afternoon Ingram would pick up her children from school but by
then her "energy [was] pretty much gone." T220. She could drive most days,
but some days she found her reflexes were too slow from fatigue and on those
days she would arrange for rides. Ingram's mother did most of the cooking,
but that was because her mother's kitchen was disorganized and Ingram had
difficulty finding what she needed. But Ingram also stated that she prepared
her own meals, and sometimes prepared her children's meals. Ingram could
wash dishes, but usually found it painful by the end. She could only vacuum
half a room at a time and found pushing the vacuum painful. Ingram found
using the stairs painful, and could do light housework but not "major
scrubbing [or] cleaning" as these were too painful. T220.
Ingram's hobbies included reading and making jewelry. She was "not
too limited with the reading" although she had "foggy days" when she was
unable to read. T221. Ingram made 1 or 2 pieces of jewelry every couple of
weeks; after making these she would feel pain in her shoulders and hands.
She attended church weekly and sang in the praise team, and attended
rehearsal once a week (although at times she was too tired to attend
rehearsal). T221.
Ingram's description of her symptoms was consistent with her previous
reports. She reported that her sleep was not restorative and she was fatigued;
she experienced debilitating pain on a daily basis; and she had difficulty
sitting, standing, and walking for any length of time without pain. T221–22.
Despite these symptoms, Ingram was still not taking any medications. T223.

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In April 2011, Ingram underwent a consultative physical examination
with Jared Adams, M.D. She continued to report similar symptoms, and
rated her pain as 15 out of 10. However, she was not taking any medications.
T357–59. On examination, Ingram reported pain in all 18 trigger points for
fibromyalgia. However, Adams noted that she also reported pain in general
throughout her body and with any touching. T361. Adams noted that
fibromyalgia is diagnosed based on symptoms rather than any specific
laboratory or diagnostic test, and that he could not rule out or completely
verify the diagnosis. He concluded:
Unfortunately this makes her exam somewhat inconclusive as
diagnostically she appears to have fibromyalgia and its
associate[d] signs and symptoms, however, subjectively it
appears that in her personal life, this is not preventing her from
doing activities such as [activities of daily living], caring for
children, and should not likely interfere with her . . . job as an
editor.
T362.
In June 2011, Ingram began treatment with David Rutz, M.D. She was
still not taking any medication and her June visit was primarily to address a
sinus infection. T393. In July 2011, Rutz evaluated Ingram, noted the
presence of multiple tender points on examination, and diagnosed her with
fibromyalgia. Rutz began Ingram on a prescription for Lyrica and discussed
the use of other treatments such as stimulants and the occasional use of
analgesics.5 T393.
On July 15, 2011, Ingram called Rutz and reported side effects from the
Lyrica, including wooziness, headaches, and fatigue. Rutz instructed her to
decrease the dosage. Three days later Ingram reported that the side effects
had resolved and Rutz instructed her to try increasing it to a level still below
the initial prescription. Three days after that, Ingram reported that the
increased dosage was again causing undesirable side effects, so Rutz
discontinued the medication. T437.
On July 28, 2011, William Stone, Jr., Ph.D., conducted a psychological
consultative examination of Ingram. Although Stone's focus was Ingram's
psychological symptoms, he made certain observations that pertain to her
fibromyalgia symptoms. First, Stone observed that despite Ingram's reports
Lyrica (pregabalin) is used to treat neuropathic pain and fibromyalgia. MedlinePlus,
Pregabalin, https://www.nlm.nih.gov/medlineplus/druginfo/meds/a605045.html (last visited
March 19, 2015).
5

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of ongoing pain, she evidenced no involuntary indicators of pain or
discomfort. T401, 406. Stone observed that Ingram was living with her
parents, and did not clean the house generally, but cleaned her own room, her
daughters' room, and their bathroom, and that she was able to care for her
children "without difficulty." T404. Ingram stated she liked to watch
television, that she read "a lot" and was in a book club that met once a
month. T404. She liked to crochet and make jewelry, and was able to make
jewelry by "'forcing' herself to do so;" and she was making some for her
daughters' school fundraiser. T404. After reviewing Ingram's hobbies and
activities of daily living, Stone noted that Ingram "describes a range of
leisure and social activities despite a level of pain and discomfort she finds
prohibitive for activities such as employment." T406. And Stone "could not
avoid observing that Ms. Ingram was smiling and cheerful much of the time
during the interview and that the parameters and demands for being
interviewed and providing information in an office are highly similar to the
parameters of office attendance for her profession." T406.
Ingram met with Rutz again in August 2011. Rutz began prescribing
Cymbalta and methylphenidate.6 In September, Ingram reported to Rutz that
the Cymbalta had helped with her anxiety and depression but had not
relieved her pain or fatigue. The methylphenidate was making her
tremulous, and she agreed to try a lower dose. Rutz prescribed tramadol for
pain.7 Ingram saw Rutz again November 1 for a follow-up. She reported that
she had found a significant benefit from the tramadol. Ingram stated if she
took too many, she became "loopy," but Rutz noted the medication was
tolerated reasonably well. T436–37. Rutz did not adjust her medications and
determined that they should continue the tramadol as part of a plan to
proceed to narcotic treatment for chronic pain. T437. Rutz also interviewed
Ingram for 35 minutes and filled out a form for Social Security benefits, but
this form does not appear in the record. On November 30, Ingram returned to
Rutz, reporting that the methylphenidate was helping her fatigue, the
tramadol continued to help, and the Cymbalta had improved her mood. T436.

Cymbalta (duloxetine) is used to treat depression, anxiety, and fibromyalgia. MedlinePlus,
Duloxetine, https://www.nlm.nih.gov/medlineplus/druginfo/meds/a604030.html (last visited
March 19, 2015). And methylphenidate (sometimes sold as Ritalin) is a stimulant used
primarily to treat attention deficit hyperactivity disorder. MedlinePlus, Methylphenidate,
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682188.html (last visited March 19,
2015).
6

Tramadol is used to relieve moderate to moderately severe pain. MedlinePlus, Tramadol,
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html (last visited March 19,
2015).
7

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Rutz continued these medications and changed her from a monthly to 3month follow-up. T436.
Ingram next saw Rutz in February 2012. She continued to report a
benefit from the Cymbalta and tramadol, but stated that she was often
fatigued to the point where she had to nap for 4 hours, up to 3 to 4 times a
week. The methylphenidate was helping with her fatigue but she did not use
it every day. Rutz continued the other medications and recommended that
she increase the daytime dose of methylphenidate to see if she could reduce
her need to nap and return to a normal sleep cycle. T494.
Rutz met with Ingram again in May 2012. Ingram reported that she
found marijuana to be the most helpful treatment for her fibromyalgia
symptoms. Rutz wrote that he could not prescribe methylphenidate if she was
using marijuana, which Ingram accepted, stating that the methylphenidate
was not working that well. Rutz refilled her tramadol and cancelled the
methylphenidate prescription but made no other changes to her treatment.
T494. Rutz saw Ingram again in September 2012 to fill out a disability form,
and continued the same medication regime. T493.
Ingram submitted two opinions from Rutz: a letter from May 2012 and
an "Impairment Questionnaire" from September 2012. T468, 483. In the
letter, Rutz briefly described Ingram's reported symptoms and his course of
treatment. He opined that her prognosis was poor based on her lack of
response and "continued fatigue and inability to sustain any type of energy
expenditure which has resulted in a significant inability to maintain
employment." T468. Rutz further opined that Ingram needed to rest
frequently throughout the day and could not maintain "significant physical
exertion" because of pain and fatigue. T468. He did not believe she could
maintain full or part-time employment due to her frequent pain and fatigue.
T468–69.
Rutz's opinion in the September 2012 Impairment Questionnaire was
similar to his May 2012 letter, and similar to Pallas' earlier opinion. He
estimated that Ingram's pain was a 7 to 8 out of 10 and her fatigue was
either a 9 to 10, or maybe a 10—the form is not clear. T485. Like Pallas, Rutz
estimated that Ingram could only sit, stand, and walk for up to 1 hour a day;
that Ingram could not sit, stand, or walk continuously; that Ingram needed to
get up and move or rest approximately every 15 to 20 minutes; and that
Ingram would be absent from work more than 3 days a month. T485–86, 488–
89. Rutz stated that Ingram could frequently carry and lift up to 5 pounds,
occasionally carry and lift up to 10 pounds, and could never carry or lift any
greater weight. T486. Rutz felt that Ingram could not perform a full-time,
competitive job that required activity on a sustained basis. Unlike Pallas, he
believed Ingram was capable of low-stress jobs. T488.
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In September 2012, Ingram responded to a set of interrogatories
regarding, among other things, her symptoms and daily activities. Her
responses to these questions were essentially the same as her responses in
the March 2011 form. Later that month, at the hearing before the ALJ,
Ingram testified concerning her symptoms and daily activities. Again, her
testimony was generally consistent with her earlier responses. See T89–91,
93–96, 246–254.
Following the September 2012 hearing before the ALJ, Ingram
submitted several new records, including treatment notes from a new
physician and a physician specializing in pain management that she began
seeing in November 2012. See, e.g., T26–30, 46–50. The Appeals Counsel
considered all of the new records, but found that they related to a period
following the date of the ALJ's hearing decision and were therefore not
material. T2.
The Appeals Council will only consider additional evidence if the
evidence "relates to the period on or before the date of the administrative law
judge hearing decision." 20 C.F.R. § 404.970(b). Evidence that is generated
after the ALJ's hearing decision may still relate to the preceding period and
thus be considered material. See Williams v. Sullivan, 905 F.2d 214, 216 (8th
Cir. 1990). However, Ingram has not objected to the Appeal Council's finding
that the new records were not material, nor has she discussed the records.
IV. ANALYSIS
Briefly stated, Ingram presents two arguments. Both concern the ALJ's
determination of her RFC. First, Ingram contends that the ALJ erred in
finding her to be less than fully credible in her testimony regarding the
limiting effects of her impairments. Second, Ingram argues that the ALJ
erred in failing to afford greater weight to, and incorporate the limitations
suggested by, the opinions of Pallas and Rutz.
A. Credibility Determination
The credibility of a claimant's subjective testimony is primarily for the
ALJ to decide. Vossen v. Astrue, 612 F.3d 1011, 1017 (8th Cir. 2010). The
ALJ's credibility determination will be upheld if the ALJ provides good
reasons for discounting the claimant's subjective complaints—such as
inconsistencies in the record or the factors set forth in Polaski v. Heckler, 739
F.2d 1320, 1322 (8th Cir. 1984)—and those reasons are supported by
substantial evidence. Grable v. Colvin, 770 F.3d 1196, 1202 (8th Cir. 2014).8
The Polaski factors include: (1) the claimant's daily activities; (2) the duration, intensity,
and frequency of pain; (3) the precipitating and aggravating factors; (4) the dosage,
effectiveness, and side effects of medication; (5) any functional restrictions; (6) the
8

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The ALJ found that Ingram was only minimally credible in her description of
the persistence, intensity, and limiting effects of her symptoms. The Court
finds that the ALJ's determination was supported by appropriate reasons and
substantial evidence.
First, the ALJ observed that the medical treatment Ingram received
was conservative and routine in nature. T65–66. From March 2010 through
July 2011, her only treatment consisted of a single brief trial of fibromyalgia
medication, which she quickly discontinued after reporting adverse side
effects. T337. Rutz attempted another brief trial of a different fibromyalgia
medication in July 2011, but quickly discontinued it after Ingram reported
side effects. T393, 437. Thereafter, his treatment was routine and
conservative in nature, consisting of prescribing tramadol for pain, Cymbalta
for depression, and methylphenidate for fatigue. And Ingram reported that
the tramadol helped her significantly, and that the Cymbalta helped her
anxiety and depression. And, for a time, she reported that the
methylphenidate helped her fatigue. See, e.g., T393, 436–37, 493–94. But, the
ALJ noted, Ingram's providers did not take further steps that might be
expected, such as recommending warm water therapy or referring her to a
specialist such as a rheumatologist. T64–65. The ALJ also noted that
Ingram's claims of debilitating pain and fatigue were inconsistent with her
use of medications. Other than the brief trial of Savella in May 2010, Ingram
took no medications, prescription or even non-prescription, from March 2010
through July 2011. See T204, 223, 230, 335, 471–72. The ALJ properly
considered both Ingram's minimal treatment and limited use of medications
as weighing against her credibility. See, Wagner v. Astrue, 499 F.3d 842, 851
(8th Cir. 2007); Depover v. Barnhart, 349 F.3d 563, 566 (8th Cir. 2003).
Substantial evidence also supports the ALJ's observation that Ingram's
activities of daily living were inconsistent with her self-reported limitations.
Ingram reported that she could only walk for about 10 minutes and stand for
about 15 minutes before she needed to sit or lie down, and could only sit for
15 to 20 minutes before needing to stand up or lie down. See, e.g., T93, 251.
Despite this, Ingram was the primary caregiver for her two children. She was
able to do some household chores; attend church twice a week to rehearse and
sing in the praise team; spend time with friends; watch movies and read;
make jewelry; and work (albeit minimally) as an editor. T66. Admittedly,
Ingram claimed that some of these activities resulted in pain and fatigue, and
these activities do not by themselves show that Ingram was capable of
working. But the ALJ properly viewed the variety and extent of these
claimant's work history; and (7) the absence of objective medical evidence to support the
claimant's complaints. Polaski, 739 F.2d at 1322; see also 20 C.F.R. § 404.1529(c)(3)(i–vii).

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activities as inconsistent with Ingram's reportedly debilitating symptoms.
See, e.g., Steed v. Astrue, 524 F.3d 872, 876 (8th Cir. 2008).
The ALJ also observed that Ingram made inconsistent and exaggerated
statements regarding her symptoms. See T66. For example, Ingram testified
that in March 2010 she became "bedridden." T88. But as the ALJ noted, the
record contained no treatment notes for that month, and while she did seek
treatment in April, the notes do not suggest that she was bedridden. Instead,
she was given minimal treatment consisting of probiotics and kept off work
for a few weeks, but then released to return to work without restrictions. T66,
261, 262–65, 443. The record contains other incidents of exaggerated
symptoms and inconsistences. For example, in April 2011 Ingram told the
consultative examiner that her pain was a 15 out of 10. T357. Yet, as
discussed above, she was not undergoing any treatment or taking any
medications. The ALJ properly considered such exaggerations and
inconsistencies in discrediting Ingram's testimony. See, Grable, 770 F.3d at
1202; Gray v. Apfel, 192 F.3d 799, 804 (8th Cir. 1999).
B. Opinions of Pallas and Rutz
In determining Ingram's RFC, the ALJ gave "little weight" to the
opinions of Pallas and Rutz. Instead, the ALJ credited the opinion of Gerald
Spethman, M.D., a consulting physician who reviewed Ingram's file in
August 2011 and generally opined that she retained the RFC to perform
sedentary and light work. T65–66, T422–29. It is the ALJ's role to resolve
conflicts among the opinions of various treatment providers. Renstrom v.
Astrue, 680 F.3d 1057, 1065 (8th Cir. 2012). The Court finds that the ALJ
performed this role properly and that the record supports the ALJ's decision
to afford little weight to the opinions of Pallas and Rutz.
The Court begins with Rutz, as he was Ingram's treating physician and
thus a "treating medical source." See 20 C.F.R. § 416.902. The opinion of a
treating medical source is generally entitled to greater weight than other
sources. Anderson v. Astrue, 696 F.3d 790, 793 (8th Cir. 2012). When it is
supported by proper medical testing, and is not inconsistent with other
substantial evidence in the record, the ALJ must give the opinion controlling
weight. Cline v. Colvin, 771 F.3d 1098, 1103 (8th Cir. 2014); 20 C.F.R. §
416.927(c)(2). But such weight is neither inherent nor automatic by virtue of
the source's status. Cline, 771 F.3d at 1103. And the ALJ may discount or
even disregard the opinion of a treating medical source where other medical
assessments are supported by better or more thorough medical evidence, or
where the source renders inconsistent opinions that undermine the
credibility of such opinions. Id. Whether granting a treating medical source's

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opinion substantial or little weight, the ALJ must always "give good reasons"
for the weight she gives. Id. The ALJ did so here.
First, the ALJ noted that Rutz "apparently relied quiet heavily on the
subjective report of symptoms and limitations provided by the claimant, and
seemed to uncritically accept as true most, if not all, of what the claimant
reported." T66. And as the Court has already explained, the ALJ properly
gave little weight to Ingram's subjective reports.9 Second, the ALJ observed
that Rutz's treatment notes, which reflected essentially conservative and
routine treatment, do not suggest that Ingram was as limited as Rutz would
later opine. Finally, the ALJ noted that Rutz was not a specialist in treating
fibromyalgia. All of these were proper reasons for discounting Rutz's
opinions. See, Cline 771 F.3d at 1104 (reliance on discredited subjective
reports); Anderson, 696 F.3d at 794 (significant limitations not reflected in
treatment notes or medical records); 20 C.F.R. § 404.1527(c)(5) (specialist's
opinion entitled to greater weight).
The ALJ was also justified in giving Pallas' opinions little weight.10
Pallas' October 2010 letter was drafted after having seen Ingram only twice.
T335–340. And when she filled out the Fibromyalgia Impairment
Questionnaire in March 2011, she had only seen Ingram twice more—and one
of those times was solely for a sinus infection. T333–34. The ALJ found that
Pallas had "not prescribed the type of treatment one would expect (referral to
a specialist, warm water therapy, etc.) if the claimant were as limited as
[Pallas] indicated." T65. This finding is supported by the record. Pallas' total
treatment consisted of prescribing a single medication, which Ingram
discontinued after about 2 weeks due to side effects. T337–38. After that,
Pallas' treatment plan was for Ingram to limit her activities and consider
pursuing disability. T335.
The Court acknowledges that fibromyalgia is, by its nature, "an elusive diagnosis; '[i]ts
cause or causes are unknown, there's no cure, and, of greatest importance to disability law,
its symptoms are entirely subjective.'" Tilley v. Astrue, 580 F.3d 675, 681 (8th Cir. 2009).
But the ALJ did not improperly fault Ingram for failing to supply objective medical
evidence. Rather, the ALJ properly discredited Ingram's subjective reports on other
grounds.
9

As an APRN, Pallas was not an acceptable medical source and thus could not qualify as a
"treating medical source." Sloan v. Astrue, 499 F.3d 883, 888 (8th Cir. 2007); 20 C.F.R. §§
404.1502, 404.1513. The opinions from "other sources" such as APRNs should be evaluated
using the same factors used to evaluate opinions from acceptable medical sources, set forth
in 20 C.F.R. § 404.1527(c). Social Security Ruling 06-03p, 71 Fed. Reg. 45593-03, 2006 WL
2263437 (Aug. 9, 2006). However, these factors are not binding on the ALJ, who has greater
discretion in dealing with opinions from other sources. Tindell v. Barnhart, 444 F.3d 1002,
1005 (8th Cir. 2006).
10

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Moreover, Pallas' October 2010 simply recited Ingram's descriptions of
her symptoms and then concluded that because Ingram's symptoms had not
improved (despite the minimal treatment she had received), Ingram was
unable to do "any type of physical labor." T321. Even if this opinion is given
weight, Ingram's inability to perform "physical labor" hardly contradicts the
ALJ's finding that she could perform sedentary work. While Pallas' March
2011 opinion is more detailed, the extreme limitations it expressed are still
inconsistent with the minimal treatment Pallas provided. And like Rutz,
Pallas based her assessment primarily on Ingram's subjective reports, which
the ALJ found unpersuasive. In sum, the ALJ did not err in affording little
weight to Pallas' findings.11
Conversely, the ALJ afforded significant weight to the opinion of
Spethman, which generally supported the ALJ's ultimate RFC finding. The
ALJ reasoned that Spethman's opinion was consistent with other substantial
evidence in the record including the medical findings, Ingram's daily
activities, and her lack of more aggressive medical treatment. The ALJ did
not err in relying on Spethman's opinion, which was supported by a
reasonable explanation. It is true that, as a general matter, the opinions of
consulting professionals who have not examined a claimant do not constitute
substantial evidence on the record as a whole. Singh v. Apfel, 222 F.3d 448,
452 (8th Cir. 2000). However, substantial evidence will support an ALJ's
determination where, as here, the ALJ did not rely solely on the opinions of
non-examining physicians, but also conducted an independent review of the
medical evidence, as well as other evidence in the record, such as a lack of
treatment and the claimant's activities of daily living. Krogmeier v. Barnhart,
294 F.3d 1019, 1023–24 (8th Cir. 2002); cf. Vossen, 612 F.3d at 1016. The ALJ
properly weighed the opinions of the various sources in this case, as well as
the record as a whole, and her assessment of Ingram's RFC was supported by
substantial evidence.

The ALJ also noted that Pallas' opinion may have been based on sympathy for Ingram.
The ALJ explained that "[w]hile it is difficult to confirm the presence of such motive, it is
more likely to occur in situations where the opinions and reports in question depart from
other substantial evidence in [the] record, as in the current case." T65. Ingram critiques the
ALJ's reasoning, pointing to the absence of any evidence to support such an improper
motive on Pallas' part. The Court need not determine if this was error, as any error in this
regard was harmless. As discussed above, there was ample cause to discredit Pallas'
opinions, and the Court finds it unlikely the ALJ would have reached a different result even
absent her speculation into Pallas' motives.
11

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V. CONCLUSION
The Court has reviewed the administrative record and finds that the
ALJ did not err in any of the ways asserted by Ingram. The Court finds that
the Commissioner's decision was supported by substantial evidence and
should be affirmed.
THEREFORE, IT IS ORDERED:
1.

The Commissioner's decision is affirmed;

2.

This case is dismissed;

3.

The parties shall bear their own costs; and

4.

A separate judgment will be entered.

Dated this 19th day of March, 2015.
BY THE COURT:

John M. Gerrard
United States District Judge

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