appropriate for ALJ to consider conservative or minimal treatment in assessing credibility
How later courts described this case
- appropriate for ALJ to consider conservative or minimal treatment in assessing credibility
- it is the claimant’s burden, not the Social Security Commissioner’s burden, to prove the claimant’s RFC
- “In this substantial- evidence determination, the entire administrative record is considered but the evidence is not reweighed.”
- court notes that “treating physician” had only treated claimant once before opinion was rendered
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
TYRONE BOOZE, )
)
Plaintiff, )
)
v. ) Case No. 4:18-CV-568 NAB
)
ANDREW M. SAUL1, )
Commissioner of Social Security, )
)
Defendant. )
MEMORANDUM AND ORDER
This matter is before the Court on Plaintiff Tyrone M. Booze’s appeal regarding the denial
of disability insurance benefits under the Social Security Act. The Court has jurisdiction over the
subject matter of this action under 42 U.S.C. § 405(g). The parties have consented to the exercise
of authority by the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). [Doc. 5.] The
Court has reviewed the parties’ briefs and the entire administrative record, including the transcript
and medical evidence. Based on the following, the Court will affirm the Commissioner’s decision.
Issues for Review
Booze contends that the administrative law judge’s (“ALJ”) residual functional capacity
(“RFC”) determination was not supported by the medical evidence; therefore the vocational
expert’s testimony regarding the RFC cannot be used to support a finding of non-disability. The
1 At the time this case was filed, Nancy A. Berryhill was the Acting Commissioner of Social Security. Andrew M.
Saul became the Commissioner of Social Security on June 4, 2019. When a public officer ceases to hold office while
an action is pending, the officer’s successor is automatically substituted as a party. Fed. R. Civ. P. 25(d). Later
proceedings should be in the substituted party’s name and the Court may order substitution at any time. Id. The Court
will order the Clerk of Court to substitute Andrew M. Saul for Nancy A. Berryhill in this matter.
Commissioner asserts that the ALJ’s decision is supported by substantial evidence in the record as
a whole and should be affirmed.
Standard of Review
The Social Security Act defines disability as an “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 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).
The Social Security Administration (“SSA”) uses a five-step analysis to determine whether
a claimant seeking disability benefits is in fact disabled. 20 C.F.R. § 404.1520(a)(1). First, the
claimant must not be engaged in substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i).
Second, the claimant must establish that he or she has an impairment or combination of
impairments that significantly limits his or her ability to perform basic work activities and meets
the durational requirements of the Act. 20 C.F.R. § 404.1520(a)(4)(ii). Third, the claimant must
establish that his or her impairment meets or equals an impairment listed in the appendix of the
applicable regulations. 20 C.F.R. § 404.1520(a)(4)(iii). If the claimant’s impairments do not meet
or equal a listed impairment, the SSA determines the claimant’s RFC to perform past relevant
work. 20 C.F.R. § 404.1520(e).
Fourth, the claimant must establish that the impairment prevents him or her from doing
past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant meets this burden, the analysis
proceeds to step five. At step five, the burden shifts to the Commissioner to establish the claimant
maintains the RFC to perform a significant number of jobs in the national economy. Singh v.
Apfel, 222 F.3d 448, 451 (8th Cir. 2000). If the claimant satisfied all of the criteria under the five-
step evaluation, the ALJ will find the claimant to be disabled. 20 C.F.R. § 404.1520(a)(4)(v).
The standard of review is narrow. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir.
2001). This Court reviews the decision of the ALJ to determine whether the decision is supported
by substantial evidence in the record as a whole. 42 U.S.C. § 405(g). Substantial evidence is less
than a preponderance, but enough that a reasonable mind would find adequate support for the
ALJ’s decision. Smith v. Shalala, 31 F.3d 715, 717 (8th Cir. 1994). The Court determines whether
evidence is substantial by considering evidence that detracts from the Commissioner’s decision as
well as evidence that supports it. Cox v. Barnhart, 471 F.3d 902, 906 (8th Cir. 2006). The Court
may not reverse just because substantial evidence exists that would support a contrary outcome or
because the Court would have decided the case differently. Id. If, after reviewing the record as a
whole, the Court finds it possible to draw two inconsistent positions from the evidence and one of
those positions represents the Commissioner’s finding, the Commissioner’s decision must be
affirmed. Masterson v. Barnhart, 363 F.3d 731, 736 (8th Cir. 2004). The Court must affirm the
Commissioner’s decision so long as it conforms to the law and is supported by substantial evidence
on the record as a whole. Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 729 (8th Cir. 2003).
Discussion
Background
This case involves an extensive record. Booze is a high school graduate who served in the
United States Navy between 1984 and 2000. (Tr. 440-41.) On March 9, 2005, Booze was found
disabled as of September 20, 2000 and awarded disability insurance benefits. (Tr. 180.) The SSA
found that Booze’s disability ceased on May 14, 2014. (Tr. 181.) Booze did not appeal the
decision. On December 2, 2014, he completed a new disability application, where Booze alleged
that his disability began on August 2, 2014. (Tr. 436.) He asserted that he was unable to work
due to panic attacks, anxiety, multiple joint sclerosis, right knee impairment, left knee impairment,
other psychiatric disorders, major depression and post traumatic stress disorder. (Tr. 439.) Booze
obtained a 100% disability rating from the Veterans Administration (“VA”) and currently receives
VA benefits. (Tr. 118, 133-46, 212-23, 380-408, 1172-76.)
The SSA initially denied Booze’s claim and denied his reconsideration request.2 (Tr. 165-
76.) Booze requested and received an administrative hearing before an administrative law judge.
(Tr. 195-96, 230-35.) The first administrative hearing was held on October 4, 2016, before ALJ
William Kumpe. (Tr. 114-32.) Booze and vocational expert Dr. Darrel Taylor testified at the
hearing and Booze was represented by counsel. ALJ Kumpe stated that he was going to order two
consultative examinations for internal medicine with a focus on Booze’s heart, back, and joints
and a psychological evaluation. (Tr. 127.) ALJ Kumpe convened a second administrative hearing
on May 3, 2017, but he then recused himself from hearing Booze’s claim, because of a conflict of
interest with Booze’s new counsel. (Tr. 109- 113.) On July 26, 2017, a third administrative
hearing presided over by ALJ Lori Imsland was held where Booze and vocational expert Deborah
Determan testified. (Tr. 78-108.) Booze was represented by a new attorney at the third
administrative hearing as well.
ALJ Imsland issued an opinion denying Booze’s claim for disability benefits on September
25, 2017. (Tr. 52-68.) On February 23, 2018, the Appeals Council denied Booze’s request for
review. (Tr. 1–5.) The decision of the ALJ thus stands as the final decision of the Commissioner.
See Sims v. Apfel, 530 U.S. 103, 107 (2000). Booze filed this appeal on April 12, 2018. [Doc 1.]
The parties completed briefing this matter on February 6, 2019.
2 Booze’s claim was initially filed in California, which allows for reconsideration of a claimant’s initial denial.
Missouri is a state that eliminates the reconsideration step of the administrative process. 20 C.F.R. § 404.906(4).
ALJ Decision
The ALJ found that Booze met the insured status requirements of the Social Security Act
through September 30, 2019. (Tr. 55.) The ALJ found that he had not engaged in substantial
activity since August 2, 2014, the alleged onset date. (Tr. 55. ) She determined that Booze had
the following severe impairments: status post repair of right quadriceps, degenerative joint disease
in the knees, obesity, psychosis (not otherwise specified), PTSD, and depression. (Tr. 55.) She
determined that Booze’s eczema, hypertension, erectile dysfunction, atrioventricular block and
status post pacemaker implantation, folliculitis were non-severe. (Tr. 55.) She found that Booze
did not have an impairment or combination of impairments that meet or medically equal the
severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1, 20 C.F.R.
§§ 404.1520(d), 404.1525, 404.1526. The ALJ then found that Booze had the RFC to perform
medium work3 with the following additional limitations: (1) lift, carry, push, or pull 50 pounds
occasionally and 25 pounds frequently; (2) never climb ropes, ladders, or scaffolds;
(3) occasionally climb ramps and stairs; (4) balance, stoop, kneel, crouch, and crawl; (5) no
exposure to extreme cold, vibration, unprotected heights, and hazardous machinery; (6) limited to
simple, routine work tasks with minimal changes in job setting and duties; (7) no contact with the
general public; and (8) only occasional contact with coworkers and supervisors. (Tr. 58.) Booze
had no past relevant work. (Tr. 66.) Due to his date of birth, he is classified as closely approaching
advanced age on the alleged onset date. (Tr. 66.) Next, the ALJ determined that considering
Booze’s age, education, work experience, and RFC, there were jobs in the national economy that
he could perform as laboratory equipment cleaner, hand packager, laundry worker, marker,
packing line worker, and palletizer. (Tr. 67.) Therefore, the ALJ held that Booze had not been
3 “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).
under a disability, as defined in the Social Security Act, from August 2, 2014 through the date of
the decision on September 25, 2017. (Tr. 67.)
Medical Opinion Evidence
The administrative record in this case contains at least thirteen medical opinions. The
Court will summarize each of these opinions to inform the discussion of the ALJ’s RFC
determination.
Dr. Camellia Clark
Dr. Camellia Clark, a psychiatrist, evaluated Booze on March 20, 2014. (Tr. 525-27, 1089-
91.) Booze reported that he had a long psychiatric history and had been previously diagnosed with
PTSD, depression, and psychosis. (Tr. 525, 1089.) Booze also reported four psychiatric
hospitalizations between 2000 and 2012. (Tr. 525, 1089.) Booze’s mental status examination was
normal. (Tr. 526, 1090.) His mood was good, his affect was full and congruent, and his thought
processes were logical and goal-directed. (Tr. 526, 1090.) Dr. Clark diagnosed Booze with
psychosis, not otherwise specified, PTSD, and depression, not otherwise specified. She opined
that he had “no mental health restrictions.” (Tr. 526, 1090.) The ALJ gave this opinion partial
weight, because additional records indicate Booze had more restrictive mental limitations. (Tr.
63.)
Dr. Preston Davis
The following month, Dr. Preston Davis, a state agency psychologist, reviewed Booze’s
mental health record and completed a Psychiatric Review Technique and Mental Residual
Functional Capacity assessment. (Tr. 530-41, 1092-1107.) Dr. Davis also reviewed Booze’s
medical record and diagnosed Booze with unspecified psychotic disorder, depressive disorder, and
anxiety disorder. (Tr. 532-34, 1098-1100.) He opined that Booze was mildly limited in activities
of daily living, moderately limited in maintaining social functioning, and moderately limited in
maintaining concentration, persistence, or pace. (Tr. 538, 1104.) Specifically, he opined that
Booze was moderately limited in his ability to interact appropriately with the general public and
respond to changes in the work setting. (Tr. 1093.) He opined that Booze could understand
remember, and carry out complex work instructions. (Tr. 1094.) He also opined that Booze could
sustain his concentration, pace, and persistence with his work tasks for two hour blocks of time
with customary breaks over the course of a regular workday. (Tr. 1094.) Dr. Davis found that
Booze can interact with supervisors and co-workers that he knows well. (Tr. 1094.) He opined
that Booze would have difficulty interacting with the general public on a consistent basis. (Tr.
1094.) He further found that Booze can adapt to a work setting that is simple and routine. (Tr.
1094.) The ALJ gave Dr. Davis’ opinion great weight stating that the limitations expressed are
consistent with the medical records and deserve great weight. (Tr. 58.)
Dr. Thu N. Do
A state agency physician, Dr. Thu N. Do, completed a medical opinion after a review of
Booze’s medical record on May 5, 2014. (Tr. 542-49, 1149-57.) He did not examine Booze. Dr.
Do opined that Booze could occasionally lift and or carry 50 pounds, frequently lift and/or carry
25 pounds, stand and/or walk for a total of about 6 hours in an 8-hour workday, and sit for a total
of about 6 hours in an 8-hour workday. (Tr. 543, 1150.) Dr. Do found that Booze may frequently
climb ramps and stairs, stoop, kneel, crouch, and crawl. (Tr. 544, 1151.) Dr. Do found that Booze
may occasionally balance and climb ladders, ropes, or scaffolds. (Tr. 544, 1151.) Dr. Do found
that Booze did not have any manipulative, visual, communicative, or environmental limitations.
(Tr. 544-46, 1151-53.) Dr. Do wrote that Booze had only received intermittent conservative
treatment. (Tr. 547, 1153.) He wrote that Booze’s reported activities of boxing, tai chi, and going
to the gym were not compatible with disabling physical limitations. (Tr. 547, 1153.) The ALJ
gave this opinion great weight finding that it was consistent with the medical records and treatment
in the case. (Tr. 59-60.) The ALJ also noted that additional medical records after Dr. Do’s opinion
indicate that additional restrictions regarding dizziness and problems with the cold were required
to be included in the RFC. (Tr. 60.)
Dr. Cory Brown
On February 5, 2015, Dr. Cory Brown, a state agency psychologist, completed a mental
medical opinion regarding Booze. (Tr. 157-58.) Dr. Brown based his opinion on Booze’s medical
records and did not examine Booze. He found that Booze did not have a severe mental impairment
and had no restrictions in activities of daily living, maintaining social functioning, or maintaining
concentration, persistence, or pace. (Tr. 158.) This opinion was relied upon during the initial
denial of Booze’s claim. The ALJ gave this opinion little weight noting that Booze’s mental
impairments were severe. (Tr. 58.)
Dr. Thomas Sabourin
On March 5, 2015, Dr. Thomas Sabourin completed an orthopedic consultative
examination of Booze. (Tr. 624-28.) Booze reported that he had pain in both knees. (Tr. 624.)
Dr. Sabourin noted that Booze’s gait and posture were normal. (Tr. 625.) Booze did not use any
assistive device and he was able to toe and heel walk. (Tr. 625.) The range of motion of his
cervical and lumbar spines was grossly normal. (Tr. 625.) His straight leg raising test was within
normal limits in both the sitting and supine positions. (Tr. 625.) He exhibited normal and painless
range of motion for his shoulders, elbows, wrists, hands, fingers, hips, ankles, and feet. (Tr. 626.)
Examination of the left knee revealed a 1+ medial instability, tenderness over the medial
compartment, and palpable spurs in that area. (Tr. 626.) There was obvious atrophy of the right
quadriceps mechanism compared with the left. (Tr. 626.) Although there was restriction in
flexion, he actually flexed a little farther on the right. (Tr. 626.) There was also mild crepitus on
the medial aspect of the left knee. (Tr. 626.) Pulses and deep tendon reflexes were normal. (Tr.
626-27.) Motor strength and sensation were normal throughout the upper and lower extremities.
(Tr. 627.)
Dr. Sabourin diagnosed Booze with tear of right quadriceps mechanism, status post repair
x2 and degenerative arthritis, mild, medial compartment of the left knee with +1 instability. (Tr.
627.) Dr. Sabourin opined that given Booze’s knee problems he has the following limitations:
(1) lift and carry 20 pounds occasionally and 10 pounds frequently; (2) stand, walk, and sit for 6
hours in an 8 hour workday; (3) limited to pushing and pulling 50 pounds occasionally and 25
pounds frequently; and (4) climb, kneel, and crouch occasionally. Dr. Sabourin did not find any
stooping or manipulative limitations. (Tr. 627.) The ALJ gave Dr. Sabourin’s opinion little
weight, because there was no support for upper extremity limitations in the record. (Tr. 60-61.)
Dr. R. Bitonte
On March 13, 2015, Dr. R. Bitonte, a state agency physician, completed a physical medical
opinion regarding Booze. (Tr. 158-161.) Dr. Bitonte reviewed Booze’s medical records and did
not examine Booze. Dr. Bitonte opined that Booze could occasionally lift and/or carry 20 pounds,
frequently lift and/or carry up to 10 pounds, stand and/or walk 6 hours in an 8 hour workday, and
sit with normal breaks 6 hours in an 8 hour workday. (Tr. 159.) Dr. Bitonte opined that Booze
could occasionally climb ramps and stairs, stoop, kneel, crouch, and crawl; never climb ladders,
ropes, or scaffolds; and frequently balance. (Tr. 160.) He opined that was Booze limited to
pushing and pulling to lifting and carrying exertional limit. (Tr. 159.) Dr. Bitonte did not find that
Booze had any manipulative, vision, or communicative limitations. (Tr. 160.) Dr. Bitonte found
that Booze must avoid concentrated exposure to extreme cold, wetness, vibration, and hazards
(machinery and heights). (Tr. 161.) This opinion was relied upon in the initial denial of Booze’s
claim. The ALJ gave Dr. Bitonte’s opinion little weight, because the record indicates that Booze
is able to do more than indicated in the opinion. (Tr. 61.)
Dr. Robert Townsend
Dr. Robert Townsend, a VA psychologist, completed a Disability Benefits Questionnaire
for Booze. (Tr. 824-27.) Dr. Townsend diagnosed Booze with other psychotic disorder. (Tr. 824.)
Dr. Townsend indicated that Booze’s symptoms included depressed mood, anxiety,
suspiciousness, chronic sleep impairment, mild memory loss, difficulty in understanding complex
commands, disturbances of motivation and mood, difficulty in establishing and maintaining
effective work and social relationships, difficulty in adapting to stressful circumstances, including
at work or a work like setting, obsessional rituals which interfere with routine activities, and
persistent delusion or hallucinations. (Tr. 827.) Dr. Townsend concluded that Booze’s “prior
depressive disorder appears to be in remission, but he is presently disabled from gainful
employment due to his unspecified psychotic disorder, with paranoia.” (Tr. 827.) The ALJ gave
the opinion no weight, because the opinion provided no supporting functional limitations. (Tr.
63.)
Dr. K. Loomis
Dr. K. Loomis, a state agency psychologist, reviewed Booze’s mental impairments at the
reconsideration level of review on May 28, 2015. (Tr. 171-72.) Dr. Loomis found that Booze’s
mental impairments were non-severe and that he had no restrictions of activities of daily living,
maintaining social functioning, or maintaining concentration, persistence, or pace. (Tr. 171-72.)
The ALJ did not mention this opinion.
Dr. S. Laiken
Dr. S. Laiken, a state agency physician, reviewed Booze’s physical impairments at the
reconsideration level of review on June 4, 2015. (Tr. 173-74.) Dr. Laiken opined that Booze could
occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, stand and/or walk
6 hours in an 8 hour workday, and sit with normal breaks 6 hours in an 8 hour workday. (Tr. 173.)
Dr. Laiken opined that Booze could occasionally climb ramps and stairs, never climb ladders,
ropes, or scaffold, frequently balance, and occasionally stoop, kneel, crouch, and crawl. (Tr. 173-
74.) He opined that Booze was limited to pushing and pulling to the above identified exertional
limits. (Tr. 173.) Dr. Laiken did not find that Booze had any manipulative, vision, or
communicative limitations. (Tr. 174.) Dr. Laiken opined that Booze must avoid concentrated
exposure to extreme cold, vibration, and hazards (machinery and heights). (Tr. 174.) The ALJ
gave no weight to Dr. Laiken’s opinion, because “there was no rational correlation between any
impairment [Booze] has been diagnosed with in this case and the preclusion from wetness
exposure.” (Tr. 61.)
Dr. David Bittleman
On June 5, 2015, Dr. David Bittleman completed a Disability Impairment Questionnaire
regarding Booze. (Tr. 751-55.) Dr. Bittleman noted that he had examined Booze once on May
18, 2015, at the time the questionnaire was completed. (Tr. 751.) Dr. Bittleman diagnosed Booze
with psychosis, chronic chest pains, back pains, knee pains, and depression. (Tr. 751.) He opined
that Booze was unable to work at all. (Tr. 753.) Dr. Bittleman stated that Booze could sit, stand,
and/or walk for less than 1 hour in an 8 hour day. (Tr. 753.) He also found that Booze would have
to get up from a seated position every 10 minutes for a 10 minute period of time while working.
(Tr. 753.) Dr. Bittleman opined that Booze could not lift or carry any weight. (Tr. 753.) He
opined that Booze would experience symptoms, pain, and fatigue frequently up to 2/3 of an 8 hour
workday. (Tr. 754.) Dr. Bittleman indicated that Booze would need to take 30 minute unscheduled
breaks every 30 minutes during an 8 hour workday to rest. (Tr. 754.) He indicated that Booze
would be absent more than 3 times per month as a result of his impairments or treatment. (Tr.
755.) Dr. Bittleman opined that Booze’s depression increased his pain. (Tr. 755.) The ALJ did
not explicitly assign a weight to the June 5, 2015 opinion, but she gave the May 18, 2015 treatment
notes that it was based off of no weight. (Tr. 60.) The ALJ wrote that June 2015 opinion was
based on a one-time assessment and he just took Booze’s word for every alleged limitation and
repeated it in the opinion. (Tr. 61.) Therefore, it appears the ALJ also gave this opinion no weight.
(Tr. 61.)
Dr. Gregory Goldman
On November 7, 2016, Dr. Gregory Goldman, a consultative examiner, evaluated Booze
and reviewed Booze’s previous psychiatric records. (Tr. 1192-1199.) Booze reported to Goldman
that he had mood swings, thoughts of bad experiences, felt on guard and distrustful of everyone,
and hearing voices. (Tr. 1192-93.) He also reported difficulty sleeping. (Tr. 1193.) He reported
that the erroneous implantation of a pacemaker ruined his career. (Tr. 1193.)
Dr. Goldman observed that Booze’s mood was up and down and his affect was appropriate
to the content. (Tr. 1194.) Booze reported passive suicidal ideation and auditory and tactile
hallucinations. (Tr. 1194.) Booze’s thought process was goal oriented and coherent. (Tr. 1194.)
His insight was adequate. (Tr. 1194.) Dr. Goldman diagnosed Booze with PTSD. (Tr. 1195.) Dr.
Goldman opined that Booze’s ability to understand and remember instructions, interact socially,
and adapt to his environment is mildly impaired. (Tr. 1195.) He opined that Booze was mildly to
moderately impaired in the ability to sustain concentration and persistence in tasks. (Tr. 1195.)
Specifically, Dr. Goldman found that Booze was mildly impaired in the ability to understand,
remember, and carry out simple instructions and the ability to make simple work related decisions.
(Tr. 1197.) He also found that Booze was moderately limited in his ability to understand,
remember, and carry out complex instructions and the ability to make complex work-related
decisions. (Tr. 1197.) Dr. Goldman indicated that Booze was mildly limited in interacting
appropriately with supervisors and responding appropriately to usual work situations and to
changes in a routine work setting. (Tr. 1198.) Dr. Goldman indicated that Booze was moderately
limited in interacting appropriately with the public and co-workers. (Tr. 1198.) The ALJ gave Dr.
Goldman’s opinion some weight, because it was “somewhat consistent with the evidence in this
case.” (Tr. 64.)
Dr. Nirmala Mathew4
Dr. Nirmala Mathew completed a physical consultative examination of Booze on
November 7, 2016. (Tr. 1177-1191.) In addition to his examination of Booze, Dr. Mathew
reviewed Booze’s VA records. (Tr. 1177.) The examination indicated essentially normal findings.
(Tr. 1179-80.) Dr. Mathew noted that Booze reported a right knee impairment, but range of motion
in the right knee was not impaired. (Tr. 1180.) Dr. Mathew also noted that Booze reported
swelling as well as exhibiting pain and crepitus in the left knee. (Tr. 1180.) Dr. Mathew observed
that Booze wore a left knee brace and showed reduced range of motion in the left knee. (Tr. 1180.)
Dr. Mathew noted that there was evidence of left knee osteoarthritis in the form of joint space
narrowing as well as osteophytes from the VA records. (Tr. 1180.) Booze’s range of motion on
flexion-extension of the right knee was reduced by 50 degrees and reduced by 60 degrees on the
left knee. (Tr. 1190.) The forward flexion of the right and left hips were reduced by 10 degrees.
4 The ALJ transposed Dr. Nirmala Mathew’s name in the opinion. (Tr. 62.)
(Tr. 1191.) The flexion-extension of the lumbar spine was reduced by 15 degrees. (Tr. 1191.)
Straight leg raise was 0 to 70 degrees in the supine position bilaterally. (Tr. 1180, 1191.)
Dr. Mathew opined that Booze could occasionally lift and carry up to 20 pounds; frequently
reach in all directions; frequently handle, finger, feel, push, and pull with both hands; and
frequently operate foot controls with both feet, occasionally climb stairs, ramps, ladders, or
scaffolds, never crawl, and occasionally kneel. (Tr. 1183-86.) He further opined that Booze could
sit for 15 minutes and stand or walk for 30 minutes at one time without interruption. (Tr. 1184.)
He found that Booze could sit for a total of 1 hour and 30 minutes, and stand or walk for 2 hours
total in an 8 hour workday. (Tr. 1184.) Booze can walk for a city block at a reasonable pace with
a left knee brace. (Tr. 1180.) Dr. Mathew opined that Booze could frequently operate a motor
vehicle and occasionally be exposed to moving mechanical parts or extreme heat. (Tr. 1187.)
Booze could never be exposed to unprotected heights, humidity and wetness, dust, odors, fumes,
and pulmonary irritants, or extreme cold. (Tr. 1187.) He must also be exposed to a quiet
environment. (Tr. 1187.) The ALJ gave Dr. Mathew’s opinion little weight, because the
examination records do not support the limitations contained in the opinion. (Tr. 62.)
Dr. Daniel Murray
Dr. Daniel Murray, Booze’s treating psychiatrist, completed a mental impairment
questionnaire on April 25, 2017. (Tr. 1395-99.) Dr. Murray indicated that he began treating Booze
on November 2, 2016 and his most recent treatment occurred on March 7, 2017. (Tr. 1395.) Dr.
Murray diagnosed Booze with major depressive disorder, severe with psychotic features. (Tr.
1395.) Dr. Murray identified the following symptoms that support Booze’s diagnosis and
treatment: depressed mood, feelings of guilt or worthlessness, hostility or irritability, grandiose
thoughts, illogical thinking, difficulty thinking or concentrating, easy distractibility, intrusive
recollections of a traumatic experience, paranoia/suspiciousness, persistent irrational fears,
vigilance and scanning, decreased energy, impulsive or damaging behavior, agitation, pressured
speech, social withdrawal or isolation, delusions, and decreased need for sleep. (Tr. 1396.) Dr.
Murray indicated that Booze’s most severe symptoms were paranoia, delusion, and social
isolation. (Tr. 1397.)
Dr. Murray opined that Booze had moderate limitations in remembering locations and
work-like procedures and understanding and remembering detailed instructions. (Tr. 1398.)
Booze had moderate limitations in asking simple questions, requesting assistance, and responding
appropriately to workplace changes. (Tr. 1398.) Booze had moderate to marked limitations in
carrying out detailed instructions, maintaining attention and concentration for extended periods,
making simple work-related decisions, performing at a consistent pace without rest periods of
unreasonable length or frequency, maintaining socially appropriate behavior, being aware of
hazards and taking appropriate precautions. (Tr. 1398.) Dr. Murray determined that Booze had
marked limitations in his ability to perform activities within a schedule and consistently be
punctual, work in coordination with or near others without being distracted by them, complete a
workday without interruptions from psychological symptoms, interact appropriately with the
public, accept instructions and respond appropriately to criticism from supervisors, get along with
coworkers or peers without distracting them, set realistic goals, and make plans independently.
(Tr. 1398.) Dr. Murray opined that Booze would likely be absent from work more than 3 times
per month. (Tr. 1399.) The ALJ gave Dr. Murray’s opinion little weight, because the marked
limitations lack support in the medical records. (Tr. 64.)
RFC Determination
Booze contends that the ALJ’s RFC determination is not supported by substantial evidence
for the following reasons. Booze states that the ALJ improperly evaluated the medical opinion
evidence, failed to properly assess Booze’s subjective complaints, and erred in her consideration
of the third party evidence of the VA’s disability rating and the statement from Booze’s fiancé.
The RFC is defined as what the claimant can do despite his or her limitations, and includes
an assessment of physical abilities and mental impairments. 20 C.F.R. § 404.1545(a). The RFC
is a function-by-function assessment of an individual’s ability to do work related activities on a
regular and continuing basis.5 SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). It is the ALJ’s
responsibility to determine the claimant’s RFC based on all relevant evidence, including medical
records, observations of treating physicians and the claimant’s own descriptions of his limitations.
Pearsall, 274 F.3d at 1217. An RFC determination made by an ALJ will be upheld if it is supported
by substantial evidence in the record. See Cox, 471 F.3d at 907.
Evaluation of Medical Opinion Evidence
Booze states that the ALJ makes unsupported medical conjecture regarding the sufficiency
of the medical opinions. Booze also states that the treatment records do not contradict the opinions
given by the doctors and are at most neutral.
Medical opinions are statements from physicians and 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
5 A “regular and continuing basis” means 8 hours a day, for 5 days a week, or an equivalent work schedule. SSR
96-8p, 1996 WL 374184, at *1.
impairments and her physical or mental restrictions. 20 C.F.R. § 404.1527(a)(2)6. All medical
opinions, whether by treating or consultative examiners, are weighed based on (1) whether the
provider examined the claimant; (2) whether the provider is a treating source; (3) length of
treatment relationship and frequency of examination, including nature and extent of the treatment
relationship; (4) supportability of opinion with medical signs, laboratory findings, and
explanation; (5) consistency with the record as a whole; (6) specialization; and (7) other factors
which tend to support or contradict the opinion. 20 C.F.R. § 404.1527(c).
Generally, a treating physician’s opinion is given controlling weight, but is not inherently
entitled to it. Hacker v. Barnhart, 459 F.3d 934, 937 (8th Cir. 2006). A treating physician’s
opinion “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). A treating physician’s opinion will be
given controlling weight if the opinion is well-supported by medically acceptable clinical and
laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the
case record. 20 C.F.R. § 404.1527(c); see also Hacker, 459 F.3d at 937. “Whether the ALJ grants
a treating physician’s opinion substantial or little weight, the regulations provide that the ALJ must
‘always give good reasons’ for the particular weight given to a treating physician’s evaluation.”
Prosch v. Apfel, 201 F.3d 1010, 1013 (8th Cir. 2000).
“Good reasons for assigning lesser weight to the opinion of a treating source exist where
the treating physician’s opinions are themselves inconsistent, or where other medical assessments
are supported by better or more thorough medical evidence.” Chesser v. Berryhill, 858 F.3d 1161,
1164 (8th Cir. 2017) (internal citations omitted). The court reviews “the record to ensure that an
ALJ does not disregard evidence or ignore potential limitations, but [it is not required for] an ALJ
6 Several Social Security regulations were changed effective March 27, 2017. The Court will use the regulations
effective at the time that this claim was filed in 2014.
to mechanically list and reject every possible limitation.” McCoy v. Astrue, 648 F.3d 605, 615
(8th Cir. 2011).
In this case, the medical opinions’ conclusions varied substantially from finding no severe
impairments to finding total disability. Most of the medical opinions indicated that Booze had
some restrictions, but was not totally disabled. Booze contends that the ALJ makes unsupported
medical conjecture regarding the sufficiency of the medical opinions. Booze does not meet his
burden to show that the ALJ’s evaluation of the medical opinion evidence was erroneous. Booze
essentially requests that the Court re-weigh the evidence, which the Court cannot do on
administrative review. See Byes v. Astrue, 687 F.3d 913, 915 (8th Cir. 2012) (“In this substantial-
evidence determination, the entire administrative record is considered but the evidence is not
reweighed.”). Booze mentions that the ALJ gave great weight to some non-examining physicians
and no weight to some of Booze’s treating physicians. But, Booze does not explain how the ALJ’s
assessment of the individual doctors violates the Social Security regulations or the applicable law.
There are situations where an ALJ’s decision to grant greater weight to a non-examining physician
rather than a treating physician would be supported by substantial evidence. For example, Booze’s
treating physician, Dr. Bittleman, wrote an opinion based on his initial visit. The ALJ gave no
weight to the opinion. The longevity of treatment is an important factor in evaluating medical
opinions as stated in 20 C.F.R. § 404.1527. See Chesser, 858 F.3d at 1164 (court notes that
“treating physician” had only treated claimant once before opinion was rendered). The ALJ also
noted that Dr. Bittleman’s opinion was not supported by other medical evidence in the record.
Therefore, the ALJ did not err in failing to grant controlling weight to this opinion. Because Booze
had not specifically identified any errors in the ALJ’s evaluation of the medial opinion evidence,
the Court finds that the ALJ’s analysis is supported by substantial evidence.
Subjective Complaints
Next, Booze asserts that the ALJ failed to properly address his subjective complaints and
their consistency with the record. In considering subjective complaints, the ALJ must fully
consider all of the evidence presented, including the claimant’s prior work record, and observations
by third parties and treating examining physicians relating to such matters as:
(1) The claimant’s daily activities;
(2) The subjective evidence of the duration, frequency, and intensity of the claimant’s
pain;
(3) Any precipitating or aggravating factors;
(4) The dosage, effectiveness, and side effects of any medication; and
(5) The claimant’s functional restrictions.
Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984). It is not enough that the record contains
inconsistencies; the ALJ is required to specifically express that he or she considered all of the
evidence. Id. The ALJ, however, “need not explicitly discuss each Polaski factor.” Strongson v.
Barnhart, 361 F.3d 1066, 1072 (8th Cir. 2004). The ALJ need only acknowledge and consider
those factors. Id. Although credibility determinations are primarily for the ALJ and not the court,
the ALJ’s credibility assessment must be based on substantial evidence. Rautio v. Bowen, 862
F.2d 176, 179 (8th Cir. 1988). “While the extent of daily living activities does not alone show an
ability to work, such activities may be considered along with other evidence when evaluating a
claimant’s credibility.” Walker v. Colvin, 124 F.Supp. 3d 918, 936 (E.D. Mo. 2015).
“Although evidence of pain suffered by a claimant may be of necessity subjective in nature,
and therefore difficult to evaluate, the [ALJ] must give serious consideration to such evidence even
though it is not fully corroborated by objective examinations and tests performed on the claimant.”
Northcutt v. Califano, 581 F.2d 164, 166 (8th Cir. 1978). “Whether or not a medical explanation
for the pain can be given, it is nevertheless possible that the claimant is suffering from disabling
pain.” Layton v. Heckler, 726 F.2d 440, 442 (8th Cir. 1984).
It appears that Plaintiff’s primary argument is that the ALJ evaluated Booze’s credibility
solely on objective medical evidence. Plaintiff further argues that the ALJ did not analyze Booze’s
credibility and merely rejected or accepted various medical opinions in the record. The Court
disagrees. The ALJ’s opinion specifically addressed Booze’s activities of daily living as alleged
in his Adult Function Report, testimony, and as reported during his medical examinations. (Tr.
56-57, 59-64.) The ALJ noted that she considered Booze’s pain allegations, including the fact that
Booze is not taking narcotic medications. (Tr. 62.) Although Booze used a cane and brace/splint
at times, the ALJ found there was no evidence that these were medically prescribed. (Tr. 63.) The
ALJ noted that Booze’s mental impairments were stable for many years on Risperdal. (Tr. 63.)
The ALJ could consider Booze’s activities that indicated a greater level of activity, conservative
treatment for pain, and the effectiveness of Booze’s medication in considering his subjective
complaints. See Wildman v. Astrue, 596 F.3d 959, 965 (2010) (an impairment controlled by
treatment or medication cannot be considered disabling), Moore v. Astrue, 572 F.3d 520, 524-25
(8th Cir. 2009) (appropriate for ALJ to consider conservative or minimal treatment in assessing
credibility). The ALJ did not rely on any one factor to assess Booze’s subjective complaints;
therefore, the Court finds that the ALJ did not err in consideration of his subjective complaints.
Third-Party Statements
Then, Booze asserts that the ALJ erred in consideration of third-party statements,
specifically the award of a 100% disability rating from the VA and Plaintiff’s fiancé’s statement.
The SSA is not bound by any finding of disability by another governmental agency. The regulation
effective at the time Plaintiff’s claim was filed states the following:
A decision by any nongovernmental agency or any other
governmental agency about whether you are disabled or blind
is based on its rules and is not our decision about whether you
are disabled or blind. We must make a disability or blindness
determination based on social security law. Therefore, a
determination made by another agency that you are disabled
or blind is not binding on us.
20 C.F.R. § 404.1504. “The ALJ should consider the VA’s finding of disability, Morrison v. Apfel,
146 F.3d 625, 628 (8th Cir.1998), but the ALJ is not bound by the disability rating of another
agency” when she is evaluating whether the claimant is disabled for purposes of social security
benefits. Pelkey v. Barnhart, 433 F.3d 575, 579 (8th Cir. 2006) (citing 20 C.F.R. § 404.1504).
Plaintiff states that the ALJ did not assess the VA’s vocational rehabilitation assessment (Tr. 212-
23). The ALJ directly cites to the assessment and states that the assessment and disability ratings
were given little weight, because the VA and SSA use different criteria to assess disability. (Tr.
65.) The Court finds no error in the ALJ’s analysis of the VA vocational rehabilitation assessment.
Booze’s fiancé, Sharon Lowery, completed a Third-Party Adult Function Report on
January 8, 2014. (Tr. 446-54.) In this statement, she states that she has known Booze for over 30
years. (Tr. 446.) She indicated that his illnesses affect his short term memory, cause mood swings,
and limit prolonged standing. (Tr. 446, 449.) She wrote that Booze was “not able to work with
people in general.” (Tr. 446.) She also noted that he was no longer able to swim much, run
marathons, or practice martial arts. (Tr. 447, 450.) She indicated that he needs reminders taking
medication and he has trouble sleeping. (Tr. 447-48.) The ALJ gave Lowery’s statement some
weight. (Tr. 66.) The ALJ noted that although Lowery indicated that Booze had trouble standing,
she noted that they shopped, took walks, and saw concerts. (Tr. 66.)
Plaintiff contends that the ALJ failed to create a “logical bridge” between Lowery and
Booze’s daily activities and Booze’s ability to engage in sustained work activity. In the evaluation
of third-party statements, the ALJ uses the statements to show the severity of impairments and
how it affects the claimant’s ability to work. 20 C.F.R. § 404.1513. The Court finds no error in
the ALJ’s evaluation of Lowery’s third party statement. The ALJ only partially discounted the
statement and the ALJ was correct that some of the activities may indicate Booze’s impairments
were less severe than alleged.
Based on the foregoing, the Court finds that the ALJ’s RFC determination is supported by
substantial evidence in the record as a whole.
Vocational Testimony
Finally, the Court finds that the vocational expert’s response to the ALJ’s hypothetical
question constitutes substantial evidence. “The ALJ’s hypothetical question to the vocational
expert needs to include only those impairments that the ALJ finds are substantially supported by
the record as a whole.” Lacroix v. Barnhart, 465 F.3d 881, 889 (8th Cir. 2006). These impairments
must be based on the “substantial evidence on the record and accepted as true and capture the
concrete consequences of those impairments.” Jones v. Astrue, 619 F.3d 963, 972 (2010). If the
hypothetical question is properly formulated, then the testimony of the vocational expert
constitutes substantial evidence. Roe v. Chater, 93 F.3d 672, 676 (8th Cir. 1996).
In this case, the ALJ’s hypothetical question included all of the limitations set forth in the
ALJ’s description of Booze’s RFC. The Court has found that the ALJ’s RFC determination was
supported by substantial evidence, therefore, the hypothetical question was proper and the
vocational expert’s answer constituted substantial evidence supporting the Commissioner’s denial
of benefits.
Conclusion
The Court finds that substantial evidence supports the ALJ’s decision as a whole. As noted
earlier, the ALJ’s decision should be affirmed “if it is supported by substantial evidence, which
does not require a preponderance of the evidence but only enough that a reasonable mind would
find it adequate to support the decision, and the Commissioner applied the correct legal standards.”
Turpin v. Colvin, 750 F.3d 989, 992-93 (8th Cir. 2014). The Court cannot reverse merely because
substantial evidence also exists that would support a contrary outcome, or because the court would
have decided the case differently. Jd. A review of the record as a whole demonstrates that Booze
has some restrictions in his functioning and ability to perform work related activities, however, he
did not carry his burden to prove a more restrictive RFC determination. See Pearsall, 274 F.3d at
1217 (it is the claimant’s burden, not the Social Security Commissioner’s burden, to prove the
claimant’s RFC). For reasons set forth above, the Court affirms the Commissioner’ final decision.
Accordingly,
IT IS HEREBY ORDERED that the relief requested in Plaintiff's Complaint and Brief
in Support of Complaint is DENIED. [Docs. 1, 16.]
IT IS FURTHER ORDERED that the Court will enter a judgment in favor of the
Commissioner affirming the decision of the administrative law judge.
IT IS FURTHER ORDERED that the Clerk of Court shall substitute Andrew M. Saul for
Nancy A. Berryhill in the court record of this case.
Ne / fi /. SA —
NANNETTE A. BAKER
UNITED STATES MAGISTRATE JUDGE
Dated this 22nd day of June 2020
23