The opinion
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
IRMA J. JAMISON, )
)
Plaintiff, )
)
v. ) Case No. 4:18-CV-00263 PLC
)
ANDREW M. SAUL, 1 )
Commissioner of Social Security, )
)
Defendant. )
MEMORANDUM AND ORDER
Plaintiff Irma J. Jamison seeks review of the decision of the Social Security
Administration (SSA) denying her application for Disability Insurance Benefits under the Social
Security Act. For the reasons set forth below, the case is reversed and remanded.
I. Background and Procedural History
Plaintiff, who was born in February 1959, applied for Disability Insurance Benefits on
December 8, 2014. (Tr. 10). In her application, Plaintiff claimed she was disabled as of January
25, 2014 as a result of: cervical fusion, herniated disc lumbar spine, arthritis in knees, lumbar
radiculopathy, diverticulitis, migraines, and acid reflux. (Tr. 162-68, 182) The SSA denied
Plaintiff’s claim, and she filed a timely request for a hearing before an administrative law judge
(ALJ). (Tr. 64-75, 155-57)
The SSA granted Plaintiff’s request, and an ALJ conducted a hearing in December 2016.
(Tr. 12, 36-63) In a decision dated March 7, 2017, the ALJ determined that Plaintiff “has not
1 On June 4, 2019, Andrew M. Saul became the Commissioner of Social Security. Pursuant to
Federal Rule of Civil Procedure 25(d), Commissioner Saul is substituted for Nancy A. Berryhill
as defendant in this suit. No further action needs to be taken to continue this suit by reason of
the last sentence of 42 U.S.C. § 405(g).
been under a disability within the meaning of the Social Security Act from January 25, 2014,
through the date of this decision.” (Tr. 19-20)
In her decision, the ALJ applied the five-step evaluation set forth in 20 C.F.R. § 404.1520,
and found that Plaintiff had the following severe impairments: “degenerative disc disease
(DDD), degenerative joint disease, obesity, tarsal tunnel syndrome, and peroneal tendinitis.” (Tr.
36-63) The ALJ determined that Plaintiff had the residual functioning capacity (RFC) to:
[P]erform a range of light work as defined in 20 CFR 404.1567(b) in that she
can lift, carry, push, or pull 20 pounds occasionally and 10 pounds frequently;
sit for 6 hours in an 8-hour workday; stand or walk for 3 hours in an 8-hour
workday; never climb ropes, ladders, or scaffolds; occasionally climb ramps
and stairs, balance, stoop, kneel, crouch and crawl; no exposure to extreme
cold, unprotected heights, or hazardous machinery.
(Tr. 14) At step four of the sequential evaluation, the ALJ found that Plaintiff could return to her
past work as a customer service representative. (Tr. 19-20)
Plaintiff filed a request for review of the ALJ’s decision with the SSA Appeals Council,
which denied review on January 12, 2018. (Tr. 1-6) Plaintiff has exhausted all administrative
remedies, and the ALJ’s decision stands as the SSA’s final decision. Sims v. Apfel, 530 U.S.
103, 106-07 (2000).
II. Evidence Before the ALJ
A. Testimony
Plaintiff testified that she was fifty-seven years old and had a high school education and
some technical school. (Tr. 48) Plaintiff lived with her daughter and grandchildren, who did “all
the chores around the house.” (Id.)
Plaintiff worked for AT&T for fifteen years, most recently as a supply attendant. (Tr. 40,
45, 49) In that position, she operated a forklift to load the truck or van she was driving and then
transported the products to “technicians in the field.” (Id.) Prior to becoming a supply attendant,
Plaintiff worked as a senior consultant, or customer service representative, for AT&T. (Tr. 42)
Plaintiff left that position because she was suffering vertigo. (Tr. 44)
Plaintiff testified that she could not work because
Due to the neck surgery, I have problem…turning my head some days, swallowing. My
arms give out, my hands tingle….I have pains that go down in my knees. If I don’t take
my medication, I burn from my waist down and it goes all between my legs, down in
my feet…I have canes and stuff, but I can’t use my canes because…some days I don’t
have the strength.
(Tr. 49) Plaintiff explained that she was unable to turn her head “side to side” because “I have the
clicking like the hardware get hung up.” (Tr. 49) Her doctors were discussing the possibility of a
“removal surgery” and “bone shaving” at the C7 level. (Tr. 50)
Plaintiff described intermittent, daily numbness and tingling in her arms. (Tr. 50)
Plaintiff stated that she could lift “maybe a gallon of milk at the most…[j]ust once or twice.” (Tr.
50-51) Some days she was unable to comb her hair. (Tr. 50) If she attempted to push or pull, her
arms “g[a]ve out,” and she was unable to “grip stuff” due to numbness and lack of strength. (Tr.
51)
Plaintiff testified that her pain was currently “coming down the back of my head going
into my shoulders, into my biceps and my fingers are tingling. I have it in my knees and my right
foot is like it’s short circuiting my toes.” (Tr. 53) Plaintiff’s lower back pain was “just burning
and it’s on the top of my hip…[i]t goes down the right side, down into the hip, down into the knee,
into the…leg, into the foot....” (Tr. 53) Plaintiff stated that the pain in her low back, knees, and
feet was constant. (Id.) Pain medications reduced the pain to “a numbness,” but they made her
“foggy” and forgetful. (Id.) She was currently taking Percocet, gabapentin, and Mobic. (Id.)
Plaintiff estimated she could walk “about ten minutes” before needing to take a break,
stand ten to fifteen minutes, and sit ten to fifteen minutes. (Tr. 55) Plaintiff explained that her
doctors prescribed her a cane, which she used once or twice a day. (Tr. 56-57) Plaintiff
elaborated: “I would use it more, but my hands give out, so it’s either take the chance of falling
without or with it and I just take the chance without because I got a metal cane and I fall on it,
that’s not good either.” (Tr. 57)
A vocational expert also testified at the hearing. (Tr. 60) The ALJ asked the vocational
expert to consider a hypothetical individual with Plaintiff’s age, education, and work history who
was “limited to work at the light exertion level in that they can lift, carry, push, or pull 20 pounds
occasionally, 10 pounds frequently; sit for six hours in an eight-hour workday; but can only stand
or walk for three hours total in an eight-hour workday.” (Id.) The vocational expert stated that
such person could perform Plaintiff’s past work as a customer service representative. (Tr. 61)
When the ALJ added to the hypothetical that “the individual would be unable to keep the neck in
a stable position for more than 30 minutes and thus would need to take an additional 10-minute
break after that period,” the vocational expert stated that such person would not be able to perform
any jobs in the national economy. (Id.) In response to Plaintiff’s counsel’s question, the
vocational expert testified that, if the first hypothetical individual could “only occasionally use
their hands for fine manipulation or gross manipulation,” she would not be able to perform the
customer service position. (Id.)
B. Relevant medical records
In early January 2014, Dr. Thomas Forget, a neurosurgeon, ordered an MRI of Plaintiff’s
lumbar and cervical spine. (Tr. 492). The MRI revealed: “(1) multilevel degenerative changes
of the lumbar spine, unchanged since the prior study; (2) annular tear identified at the posterior
aspect of the L4-L5 disc; [and] (3) multilevel foraminal and lateral recess stenosis....” (Tr. 494)
Later that month, at an appointment with her primary care physician, Dr. Marketa
Kasalova, Plaintiff complained of fatigue and stated that “she is worried that she will lose her job
due to her chronic neck and low back pain.” (Tr. 351) Dr. Kasalova diagnosed Plaintiff with
cervical radiculopathy, generalized anxiety disorder, depressive disorder, and hyperlipidemia.
(Tr. 352)
Two days later, Plaintiff had a follow-up appointment with Dr. Nabil Ahmad, a pain
management specialist.2 (Tr. 495) Plaintiff complained of neck, back, leg, and right arm pain.
(Tr. 495) Plaintiff reported she “was still having pain in her lower back and bil[ateral] legs
worse than before injections.” (Id.) Plaintiff’s pain was “constant” and she rated it at a four to
six on a ten-point scale. (Id.) A physical examination revealed: tenderness and reduced range
of motion in her neck; tenderness to palpation and mildly reduced range of motion on bilateral
rotation in her cervical spine; tenderness to palpation and mildly reduced range of motion of the
lumbar spine; positive straight-leg raise, FABER, and Gaenslen tests on the right; and bilateral
knee crepitus. (Tr. 498) Dr. Ahmad diagnosed the following: “cervical radiculopathy, cervical
spondylosis, HNP (cervical), lumbar spondylosis, lumbar degenerative disc disease, lumbar
radiculopathy, sacroiliitis, low back pain, and osteoarthritis knee.” (Tr. 499-500).
In February 2014, Dr. Ahmad administered a “L5 transforaminial epidural steroid
injection” and a “sacroiliac joint injection.” (Tr. 500) Dr. Ahmad noted: “The injections don’t
last long.” (Id.) Dr. Ahmad placed Plaintiff on light duty, stating “[h]er restrictions are
permanent,” scheduled knee Synvisc injections, ordered physical therapy, and recommended at-
home exercises. (Tr. 500) Five days later, Dr. Ahmad administered knee joint injections. (Tr.
501)
When Plaintiff presented to Dr. Kasalova in late-February 2014, she reported that the
2 This is the earliest treatment record from Dr. Ahmad. However, according to Dr. Ahmad’s
medical source statement, he first treated Plaintiff on December 13, 2012. (Tr. 487)
weekly knee Synvisc injections helped “some.” (Tr. 353) Plaintiff complained that Tramadol
was not controlling her cervical pain and made her sleepy. (Tr. 353) Dr. Kasalova provided
Plaintiff a sample of Lyrica and instructed her to follow up with her orthopedic surgeon. (Tr.
353-54)
Plaintiff returned to Dr. Forget’s office in early April 2014. (Tr. 248) Plaintiff complained
of “extreme” neck pain “localized at the posterior cervical region that has been present for 2
weeks. It is extreme (9-10/10) and radiates into the right and left arm in a non-specific
distribution.” (Id.) Additionally, Plaintiff reported an acute onset of weakness in her right
tricep. (Tr. 252) Plaintiff informed Dr. Forget that she recently began taking Lyrica, “which has
improved the global pain.” (Id.) Upon examination, Dr. Forget noted limited range of motion in
Plaintiff’s cervical spine, normal range of motion in her right and left upper and lower
extremities, and weakness in her right upper extremity. (Tr. 250). Dr. Forget wrote a letter to
Dr. Ahmad recommending another MRI. (Tr. 252)
Plaintiff underwent an MRI in April 2014, which revealed : “[d]egenerative changes at C4-
C5, C5-C6 and C6-C7” and “[c]entral spinal canal stenosis…, most pronounced at C6-C7 with
flattening of the spinal cord.” (Tr. 254). At Plaintiff’s next appointment with Dr. Kasalova in
May 2014, she complained of ankle swelling on the right side and neck pain. (Tr. 355) Dr.
Kasalova recommended weight loss and continued Plaintiff’s medications. (Id.)
Dr. Donald deGrange, an orthopedic surgeon, examined Plaintiff in late-May 2014.3 (Tr.
379) Dr. deGrange noted that Plaintiff’s chief complaint was “mechanical neck pain at the base
of the neck extending into both shoulders, usually worse on the right than the left as well as the
3 In regard to this change in Plaintiff’s treating orthopedic surgeons, Dr. deGrange wrote that
Plaintiff “has been a long-time patient of Dr. Forget and had a consultation with him in March
2014….Upon follow up, there was some mention or involvement of Workers’ Compensation, at
which time Dr. Forget referred her to our practice.” (Tr. 379)
pain, tingling, numbness, and weakness that has appeared in the last several weeks.” (Id.)
Plaintiff informed Dr. deGrange that she had “dropped several items…because of unexpected
weakness of grip and has actually gotten stuck in the bathtub on a couple of occasions unable to
pull herself out because of the weakness in her arm.” (Id.) Dr. deGrange noted that Plaintiff
experienced “no significant improvement” from physical therapy and “no significant or sustained
benefit” from a series of epidural injections administered by Dr. Ahmad. (Id.)
Plaintiff returned to Dr. deGrange’s office in mid-July 2014 “[h]aving failed prolonged and
appropriate conservative care[.]” (Tr. 387) Dr. deGrange noted that Plaintiff’s recent MRI showed
“2 large disc herniations with severe stenosis of C4-5 and C5-6 corresponding to the patient’s
symptoms.” (Id.) Dr. deGrange performed an elective decompression and fusion at C4-5 and C5-
6. (Tr. 431) Following the procedure, Dr. deGrange applied a cervical collar and prescribed
Percocet. (Tr. 433, 435). When Plaintiff followed up with Dr. deGrange eleven days later, she
complained of “the normal surgical pain in the cervicothoracic junction,” but reported that her
“arms and hands feel better noticeably.” (Tr. 392)
In August 2014, Plaintiff followed up from her cervical spine fusion with Nurse
Practitioner (NP) Eileen McKeon at Dr. Kasalova’s office. (Tr. 338) Plaintiff reported that her
“neck pain is much better.” (Tr. 340) NP McKeon noted that Plaintiff was “moving all
extremities equally strong” and advised Plaintiff to discuss all pain management and medication
with Dr. deGrange. (Tr. 339).
At Plaintiff’s follow-up appointment in September 2014, Dr. deGrange wrote that
Plaintiff’s “neck continues to improve,” “[h]er arms and hands feel much better,” and “[s]he has
no residual numbness or tingling,”but she “still is having some difficulty swallowing. (Tr. 394)
Plaintiff only required her pain medicine “a couple of days a week.” (Id.) Dr. deGrange observed
“excellent strength in both upper extremities,” and they discussed the possibility of Plaintiff
returning to work “depend[ing] upon her continued progress.” (Id.)
When Plaintiff saw Dr. deGrange the following month, she reported “some improvement
in her neck and shoulder pain as well as the hand symptoms, but she does have some tingling that
persists on the fingertips of both hands.” (Tr. 395) Plaintiff also complained of “issues regarding
her back and involuntary plantar flexion that happened during the night[.]” (Id.)
At her follow-up appointment with Dr. deGrange in early November 2014, Plaintiff
complained of difficulty swallowing and she “still has a stiff neck and some occasional numbness
and tingling in the hands, but that is slowly and steadily improving.” (Tr. 397) Plaintiff was
“usually able to lift about five or 10 pounds occasionally” and she exhibited no focal motor or
sensory deficits. (Id.)
Based on that examination, Dr. deGrange completed an “AT&T Integrated Disability
Physical Capacities Evaluation” for Plaintiff in November 2014. (Tr. 398) Dr. deGrange
characterized Plaintiff’s level of functioning as “moderate level of disability and dysfunction.”
(Tr. 399) Dr. deGrange opined that Plaintiff could: sit thirty to forty-five minutes; stand fifteen
to twenty minutes; walk fifteen to twenty minutes; and view a computer screen fifteen to twenty
minutes. (Id.) Plaintiff could occasionally lift a maximum of five pounds, but never above the
waist. (Tr. 400)
Additionally, Dr. deGrange stated that Plaintiff could “rarely” climb stairs due to “severe
knee arthritis,” rarely bend, rarely kneel because “requires help to get up,” and occasionally
flex/extend neck or walk on uneven ground. (Tr. 402-03) Plaintiff could perform “simple
grasping” with both hands “continuously,” and she could occasionally use both hands for “fine
manipulation,” pushing/pulling, and reaching. (Tr. 404) Dr. deGrange estimated that Plaintiff
would require breaks “every hour twenty minutes.” (Tr. 406) Finally, Dr. deGrange wrote that
Plaintiff’s restrictions were “permanent,” but he would reassess her restrictions on December 1,
2014. (Id.)
In early December 2014, Plaintiff presented to Dr. Ahmad for “bilateral shoulder pain,
back pain, and some knee pain.” (Tr. 373) Dr. Ahmad noted that Plaintiff’s neck and shoulder
pain “radiates down the posterior arm and into the palmar aspect of hand and 3rd/4th digits on
the right. She has some numbness in these digits as well.” (Id.) Dr. Ahmad wrote that
Plaintiff’s “[l]ower back pain is a burning pain and is wors[e] with overactivity or sitting
prolonged periods of time. Pain is shooting down bilateral legs past the knee in the L5-S1
dermatone – burning pain with electrical shock sensation….” (Id.) Dr. Ahmad stated that
Plaintiff’s most recent MRI showed changes of foraminal stenosis at L4-5, L5-S1, with disc
protrusion and facet arthropathy. (Id.)
Upon physical examination of Plaintiff’s cervical spine, Dr. Ahmad observed tenderness
to palpation and spasm in the paravertebral muscles, restricted range of motion in all planes,
trapezius tenderness bilaterally, and positive myofascial trigger points on the left and right.
(Tr. 373) As to Plaintiff’s lumbar spine, Dr. Ahmad noted “abnormal sacroiliac joint mobility
bilaterally,” limited extension, positive Patrick’s on the right, and positive FABER/figure-of-four
tests on right. (Tr. 374). Plaintiff’s shoulders and thoracic spine had normal ranges of motion.
(Id.) Noting that Dr. deGrange was managing Plaintiff’s Percocet, Dr. Ahmad decided to
“supplement pain management control with TENS unit and topical cream.” (Tr. 474) Dr. Ahmad
continued Plaintiff’s Lyrica and prescribed cyclobenzaprine, flurbiprofen, baclofen, and
gabapentin. (Tr. 474) Finally, Dr. Ahmad administered knee joint injections and recommended a
repeat epidural steroid injection in the lumbar spine when Plaintiff healed from cervical surgery.
(Id.)
Dr. deGrange examined Plaintiff approximately one week later in December 2014. (Tr.
409) Dr. deGrange wrote that Plaintiff “has multiple somatic complaints today with some
numbness and tingling in the arms and fingers. She still has some difficulty swallowing but is
moving her head better and appears clinically to be much improved despite the subjective.” (Id.)
Dr. deGrange also observed: “There is some mild give-way weakness in terms of bilateral elbow
flexion and extension, grip strength, and wrist extension.” (Id.)
Dr. deGrange stated that Plaintiff’s x-rays showed “radiographic healing, and she can be
safely discharged from the practice.” (Tr. 409) In regard to her ability to return to work, Dr.
deGrange wrote:
I understand that there are some significant and heavy demands regarding her
employment. It is highly unlikely that she is going to be able to return to those
based upon her current physical condition. I would contemplate as regards
permanent limitations placing her in a medium demand capacity as defined by
the Department of Labor Dictionary of Occupational Titles. She would meet
the criteria for a light/medium demand capacity indicating that on a constant
basis she can lift, carry, push, and pull five pounds, frequently up to 15 pounds,
and occasionally up to 25 pounds.
(Tr. 409-10) Dr. deGrange concluded: “No further testing is required and no medications or
treatments after today are indicated.” (Tr. 410)
Plaintiff also saw NP McKeon for back and leg pain later that month. (Tr. 481) Plaintiff
described “low back pain radiating to buttocks and down both legs to feet, both sides,
twitching to right leg, feels crawling sensation to right leg. Onset 3-4 weeks ago and
persisting. She reports pain shoots out of great toe on both sides with right being worse than
left.” (Id.) Plaintiff was taking Percocet and Lyrica for pain “with little relief.” (Id.) Upon
examination, NP McKeon noted decreased range of motion and paraspinal tenderness in
Plaintiff’s cervical spine area. (Tr. 482)
In March 2015, Plaintiff presented to NP McKeon with complaints of dizziness,
forgetfulness, and “feeling anxious mostly due to her memory or thought process.” (Tr. 524)
NP McKeon attributed these feelings to Plaintiff’s recently “increased and large dose of Lyrica.”
(Tr. 526)
Dr. Ahmad completed a medical source statement (MSS) in April 2015.4 (Tr. 487-90) Dr.
Ahmad listed Plaintiff’s diagnoses as: knee degenerative joint disease, cervical radiculitis, neck
pain, lumbar radiculopathy, and low back pain. (Tr. 487) Dr. Ahmad opined that Plaintiff could
sit for one hour and stand/walk one hour in an eight-hour workday. (Id.) Plaintiff could not
perform repetitive motion tasks, but she was able to use her hands for simple grasping and fine
manipulation. (Id.) Dr. Ahmad stated that Plaintiff could occasionally lift/carry five pounds, but
never lift/carry more than five pounds. (Id.)
In July 2015, Plaintiff presented to Dr. Ahmad with neck pain and complained that her
“[h]ead gets stuck in one position.” (Tr. 556) Plaintiff described her pain as “aching and
throbbing. The pain radiates to the left shoulder, left upper arm, left forearm, left hand, left
fingers, right shoulder, right upper arm, right forearm, right hand, and right fingers.” (Id.)
Plaintiff’s average pain was a seven and, at its worst, it was a ten. (Id.) On physical
examination, Dr. Ahmad noted: cervical spine was tender to palpation and had “palpable
trigger points”; pain with lumbar extension; pain “over lumbar intervertebral spaces (discs) on
palpation”; and right and left sided pain on palpation of the bilateral sacroiliac joint area.” (Tr.
557) Upon examination of Plaintiff’s extremities, Dr. Ahmad noted: pain, crepitation, mild
effusion, and tenderness to palpation in both knees; and decreased sensation in right arm and
right ankle. (Tr. 557)
4 In the MSS, dated April 6, 2015, Dr. Ahmad stated that he last examined Plaintiff on April 1,
2015. (Tr. 487) Records from this examination do not appear in the record.
Plaintiff followed up with Dr. Ahmad in August 2015 and reported knee pain, left knee
swelling, and low back pain. (Tr. 553) Plaintiff’s physical examination was similar to that of
July 2015. (Tr. 554) Plaintiff informed Dr. Ahmad that her meloxicam caused nausea and
Lyrica made her feel “sedated.” (Tr. 553, 555) Dr. Ahmad scheduled Plaintiff for a left knee
steroid injection, renewed her Norco, and continued her other medications. (Tr. 555) Dr.
Ahmad administered the knee joint injection in September 2015. (Tr. 550)
In January 2016, Plaintiff contacted Dr. deGrange’s office at her primary care
physician’s recommendation. (Tr. 643) Plaintiff reported “pain in the back of her neck and
into her L arm and fingers” and “weakness where she cannot open things.” (Tr. 643) In
February 2016, Plaintiff underwent a CT cervical spine, which revealed: “Status post C4-C5
and C5-C6 anterior cervical discectomy and fusion. Central C6-C7 disc herniation is
suspected. No evidence of pseudoarthrosis.” (Tr. 64) Plaintiff called Dr. deGrange’s office
later that month to advise that “she is now hav[ing] trouble with her L leg.” (Tr. 646)
Plaintiff returned to Dr. deGrange’s office in mid-March 2016. (Tr. 638) Dr. deGrange
wrote that Plaintiff was “doing quite well” until October “when she started noticing some
swelling and stiffness in her neck. That has progressed over the ensuing months, and she now
has neck pain with left upper extremity pain, tingling, and numbness into the ulnar aspect and
hypothenar imminence of the left hand.. . .She has some numbness and tingling in her right
upper extremity[.]” (Id.) Upon examination, Dr. deGrange observed “some mild weakness of
left hand grip strength, elbow extension, EPL and ADQ” and “sensation is decreased over the
hypothenar imminence of the left hand.” (Id.) Plaintiff’s most recent CT revealed “solid
fusion at C4-5 and C5-6 but noticeable degeneration with spurring and decreased disc space
height as well as stenosis of a moderately severe degree on the left, all at C6-7.” (Id.) Dr.
deGrange diagnosed Plaintiff with C6-7 degenerative disc disease with stenosis and prescribed
physical therapy. (Id.)
Plaintiff followed up with Dr. deGrange in April 2016. (Tr. 625) Dr. deGrange noted
that Plaintiff “has had a very good response with therapy after six visits” and the range of
motion in her cervical spine had improved. (Id.) Plaintiff informed Dr. deGrange that she
“still has pain and some stiffness in the neck,” and she recently “had a choking fit” that “lasted
for quite some time.” (Id.) A CAT scan confirmed a solid fusion, “but she does have the large
bone spur in front of C6-7.” (Id.) Dr. deGrange and Plaintiff discussed “a hardware removal
at C4-5 and C5-6.” (Id.) Plaintiff asked whether “while we are in there if we can just take the
bone spur off at C6-7,” but she decided to “hold off for the time being.” (Id.) Dr. deGrange
referred Plaintiff to an ENT specialist. (Id.)
Plaintiff returned to Dr. deGrange’s office in early July 2016. (Tr. 627) Plaintiff reported
continued “difficulty swallowing as well as some persistent neck and shoulder symptoms. There is
also a spot just to the midline of the left scapula, which no doubt is cervical in origin.” (Id.) Dr.
deGrange diagnosed tarsal tunnel syndrome in Plaintiff’s right foot and noted that Plaintiff was
“contemplating the foot surgery.” (Tr. 627) Dr. deGrange wrote that Plaintiff “appears to be
inclined toward the foot surgery now and perhaps later on in the summer or the autumn the neck
surgery and hardware removal.” (Id.)
III. Standard for Determining Disability Under the Act
Eligibility for disability benefits under the Social Security Act requires a claimant to
demonstrate that he or she suffers from a physical or mental disability. 42 U.S.C. § 423(a)(1).
The Act defines disability as “the inability to do 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 not less than 12 months.”
42 U.S.C. § 423(d)(1)(A); see also 20 C.F.R. § 404.1505(a). The impairment must be “of such
severity that [the claimant] is not only unable to do his previous work but cannot, considering his
age, education, and work experience, engage in any other kind of substantial gainful work which
exists in the national economy ....” 42 U.S.C. § 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. Those steps require a Plaintiff to show that he or
she: (1) is not engaged in substantial gainful activity; (2) has a severe impairment or
combination of impairments which significantly limits his or her physical or mental ability to do
basic work activities or (3) has an impairment which meets or exceeds one of the impairments
listed in 20 C.F.R., Subpart P, Appendix 1; (4) is unable to return to his or her past relevant
work; and (5) the impairments prevent him or her from doing any other work. Id.
IV. ALJ’s Decision
The ALJ found that Plaintiff: (1) had not engaged in substantial gainful activity since
January 25, 2014, the alleged onset date of disability; (2) had the severe impairments of
degenerative disc disease, degenerative joint disease, obesity, tarsal tunnel syndrome, and
peroneal tendinitis, and the non-severe impairments of general anxiety disorder and depression;
and (3) did not have an impairment or combination of impairments that met or medically equaled
the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr.
12-14)
The ALJ reviewed Plaintiff’s testimony and the medical evidence and determined that,
while her impairments “could reasonably be expected to cause some of the alleged symptoms,”
her “statements concerning the intensity, persistence and limiting effects of these symptoms are
not entirely credible for the reasons explained in this decision.” (Tr. 15) The ALJ determined
that Plaintiff had the residual functional capacity (RFC) to perform a range of light work with the
following limitations:
she can lift, carry, push, or pull 20 pounds occasionally and 10 pounds
frequently; sit for 6 hours in an 8-hour workday; stand or walk for 3 hours in
an 8-hour workday; never climb ropes, ladders, or scaffolds; occasionally
climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; no exposure
to extreme cold, unprotected heights, or hazardous machinery.
(Tr. 14) Finally, based on the testimony of the vocational expert, the ALJ determined that
Plaintiff was capable of performing her past relevant work as a customer service representative
and, therefore, was not disabled. (Tr. 19-20)
V. Discussion
Plaintiff claims that the ALJ erred in evaluating the medical opinion evidence and
determining her RFC. [ECF No. 23] More specifically, Plaintiff argues that the ALJ erred in the
weight she assigned to Plaintiff’s treating physicians, Dr. Ahmad and Dr. deGrange. Defendant
counters that substantial evidence supported the ALJ’s assessment of the medical opinion
evidence and the ALJ properly concluded that Plaintiff was not disabled. [ECF No. 29]
A. Standard for Judicial Review
A court must affirm an ALJ’s decision if it is supported by substantial evidence. 42
U.S.C. § 405(g). “Substantial evidence is less than a preponderance, but is enough that a
reasonable mind would find it adequate to support the Commissioner’s conclusion.” Chesser v.
Berryhill, 858 F.3d 1161, 1164 (8th Cir. 2017) (quoting Prosch v. Apfel, 201 F.3d 1010, 1012
(8th Cir. 2000)). The Court must consider “both evidence that supports and evidence that
detracts from the ALJ’s decision, [but it] may not reverse the decision merely because there is
substantial evidence supporting a contrary outcome.” Id. (quoting Warburton v. Apfel, 188 F.3d
1047, 1050 (8th Cir. 1999)).
The Court does not “reweigh the evidence presented to the ALJ and [it] defer[s] to the
ALJ’s determinations regarding the credibility of testimony, as long as those determination are
supported by good reasons and substantial evidence.” Renstrom v. Astrue, 680 F.3d 1057, 1064
(8th Cir. 2012) (quoting Gonzales v. Barnhart, 465 F.3d 890, 894 (8th Cir. 2006)). T herefore, a
Court must affirm the ALJ’s decision “if it is possible to draw two inconsistent positions from
the evidence and one of those positions represents the agency’s findings.” Cruze v. Charter, 85
F.3d 1320, 1323 (8th Cir. 1996) (quoting Oberst v. Shalala, 2 F.3d 249, 250 (8th Cir. 1993));
Wright v. Colvin, 789 F.3d 847, 852 (8th Cir. 2015) (quoting Perkins v. Astrue, 648 F.3d 892,
897 (8th Cir. 2011)).
B. Medical Opinion Evidence
Medical opinions are statements from physicians, psychologists, or other acceptable
medical sources that reflect judgments about the nature and severity of a claimant’s impairments,
including symptoms, diagnosis and prognosis, and what the claimant can still do despite her
impairments and physical or mental restrictions. 20 C.F.R. § 404.1527(a)(2).5 A treating
physician’s opinion regarding a plaintiff’s impairments is entitled to controlling weight where
“the opinion is well supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial evidence in the record.” Singh v.
Apfel, 222 F.3d 448, 452 (8th Cir. 2000). “Although a treating physician’s opinion is entitled to
great weight, it does not automatically control or obviate the need to evaluate the record as [a]
whole.” Leckenby v. Astrue, 487 F.3d 626, 632 (8th Cir. 2007) (quotation omitted).
If an ALJ declines to give controlling weight to a treating physician’s opinion, the ALJ
5 Many Social Security regulations were amended effective March 27, 2017. Per 20 C.F.R. §
404.1527, the Court will use the regulations in effect at the time that this claim was filed.
must consider the following factors in determining the appropriate weight: length and frequency
of the treatment relationship; nature and extent of the treatment relationship; evidence provided
by the source in support of the opinion; consistency of the opinion with the record as a whole;
and the source’s level of specialization. 20 C.F.R. § 404.1527(c). Whether the ALJ grants a
treating physician’s opinion substantial or little weight, “[t]he regulations require that the ALJ
‘always give good reasons’ for the weight afforded to a treating physician’s evaluation.” Reed v.
Barnhart, 399 F.3d 917, 921 (8th Cir. 2005) (quoting 20 C.F.R. § 404.1527(d)(2)).
1. Dr. Ahmad
Plaintiff asserts that the ALJ erred in assigning “little weight” to Dr. Ahmad’s medical
opinion. Dr. Ahmad was Plaintiff’s pain management specialist from December 2012 until April
2016. Plaintiff’s medical records reveal that shortly after Plaintiff’s January 2014 alleged onset
date, Dr. Ahmad diagnosed her with: “cervical radiculopathy, cervical spondylosis, HNP
(cervical), lumbar spondylosis, lumbar degenerative disc disease, lumbar radiculopathy,
sacroiliitis, low back pain, and osteoarthritis knee.” In February 2014, Dr. Ahmad administered
an L5 transforaminal epidural steroid injection and Hyalgan knee joint injections.
Plaintiff underwent decompression and fusion at C4-5 and C5-6 in July 2014, after which
Dr. deGrange, Plaintiff’s orthopedic surgeon, and NP McKeon treated Plaintiff’s pain. Dr.
deGrange discharged Plaintiff in December 2014, and Plaintiff returned to Dr. Ahmad’s practice
the same month with bilateral shoulder pain, back pain, and knee pain. Dr. Ahmad completed a
physical examination and reviewed Plaintiff’s most recent MRI, which revealed changes of
foraminal stenosis at L4-5, L5-S1, with disc protrusion and facet arthropathy. Physical
examination of Plaintiff’s cervical spine revealed tenderness and spasm in the paravertebral
muscles, restricted range of motion in all planes, trapezius tenderness, and positive myofascial
trigger points. In Plaintiff’s lumbar back, Dr. Ahmad observed abnormal sacroiliac joint
mobility bilaterally, “palpation + Patrick’s on right,” limited extension, negative straight leg
raising test, and positive FABER test. Dr. Ahmad administered Hyalgan knee joint injections,
noted that Plaintiff continued to take Percocet, continued Plaintiff’s Lyrica, and prescribed
flurbiprofen, cyclobenzaprine, baclofen, gabapentin, a TENS unit, and topical cream.
Dr. Ahmad completed an MSS for Plaintiff in April 2015. (Tr. 487) Dr. Ahmad listed
Plaintiff’s diagnoses as: knee degenerative joint disease, cervical radiculitis, neck pain, lumbar
radiculopathy, and low back pain. (Tr. 487) Dr. Ahmad opined that Plaintiff could sit for one
hour and stand or walk one hour in an eight-hour workday. (Id.) Plaintiff could not perform
repetitive motion tasks, but she was able to use her hands for simple grasping and fine
manipulation. (Id.) Dr. Ahmad stated that Plaintiff could occasionally lift/carry a maximum of
five pounds. (Id.)
The ALJ reviewed Dr. Ahmad’s MSS and determined that it was “not supported by the
record.” (Tr. 18) In particular, the ALJ discredited Dr. Ahmad’s opinion that Plaintiff was
limited to lifting only five pounds occasionally, sitting for one hour per day, and standing or
walking for one hour per day. (Id.) In support of her decision to assign “little weight” to Dr.
Ahmad’s opinion, the ALJ explained:
Dr. Ahmad completed this form on April 6, 2015, indicating the claimant was
last seen on April 1, 2015. He also stated that the claimant had been under his
care since December 13, 2012. Treatment notes in evidence for December 4,
2014 indicate prior care, but that was almost a year after the claimant stopped
working due to pain. There is nothing in the record to indicate that the
claimant was seen again prior to the opinion dated April 6, 2015. Subsequent
records indicate the claimant was seen several times later that year. Not only is
Dr. Ahmad’s assessment inconsistent with the medical records as a whole, it is
not supported by his own treatment notes.
(Tr. 18)
The ALJ’s conclusory statement that Dr. Ahmad’s opinion was not supported by his own
treatment notes or the medical record as a whole did not constitute “good reason” for discrediting
Dr. Ahmad’s opinion. The ALJ failed to identify the objective medical evidence or
inconsistencies that she relied upon in determining that Dr. Ahmad’s opinion was not entitled to
controlling, or even substantial, weight.
Contrary to the ALJ’s finding, Plaintiff’s medical records contain significant objective
evidence supporting Dr. Ahmad’s opinions. An MRI of April 2014, performed prior to
Plaintiff’s cervical surgery, showed: “degenerative changes at C4-C5, C5-C6, and C6-C7 not
significantly changed since the prior study from 3/14/12” and “central spinal canal stenosis…,
most pronounced at C6-C7 with flattening of the spinal cord.” (Tr. 254) Five months after the
surgery, in December 2014, Dr. Ahmad noted that Plaintiff’s most recent MRI revealed changes
of foraminal stenosis at L4-5 and L5-S1 with disc protrusion and facet arthropathy. (Tr. 373) A
CT cervical spine of February 2016 showed “solid fusion at C4-5 and C5-6 but noticeable
degeneration with spurring and decreased disc space height as well as stenosis of a moderately
severe degree on the left, all at C6-7.” (Tr. 576) A CAT scan in April 2016 showed a large bone
spur at C6-7. (Tr. 625)
Physical examinations also supported Dr. Ahmad’s opinion. In December 2014, both Dr.
Ahmad and NP McKeon noted decreased range of motion and paraspinal tenderness. Physical
examinations in July and August 2015, showed tenderness to palpation in cervical and lumbar
spine, palpable trigger points in the muscles of the head and neck, pain with lumbar extension,
and positive FABER tests on the left and right sides. At the same time, Plaintiff’s knees
exhibited tenderness to palpation, effusion, crepitations, and mild effusion, and she had
decreased sensation in her right ankle. In March 2016, Dr. deGrange examined Plaintiff and
noted: moderate tenderness along the medial border of the left scapula; weakness of left hand
grip strength and elbow extension; and decreased sensation in the left hand.
Dr. Ahmad’s opinion was also consistent with his own treatment notes. When Plaintiff
returned to Dr. Ahmad’s care in December 2014, she presented with bilateral shoulder pain, back
pain, and knee pain. On physical examination of Plaintiff, Dr. Ahmad noted: tenderness and
reduced range of motion in the neck; tenderness to palpation to the cervical and lubosacral
regions; mildly reduced range of motion on bilateral rotation; mildly reduced range of motion of
the lumbar spine extension; positive straight-leg raise test, FABER test, and Gaenslen test on the
right; and bilateral knee crepitus. Dr. Ahmad diagnosed Plaintiff with cervical radiculitis, neck
pain, low back pain, lumbar radiculopathy, and knee degenerative joint disease. Dr. Ahmad
noted that Plaintiff was already taking Percocet and Lyrica, and he prescribed flurbiprofen,
cyclobenzaprine, baclofen, gabapentin, lidocaine, and a TENS unit. Dr. Ahmad also
administered knee joint injections and recommended a repeat ESI in the lumbar spine. Dr.
Ahmad’s observations and treatment of Plaintiff’s symptoms was consistent with the level of
impairments he identified in the MMS.
Finally, contrary to the ALJ’s finding that Dr. Ahmad’s opinion was inconsistent with the
record as a whole, Plaintiff’s medical records are replete with consistent complaints of chronic
neck, back, leg, and knee pain, as well as pain and weakness in her upper extremities. In July
2014, Plaintiff underwent cervical spine fusion, which temporarily improved, but did not resolve,
her neck and upper extremity symptoms. While Dr. deGrange noted significant improvement in
September 2014, his notes from October 2014 reflected only “some improvement in her neck
and shoulder pain as well as the hand symptoms” and “some tingling that persists on the
fingertips of both hands.” Plaintiff renewed these complaints at her appointment with Dr.
deGrange in November 2014. By December 2014, Plaintiff’s complaints of pain had increased
significantly and she returned to Dr. Ahmad for pain management.
At Plaintiff’s appointment with Dr. Ahmad in December 2014, she described neck and
shoulder pain that radiated down the right arm and into her fingers, as well as low back pain that
was “shooting” down her legs and past her knees. When Dr. deGrange examined Plaintiff that
month, he noted bilateral arm weakness and numbness and tingling in the arms and fingers. NP
McKeon’s treatment notes from December 2014 revealed that Plaintiff described low back pain
radiating to her buttocks, down her legs, and into her feet. Plaintiff informed NP McKeon that
she was experiencing “little relief” from her pain medications, and NP McKeon observed that
Plaintiff’s had a decreased range of motion and paraspinal tenderness in her cervical spine area.
Dr. Ahmad’s MSS was also consistent with Dr. deGrange’s November 2014 opinion.
There, Dr. deGrange opined that Plaintiff could occasionally lift/carry five to ten pounds; sit
thirty to forty-five minutes; stand fifteen to twenty minutes; walk fifteen to twenty minutes; and
view a computer screen fifteen to twenty minutes. (Id.) In regard to Plaintiff’s upper
extremities, Dr. deGrange limited her to occasional use of both hands for fine manipulation,
reaching, and pushing/pulling.
Finally, Dr. Ahmad’s opinion was consistent with Plaintiff’s testimony and function
reports. At the hearing, Plaintiff testified that her pain travelled down her neck, into her
shoulders and biceps. She experienced intermittent, but regular, tingling and numbness in her
arms and hands. Plaintiff estimated that she could walk about ten minutes before needing to take
a break and sit down, sit for ten to fifteen minutes, and stand for ten to fifteen minutes. She
stated she could not lift anything heavier than “a gallon of milk at the most,” her arms “gave out”
if she attempted to push or pull anything, and she could not “grip stuff.”
In her function report of December 2014, Plaintiff stated she had difficulty dressing and
combing her hair and could no longer cook, do household chores, open letters, or hold a book.
(Tr. 197-204) Likewise, Plaintiff’s daughter completed a function report dated February 2015,
which stated that Plaintiff had difficulty dressing, bathing, caring for her hair, using a knife, and
cooking anything more than a frozen dinner. (Tr. 209-216) Plaintiff’s daughter estimated that
Plaintiff could lift “10 lbs but that may be too much” and walk “3-5 maybe 7” minutes before
needing to “catch breathe and get legs together.” (Tr. 214)
“Even if the [treating physician’s] opinion is not entitled to controlling weight, it should
not ordinarily be disregarded and is entitled to substantial weight.” Papesh v. Colvin, 786 F.3d
1126, 1132 (8th Cir. 2015) (quoting Samons v. Astrue, 497 F.3d 813, 817 (8th Cir. 2007)). Dr.
Ahmad’s opinion about the severity and debilitating effects of Plaintiff’s impairments was
entitled to substantial, if not controlling, weight because it was consistent with his own treatment
notes, the treatment records of other providers, and Plaintiff’s testimony about her own
symptoms. Indeed, substantial evidence supported Dr. Ahmad’s opinion that Plaintiff’s
impairments caused her continuing and debilitating pain. For these reasons, the ALJ’s decision
to discount Dr. Ahmad’s opinion is not supported by substantial evidence.
2. Dr. deGrange
Plaintiff also challenges the ALJ’s decision to assign Dr. deGrange’s November 2014
opinion “little weight” and his December 2014 opinion “great weight.” In response, Defendant
asserts that the ALJ properly evaluated Dr. deGrange’s opinions and substantial evidence
supported the ALJ’s finding that the December opinion was consistent with the record.
As previously discussed, in November 2014, Dr. deGrange completed a form for Plaintiff
entitled “AT&T Integrated Disability Physical Capacities Evaluation.” On that form, Dr.
deGrange estimated that Plaintiff could sit thirty to forty-five minutes, stand fifteen to twenty
minutes, and walk fifteen to twenty minutes. Dr. deGrange also stated that Plaintiff could:
occasionally lift and carry a maximum of five pounds; occasionally use both hands for fine
manipulation, pushing/pulling, and reaching; and continuously perform a simple grasp. Dr.
deGrange noted these restrictions were permanent and “supersede[] previous statements of
functional capacities,” but stated that he would reassess Plaintiff’s restrictions in December. (Tr.
406)
Dr. deGrange reassessed Plaintiff in December 2014. In his treatment notes, Dr.
deGrange stated that Plaintiff “appears clinically to be much improved despite the subjective,”
but observed “some mild give-way weakness” in her arms. (Tr. 409) Unlike the November
opinion, Dr. deGrange opined that Plaintiff’s permanent limitations “plac[ed] her in a medium
demand capacity as defined by the Department of Labor Dictionary of Occupational Titles.”6
(Id.) Dr. de Grange further stated that Plaintiff “would meet the criteria for a light/medium
demand capacity indicating that on a constant basis she can lift, carry, push, and pull five pounds,
frequently up to 15 pounds, and occasionally up to 25 pounds.” (Tr. 409-10). Dr. deGrange did
not explain his reason for finding that, in one month’s time, Plaintiff’s limitations on
lifting/carrying, sitting, and walking/standing became significantly less restrictive.
The ALJ assigned the December opinion “great weight” and discredited the “much more
restrictive” November opinion. (Tr. 17-18) The ALJ explained that she was according the
6 Under the regulations, medium work “involves lifting no more than 50 pounds at a time with
frequent lifting or carrying of objects weighing up to 25 pounds.” 20 C.F.R. § 404.1567(c).
Light work, which the ALJ ultimately adopted for Plaintiff’s RFC, “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).
December opinion great weight because those findings were “consistent with the evidence” and
Dr. deGrange was a board-certified orthopedic surgeon who “as the treating source, [was] very
familiar with the claimant’s limitations.” (Id.) In support of her decision to discount the
November opinion, the ALJ wrote:
An earlier opinion from Dr. deGrange dated November 4, 2014, in conjunction
with the claimant’s claim for short-term disability from her employer before
she was released and while she was recuperating. It was much more
restrictive. Although he indicated the restrictions were permanent, he also
indicated that the restrictions would be reassessed in December and, therefore,
the subsequent opinion essentially rejects the prior limitations and therefore it
is entitled to little weight.
(Tr. 18)
The ALJ failed to provide any support for her conclusory statement that the December
opinion was consistent with the evidence. To the contrary, Plaintiff’s records reveal that she
consistently complained of weakness, pain, tingling, and numbness in her arms, hands, and
fingers, including at her appointments with Dr. deGrange in October, November, and December.
Neither Dr. deGrange nor the ALJ identified any medical reasons for finding Plaintiff was
capable of light or medium work when, one month earlier, Dr. deGrange had limited Plaintiff to
lifting/carrying five pounds, standing or walking fifteen to twenty minutes, and sitting thirty to
forty-five minutes. Moreover, Plaintiff’s subsequent medical records reflected that her condition
deteriorated rather than improved.
Nor did the ALJ provide “good reasons” for assigning Dr. deGrange’s November opinion
“little weight.” As previously discussed, Dr. deGrange’s November opinion was consistent with
Dr. Ahmad’s opinion, as well as the objective medical evidence, treatment records, and
Plaintiff’s testimony. “Confronted with a decision that fails to provide ‘good reasons’ for the
weight assigned to a treating physician’s opinion, the district court must remand.” Land v.
Berryhill, 2017 WL 4236976, at *7 (E.D. Mo. Sep. 25, 2017) (quoting Clover v. Astrue, 4:07-
CV-574-DJS, 2008 WL 3890497, at *12 (E.D Mo. Aug. 19, 2008)).
3. Conclusion
For the above reasons, the Court finds that the ALJ failed to properly weigh Dr. Ahmad’s
and Dr. deGrange’s opinions and thus failed to properly assess Plaintiff's disability claim such
that substantial evidence did not support the ALJ’s determination.’ See, e.g., Gordon v. Astrue,
801 F.Supp.2d 846, 859 (E.D.Mo. 2011).
Though the Court does not make the ultimate determination regarding Plaintiff's
disability, the Court finds this case should be reversed and remanded. On remand, the ALJ is
directed to properly evaluate and weigh the medial opinion evidence; formulate a new RFC for
Plaintiff based on the medical evidence in the record; further develop the record if necessary; and
proceed with the next steps of the sequential evaluation.
IT IS HEREBY ORDERED that this action is REVERSED AND REMANDED to the
Commissioner pursuant to sentence four 42 U.S.C. § 405(g) for further consideration in
accordance with this Memorandum and Order.
A separate judgment with accompany this order.
plain Metis
PATRICIA L. COHEN
UNITED STATES MAGISTRATE JUDGE
Dated this 16th day of September, 2019
7 Because the ALJ erred in evaluating the medical opinion evidence, the Court addresses only
that issue. See Western v. Berryhill, No. 1:16-cv-49 JAR, 2017 WL 1407118, at *3 (E.D. Mo.
Apr. 20, 2017).
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