Redd v. Saul

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF MISSOURI

JOHN REDD, )

)

Plaintiff, )

)

vs. ) No. 4:20-cv-000880-MTS

)

KILOLO KIJAKAZI, acting commissioner )

of the Social Security Administration, )

)

Defendant. )

MEMORANDUM AND ORDER

This matter is before the Court for review of the final decision of Defendant, the acting

Commissioner of Social Security, denying the application of John Redd (“Plaintiff”) for Disability

Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. (the “Act”).

I. Procedural History

On August 11, 2016, Plaintiff filed an application for disability insurance benefits under

the Act with an alleged onset date of May 19, 2015. (Tr. 80, 261–62, 279). After Plaintiff’s

application was denied on initial consideration, he requested a hearing from an Administrative

Law Judge (“ALJ”). (Tr. 10, 197–200, 201–202). Plaintiff and his counsel appeared for an in-

person hearing before the ALJ on March 20, 2018. (Tr. 100–43). In a decision dated August 17,

2018, the ALJ concluded Plaintiff was not disabled under the Act. (Tr. 7–25). The Appeals

Council denied Plaintiff’s request for review on May 12, 2020. (Tr. 1–7). Accordingly, the ALJ’s

decision stands as the Commissioner’s final decision.1

1 Section 1383(c)(3) of Title 42 provides for judicial review of the SSA Commissioner’s “final decision.”

II. Evidence Before The ALJ

A. Overview and Function Report

Plaintiff was born in 1970, and he alleged he became disabled beginning May 19, 2015, at

age 45, due to lower back issues, leg nerve damage, diabetes, arthritis in his knee, neuropathy in

his feet, and memory loss. (Tr. 279). Plaintiff has a college education and past work as an

instructor in the U.S. Army, a corrections officer, a jailer for a sheriff, a small product assembler,

and a house parent. (Tr. 288–98).

In an August 2016 Function Report, (Tr. 299–313), Plaintiff indicated his medical

conditions affected lifting, squatting, bending, standing, reaching, walking, sitting, kneeling,

hearing, stair climbing, and using his hands. Additionally, these conditions kept him from being

active, cutting firewood, handling water, washing dishes, woodworking, mowing the lawn,

cooking, sitting too long, standing too long, walking too far, and driving long distances. He wore

a brace for his knee and used a cane and a hearing aid. Plaintiff indicated his medical conditions

also affected memory, completing tasks, concentration, understanding, and getting along with

others. He could pay attention for about 10 minutes; he did not do well with spoken instructions

because he gets lost and frustrated. Plaintiff indicated he did not handle stress well and that he

would get frustrated and angry. Plaintiff stated he could not stop seeing things from his military

experiences, PTSD; had bad dreams; did not want to do anything or go anywhere; could not

remember things; and could not be around large crowds.

Plaintiff indicated he was in a lot of pain; sometimes he cried from the pain in his back and

legs. He also had to walk on the side of his foot, which caused knee pain, hip pain, and back pain.

The pain also interfered with his sleep because he would wake up in the middle of the night in pain

and needed to move around. Plaintiff indicated his medications had many side effects, especially

making him sleepy. Plaintiff stated there was not much he could do; he used to be active and now

could do nothing. Plaintiff indicated his day consisted of sitting watching TV; taking a nap or

lying in the bed, because it helps with his back-pain; walking to the living room; sitting; letting the

dogs out; taking a nap; making dinner; watching TV; and going to bed.

Plaintiff indicated his basic living is poor. Regarding dressing, Plaintiff had to take his

time; as to bathing, he endorsed difficulty washing his hair and his wife had to check the water to

make sure it is not too hot;, he endorsed difficulty wiping after using the toilet. Plaintiff reported

his wife had to remind him to take medications, as well as help with his medications so he did not

take too much; when his wife worked late, Plaintiff had to have medications all in a row with notes.

Plaintiff could feed himself but did not cook and only heated up leftovers. Plaintiff indicated he

could drive a car, but his wife did most of the driving. His wife also did the shopping, indicating

he could not do it for long or very much. If he did walk, Plaintiff used a cane or a cart while in a

store.

B. Medical Evidence

The relevant time period for consideration of Plaintiff’s claim is from May 19, 2015, the

alleged onset date, until December 31, 2016, the date his insured status expired. This point is not

contested.

1. Left Knee

Plaintiff’s knee pain began after a fall in July 2014. A February 2015 x-ray of the left knee

was considered unremarkable. (Tr. 409–10). In May 2015, Plaintiff was diagnosed with iliotibial

band tendonitis. (Tr. 490). That month, Plaintiff reported pain had not resolved with conservative

care; he had tried therapy, including a steroid injection, and taking anti-inflammatories, but his

doctor had taken him off the anti-inflammatories secondary to esophageal stricture. (Tr. 706).

Plaintiff noted pain limits him from doing a lot of things, and he wears a brace, which helps quite

a bit, but he reports it catching. During the exam Plaintiff reported pain and showed tenderness

along the IT band insertion and LCL. The provider noted his ligaments were very stable, and that

Plaintiff showed no joint line tenderness, no medical pain with palpation, and no acute distress. A

previous MRI was reviewed, and the clinician indicated possible degenerative medial meniscus

but no acute findings. (Tr. 707). The provider recommended aggressive physical therapy and did

not recommend an arthroscopy due to benign MRI findings. In October 2015, the MRI was again

reviewed; no tears noted or any other concerns for the causes of Plaintiff’s pain. (Tr. 661–63).

The provider recommended to continue conservative care and ordered physical therapy for left

knee pain and strengthening. (Tr. 471).

A February 2016 x-ray of the left knee was considered unremarkable. (Tr. 402). That

month, Plaintiff visited orthopedics with complaints of constant knee pain—worse pain with sitting

or standing for long periods of time—and pops in the knees, described as painful. (Tr. 634).

Plaintiff said his knee brace helped, but he occasionally did not wear it as he knew it can weaken

his muscles. He reported tenderness, hypersensitivity, and pain with range of motion. (Tr. 635).

On physical exam, it was noted Plaintiff’s left knee had no effusion, erythema, or warmth, and his

range of motion was at 0 to 120, stable to varus and valgus stress. The assessment was left chronic

knee pain per arthroscopy, some chondromalacia. The provider recommended Plaintiff continue

with the knee brace and physical therapy and told Plaintiff he would have to live with some chronic

pain because he was ineligible for a total knee arthroscopic arthroplasty due to his age.

In September 2016, Plaintiff reported left knee arthritis with pain and wore a brace and

walked with a cane. (Tr. 1327). In November 2016, Plaintiff reported ongoing knee pain, and x-

rays were to be ordered; he was to call orthopedics if symptoms worsened. (Tr. 1290).

2. Diabetes with Neuropathy and Neuroma of the Right Foot

Doctors diagnosed Plaintiff with diabetes mellitus with neuropathy and neuroma of the

right foot. (Tr. 613, 620). Plaintiff reported his painful neuroma of the right foot began in 2011.

(Tr. 1272). A January 2016 x-ray of the right foot was considered “unremarkable.” (Tr. 649, 403).

In April 2016, Plaintiff’s chief complaints were of myoclonus, headache, and neuropathy. (Tr.

620). He reported a lot of jumping in his legs, particularly at night, which interfered with his

ability to fall asleep. Plaintiff also endorsed upper extremity jerking multiple times of the day,

right greater than left. (Tr. 621). An assessment noted diabetes, with painful ambulation,

secondary to a foot neuroma. (Tr. 620). Plaintiff’s foot had not responded to corrective inserts,

shoe changes, or cortisone injections. (Tr. 1272). Plaintiff was seen in prosthetics and prescribed

shoe/boots secondary to his type II diabetes mellitus with diabetic neuropathy. (Tr. 463).

At a May 2016 follow-up examination related to his diabetes, Plaintiff reported a small

eruption on his right forearm and no other new problems. (Tr. 614). Plaintiff’s objective physical

status was “unremarkable,” despite a very high hemoglobin A1C level, indicative of non-

compliance with his prescribed diet. (Tr. 615).

In August 2016, Plaintiff presented with a hemoglobin A1C of 9.1 and he complained of

muscle jerks, which a provider stated could be related to uncontrolled diabetes. (Tr. 578). He

complained of jerking motions on bilateral sides, primarily at night; they involved the hands, arms,

legs, and feet and may have awoken him at night. (Tr. 575). In September 2016, Plaintiff reported

symptoms of neuropathy with numbness, burning, and tingling in his feet and legs and that it had

been getting worse. (Tr. 1327). Plaintiff indicated if he was on his feet too long or sat down too

long, he felt this neuropathy. The provider recommended dietary changes, exercise, and

maintaining his glucose, blood sugar, and A1C at appropriate levels. (Tr. 1329).

In December 2016, Plaintiff’s reported an HbA1c of 8.7, which was down from 9.1, but

still at a high-level attributed to missing doses of medication. (Tr. 1284). The assessment at that

time was Plaintiff was clinically doing fine but having foot pain. (Tr. 1285). The provider noted

Plaintiff’s diagnoses of uncontrolled type II diabetes mellitus, complicated by DKD on ACEI;

obesity; hyperlipidemia; and chronic pain. (Tr. 1285). That same month, Plaintiff underwent

surgical excision of the neuroma on the right foot. (Tr. 1188, 1333–37, 1235–1240). Treatment

notes indicate Plaintiff tolerated the procedure well, with no complications.

3. Headaches

In July 2015, a brain MRI showed abnormalities. (Tr. 406). Later that year, Plaintiff

reported headaches at times for several days. (Tr. 665). In December 2015, Plaintiff reported

worsening chronic headaches, occurring three times per week. (Tr. 474, 652–655). He reported

the headaches could last anywhere from one hour to two to three days, with pain described as

throbbing, sometime sharp. He described two types of headaches, one more severe than the other,

occurring one to two times per week. Plaintiff reported the more severe headaches began with

seeing stars 20 minutes to one hour before beginning, and the headache was often associated with

nausea, causing him to lay down. He reported improvement when lying down in a dark room.

Plaintiff’s symptoms pointed against tension and cluster headaches. (Tr. 477). Plaintiff received

a bilateral occipital nerve block in the clinic that day. (Tr. 656).

In February 2016, Plaintiff endorsed a headache, noting the headaches were worse in the

daytime when fighting severe sleepiness, secondary to the obstructive sleep apnea. (Tr. 637).

Plaintiff noted the previous nerve block helped for two days but he did not like the way it made

him feel. The diagnoses offered at that time was migrainous headaches, with occipital neuralgia,

and incomplete treatment for obstructive sleep apnea. (Tr. 639). Imitrex was prescribed for severe

headaches.

In April 2016, Plaintiff visited the hospital for a headache but indicated his headaches were

doing much better; he only had two bad ones since the last visit. (Tr. 620–21). Plaintiff indicated

Imitrex breaks them for him. The impression on this visit reflected his headaches were doing okay

with some reported mild clonus. (Tr. 623).

In June 2016, Plaintiff reported his headaches and overall pain worsened, but Imitrex

helped sometimes. (Tr. 598). He described his headaches as dull to severe pain, lasting throughout

the day; made worse with moving the head or laying on the back; with associated neck stiffness

and spasms; occasional squiggly lines in vision; occasional nausea; and no light or sound

sensitivity. Plaintiff declined an occipital nerve block and was going to try a different medication

instead. It was noted Plaintiff had occipital neuralgia with cervicogenic and migrainous features.

An MRI of the C-spine was ordered to see if the cervicogenic nature of the headache could be

secondary along with the sensory level and myoclonic jerks’ history. (Tr. 600, 398). The cervical

MRI and x-ray demonstrated no soft tissue swelling and minimal multilevel degenerative disc

disease. (Tr. 399–400).

In August 2016, Plaintiff described his headaches as bilateral, radiating to the temples and

frontal forehead, and occurring four days a week while lasting for hours. (Tr. 575–78). His worse

headaches occurred two times per month. Prior to the start of a headache, Plaintiff noticed

twinkling in his vision. The headaches were assessed as multifactorial with migraine type and

cervicogenic, as well as medication overuse headache and from obstructive sleep apnea. (Tr. 578).

Plaintiff switched to Naproxen.

4. Dysphagia

Plaintiff was diagnosed with dysphagia, (Tr. 493, 583, 610, 632, 672), likely attributed to

a weakened esophagus from his diabetes. (Tr. 633, 612). A medical procedure in 2015 showed

Plaintiff had a “normal esophagus” as well as normal biopsies. (Tr. 672, 351, 1397, 1400). In

2015, Plaintiff reported dysphagia for around three years and endorsed difficulty swallowing

solids, liquids, and pills, as well as food materials getting stuck in his mid-esophagus. (Tr. 672).

Plaintiff reported the impairment sometimes causes him difficulty swallowing 50-percent of the

time. (Tr. 354, 1395). In May 2016, Plaintiff reported his dysphagia was two to three times per

week and mainly limited to solids but also sometimes pills. (Tr. 610). He also reported food still

got stuck in his chest, and he may get chest pain; and at times, it happened with liquids also. In

July 2016, Plaintiff reported dysphagia to both liquids and solids. (Tr. 582–85).

5. PTSD, Depression, and Anxiety

Plaintiff was diagnosed with PTSD. (Tr. 812). He reported flashbacks and nightmares—

about traumatic experiences in the military—beginning in October 2011 after his primary care

doctor asked if he experienced any trauma. (Tr. 1314). The provider noted that one month before

his symptoms began, Plaintiff was laid off due to budget cuts. (Tr. 1315). Plaintiff explained he

had put these memories on the “back burner” since his discharge in 1998 because he had to go on

with his life. Plaintiff reported nightmares every night since October 2011.

From May to December 2015, several mental status evaluations were “unremarkable” and

“normal.” (Tr. Tr. 670, 678, 659–660, 657). During this time, providers assessed Plaintiff’s PTSD

symptoms as “moderate to marked,” (Tr. 657, 651), and sometimes that these symptoms interfered

with normal psychosocial functioning. (Tr. 678, 671). Plaintiff described his mood as stressed,

concerned, and frustrated. He reported stress associated with family issues, finances, and VA

benefits claim. (Tr. 657, 650, 659). Providers reported his affect was mood-congruent, with no

evidence of thought disorder. (Tr. 650, 660). In December 2015, Plaintiff exhibited signs of major

depressive disorder. (Tr. 477).

In January and February 2016, Plaintiff received diagnoses of generalized anxiety disorder

and of major depressive disorder. (Tr. 643, 630). During that time, providers noted Plaintiff’s

PTSD symptoms interfered with normal psychosocial functioning, noted he was mood-congruent,

with no evidence of thought disorder or suicidal or homicidal ideations. (Tr. 647, 630). Plaintiff

denied being depressed and endorsed issues with his family causing anxiousness; a frustrated and

concerned mood; and nightmares and flashbacks relating to his traumatic experience in the

military. (Tr. 646, 629, 642). Plaintiff reported medication decreased the nightmares, and since a

change in his family situation, his nightmares became less vivid.

In April 2016, Plaintiff reported the loss of his father-in-law triggering traumatic memories.

(Tr. 624). Plaintiff identified a sad and frustrated mood but was also somewhat relieved, depending

on the topic. A provider reported his affect was mood-congruent, with no evidence of thought

disorder or suicidal or homicidal ideations. Severity of symptoms were rated as moderate to

marked, and his mental status evaluated as “unremarkable.” (Tr. 625).

In June and July 2016, Plaintiff endorsed depression, anxiety, negative thoughts, and

nightmares and flashbacks regarding his military experience. (Tr. 594, 586). He discussed

stressors such as traveling with his wife and the recent loss of his father-in-law. Plaintiff stated he

avoided crowds, loud noises, and news about people dying from accidents and swimming. (Tr.

587). Plaintiff indicated he would like to do more activities with his spouse, but pain limited him.

(Tr. 594).

In October 2016, Plaintiff reported experiencing many stressors at the VA, as it had

dropped his service connection for his injuries, but he was appealing. (Tr. 1314). Plaintiff

indicated he had increased nightmares about the war in Iraq and Afghanistan, the election, and

other stressors. He denied being depressed but was more anxious about the stressors. (Tr. 1315).

The provider noted mood disorder, major depression, generalized anxiety disorder, and PTSD. In

November 2016, Plaintiff reported depression and frustration with the system and discussed

experiencing stress regarding benefits at the VA. (Tr. 1294). In December 2016, Plaintiff showed

depression, anger, grief, and loss. (Tr. 1223). He was unhappy at the VA for dropping his

disability, angry about surgery, and upset about seeing his dog struck by a vehicle and killed.

C. Opinion Evidence

1. Dr. Stephen Scher

In September 2016, Dr. Stephen Scher, a non-examining state agency physician, reviewed

Plaintiff’s medical records. (Tr. 169–70, 174–76, 178). In his opinion, he discussed Plaintiff’s

daily living such as needing reminders; inability to be in crowds; bad dreams; inability to handle

stress or changes in routines; difficulty following spoken instructions; and Plaintiff’s ability to

drive, go out alone, and handle money. Dr. Scher found Plaintiff’s reported functional limitations

partially inconsistent with the total evidence in the file. For example, Plaintiff stated he could only

pay attention for 10 minutes, however, multiple mental status evaluations noted concentration to

be at least fair.

Dr. Scher found Plaintiff suffered from impairments of affective disorders and anxiety

related disorders that caused mild restrictions of activities of daily living and moderate difficulties

in maintaining social functioning, concentration, persistence, and pace. Specifically, that Plaintiff

was moderately limited in his ability to understand, remember, and carry out detailed instructions;

maintain attention and concentration for extended periods; and interact with the general public.

Dr. Scher also found Plaintiff was not significantly limited in his ability to remember locations,

work-like procedures, and very short and simple instructions. In conclusion, Dr. Scher opined that

Plaintiff could remember and perform short and simple instructions, make simple work-related

decisions, adapt to most changes in the workplace, and could work with others but would do best

with limited public contact.

2. Dr. Susan Rosamond

In September 2016, Dr. Susan Rosamond, a non-examining state agency physician,

reviewed the medical records and opined that Plaintiff could perform a range of light work. (Tr.

172–74). She found Plaintiff could lift 20 pounds occasionally and 10 pounds frequently, sit for

six hours, and stand and walk for six hours. He could frequently balance, kneel, crouch, and climb

ramps and stairs, and occasionally stoop, crawl, and climb ladders, ropes, and scaffolds. Dr.

Rosamond found Plaintiff had no manipulative, visual, or communicative deficits. However, she

opined that Plaintiff had some environmental limitations, such that he must avoid concentrated

exposure to temperature extremes, vibration, and hazards including machinery and heights.

3. Third-Party Statement by Plaintiff’s Wife

In August 2016, Lisa Redd, Plaintiff’s wife, submitted a third-party function report. (Tr.

314–20). Mrs. Redd indicated her husband is not able to do much of anything; he would lie down

a lot, because of back and knee pain; when he was up, he watched TV, which was his only hobby.

She stated Plaintiff was not able to stand for long periods and had a hard time walking because of

his back, knee, and neuropathy in the feet. Mrs. Redd estimated Plaintiff could only walk for about

10 to 15 minutes and after a few minutes could resume. Mrs. Redd reported Plaintiff did not feel

comfortable doing things. She stated Plaintiff would sometimes fold clothes and sweep, but Mrs.

Redd did the rest, including the yard work, grocery shopping, and preparing meals. While Plaintiff

would let the dogs in and out, Mrs. Redd feeds and bathes the dogs. She stated Plaintiff took more

time with dressing, showering, shaving, and going to the bathroom. Mrs. Redd indicated Plaintiff

had a hard time with driving, secondary to not having much feeling in his feet, and while he had

no problem feeding himself, Plaintiff sometimes dropped plates of food because he lost feeling in

his hand. Mrs. Redd stated Plaintiff needed to be reminded about his doctor appointments, she

constantly reminded him to take medication, and she sometimes reminded him to shower and get

haircuts. Mrs. Redd indicated Plaintiff’s attention span was short and that he had never been good

with instructions, sometimes requiring the same explanation several times. She reported Plaintiff

took so much medication that affected him to the point of no energy.

D. Hearing Testimony

Plaintiff appeared and testified before the ALJ on March 20, 2018. (Tr. 101–43). Plaintiff,

through his representative, noted he suffered from PTSD, diabetes, significant back problems,

migraine headaches, some degree of paralysis in the nerves, and had been described as having

neuropathy in the upper and lower extremities, with numbing and tingling of his hands and legs.

Plaintiff stated the combination of his impairments rendered him incapable of engaging in even

unskilled sedentary work.

When asked about his migraine headaches, Plaintiff indicated he had frequent headaches

two to three times per week, with it starting in his neck, and averaged around an hour causing him

to need to lay down and close his eyes. He had seen a neurologist, who did an MRI and told him

he had unhappy blood vessels in his brain, but there was nothing serious and it was common for

headaches. Plaintiff indicated he took Naproxen for his head pain.

Plaintiff estimated he could only sit for one-hour tops, secondary to his legs going numb,

tight back, and knotting of the muscles. Plaintiff testified he was able to walk 20 to 30 feet and

then stop and take a break for a couple of seconds and try to stretch his back out. Plaintiff indicated

he used a cane, prescribed by a doctor, to help with stability, so he keeps from falling. Plaintiff

testified to difficulty bending over and reaching items high up. Plaintiff also indicated some degree

of problems with his hands, which he reported is part of the neuropathy, and experiences numbness

daily. Plaintiff indicated he had problems with buttons, zippers, and coins, as well as issues with

larger items, such as glasses and plates; he sometimes dropped them.

When questioned about frequent flashbacks relating to his military service, Plaintiff

indicated they could hit him whether he was watching television or heard running of water. He

reports flashbacks happened daily, with episodes lasting a couple of seconds. These episodes

caused him to feel drained and withdrawn, typically requiring him to stop what he is doing and sit

or lay down. He reported these frequent flashbacks restricted him from dealing with people face-

to-face. With regards to depression, Plaintiff indicated he had become suicidal, his dog had stopped

him from a suicide attempt, and he subsequently went to the hospital for secondary treatment.

Plaintiff further testified to difficulty following instructions and remembering part of the

instructions given. Plaintiff indicated he did not work well with others. He reported daily episodes

of yelling at people, including violent outbursts without provocation, as well as getting upset at

everyday things. Plaintiff reported poor hygiene; his wife had to remind him every day to shower,

put on deodorant, and change clothes.

III. Standard of Review and Legal Framework

To be eligible for disability benefits, Plaintiff must prove that he is disabled under the Act.

Baker v. Sec’y of Health & Hum. Servs., 955 F.2d 552, 555 (8th Cir. 1992). The Act defines a

disability as the “inability to engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result in death or which has

lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C.

§ 423(d)(1)(A). A claimant will be found to have a disability “only if his physical or mental

impairment or impairments are of such severity that he is not only unable to do his previous work”

but also unable to “engage in any other kind of substantial gainful work which exists in the national

economy.” Id. at § 423(d)(2)(A).

The Social Security Administration has established a five-step sequential process for

determining whether a person is disabled. 20 C.F.R. § 416.920(a)(4) (explaining the five-step

sequential evaluation process). Steps 1–3 require the claimant to prove: (1) he is not currently

engaged in substantial gainful activity; (2) he suffers from a severe impairment; and (3) his

disability meets or equals a listed impairment. Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th Cir.

2009); 20 C.F.R. §§ 416.920(a)-(d), 404.1522. If the claimant does not suffer from a listed

impairment or its equivalent, the analysis proceeds to Steps 4 and 5. Pate-Fires, 564 F.3d at 942;

see also 20 C.F.R. § 416.920(e). At this point, the ALJ assesses the claimant’s residual functioning

capacity (“RFC”), “which is the most a claimant can do despite her limitations.” Moore v. Astrue,

572 F.3d 520, 523 (8th Cir. 2009); see also 20 C.F.R. §§ 416.920(e), 404.1545. At Step 4, the

ALJ must determine whether the claimant can return to his past relevant work. 20 C.F.R.

§ 416.920(f). If the ALJ finds at Step 4 that a claimant cannot return to past relevant work, the

burden shifts to the Administration at Step 5 to establish that the claimant maintains the RFC to

perform a significant number of jobs within the national economy. Id. §§ 416.920(g), 912, 960(c).

The court’s role on judicial review is to decide whether the ALJ’s determination is

supported by “substantial evidence” on the record as a whole. Wagner v. Astrue, 499 F.3d 842,

848 (8th Cir. 2007); see also Bowman v. Barnhart, 310 F.3d 1080, 1083 (8th Cir. 2002).

Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to

support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). In determining whether

the evidence is substantial, the Court considers evidence that both supports and detracts from the

ALJ’s decision. Cox v. Astrue, 495 F.3d 614, 617 (8th Cir. 2007). Even if substantial evidence

would have supported an opposite decision or the reviewing court might have reached a different

conclusion had it been the finder of fact, the Court must affirm the Commissioner’s decision if the

record contains substantial evidence to support it. See McNamara v. Astrue, 590 F.3d 607, 610

(8th Cir. 2010) (explaining that if substantial evidence supports the Commissioner’s decision, the

court “may not reverse, even if inconsistent conclusions may be drawn from the evidence, and

even if [the court] may have reached a different outcome”); Locher v. Sullivan, 968 F.2d 725, 727

(8th Cir. 1992) (explaining a court may not reverse merely because substantial evidence would

have supported an opposite decision). The Eighth Circuit has emphasized repeatedly that a district

court’s review of an ALJ’s disability determination is intended to be narrow and that courts should

“defer heavily to the findings and conclusions of the Social Security Administration.” Hurd v.

Astrue, 621 F.3d 734, 738 (8th Cir. 2010) (quoting Howard v. Massanari, 255 F.3d 577, 581 (8th

Cir. 2001)). Despite this deferential stance, a district court’s review must be “more than an

examination of the record for the existence of substantial evidence in support of the

Commissioner’s decision,” Beckley v. Apfel, 152 F.3d 1056, 1059 (8th Cir. 1998), and not merely

a “rubber stamp,” Cooper v. Sullivan, 919 F.2d 1317, 1320 (8th Cir. 1990).

IV. The ALJ’s Decision

The ALJ’s decision in this matter conforms to the five-step sequential process outlined

above. At Step 1, the ALJ found Plaintiff did not perform substantial gainful activity (“SGA”)

since May 19, 2015, the alleged onset date. (Tr. 83). At Step 2, the ALJ found Plaintiff had severe

impairments of diabetes mellitus with neuropathy and right foot neuroma, major depressive

disorder, generalized anxiety disorder, and PTSD. (Tr. 83–84). At Step 3, however, the ALJ found

Plaintiff did not have an impairment or combination of impairments that met or medically equaled

a statutorily recognized impairment. (Tr. 84–86). The ALJ determined Plaintiff retained the RFC

to perform a reduced range of simple, sedentary work with postural, environmental, and social

limitations. (Tr. 86). He required a cane and needed an option to stand every hour for two minutes

before returning to a seated position. Plaintiff could occasionally balance, stoop, kneel, crouch,

crawl, as well as climb ramps and stairs, but never climb ladders, ropes, or scaffolds. He could

occasionally operate foot controls and frequently grasp and handle. He must avoid exposure to

heights, unprotected moving mechanical parts, and concentrated exposure to temperature extremes

and vibrations. He could perform simple instructions, make simple work-related decisions, and

occasionally interact with supervisors, co-workers, and the public. At Step 4, the ALJ found

Plaintiff unable to perform any past relevant work. (Tr. 94). At Step 5, the ALJ considered

Plaintiff’s age, education, work experience, and RFC, and found there were jobs in the national

economy that Plaintiff can work, such as an addressing clerk, a table worker, and a document

preparer. (Tr. 96). Therefore, the ALJ concluded that Plaintiff is not disabled.

V. Discussion

Three specific issues exist between the parties in this case: (1) whether the ALJ erred at

Step 2 by not considering certain medical impairments “severe” impairments, (2) whether the ALJ

properly discounted Plaintiff’s subjective complaints, and (3) whether the RFC is supported by

substantial evidence.

A. The ALJ Properly Found Plaintiff’s Impairments Non-Severe

Plaintiff argues that the ALJ erred at Step 2 of the sequential analysis by not finding his

left knee degenerative joint disease, migraines, and dysphagia to be severe impairments. A severe

impairment is an impairment that significantly limits a claimant’s ability to perform basic work

activities without regard to age, education, or work experience. See 20 C.F.R. §§ 404.1522,

404.1520(c). Basic work activities are “abilities and aptitudes necessary to do most jobs,”

including, for example, walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or

handling. Id. § 404.1522(b). The ALJ finds impairments non-severe if the medical evidence

establishes only a “slight abnormality” that would have “no more than a minimal effect on an

individual’s ability to work.” Kirby v. Astrue, 500 F.3d 705, 707–08 (8th Cir. 2007) (“An

impairment is not severe if it amounts only to a slight abnormality that would not significantly

limit the claimant’s physical or mental ability to do basic work activities.”); Nguyen v. Chater, 75

F.3d 429, 431 (8th Cir. 1996) (explaining that no Step 2 impairment is found if it has “no more

than a minimal effect on the claimant’s ability to work”).

1. Left Knee Degenerative Joint Disease

The ALJ considered objective images of Plaintiff’s left knee, which showed mostly

“unremarkable” imaging and normal x-rays. The ALJ also considered multiple observations from

physicians that Plaintiff had stable knee ligaments, with no significant tears or areas of concern.

The ALJ noted that in physical examination, Plaintiff retained full strength and intact sensation

and coordination. Also, Plaintiff frequently exhibited normal muscle bulk and tone, 5/5 strength

of the lower extremities with the ability to move all four extremities spontaneously, and no en bloc

turning when using a cane. Additionally, the ALJ noted that on physical exams, on some

occasions, Plaintiff walked with an antalgic gait, used a cane, and showed myoclonic jerks,

tenderness, and relax deficits; and on other exams he walked with a normal gait and ambulated

independently. The ALJ noted Plaintiff relied on a knee brace that helped with movement and

pain as well as a cane for stability. Thus, the ALJ’s determination that Plaintiff’s knee impairment

has no “more than a minimal effect” on his ability to work is supported by substantial evidence.

Nguyen, 75 F.3d at 431.

2. Dysphagia

Although Plaintiff was diagnosed with dysphagia, those physicians did not impose

limitations that prohibited Plaintiff from performing “basic work activities.” To the contrary, Dr.

Rosamond considered the impairment and found it non-severe. The record also shows Plaintiff

had a “normal esophagus” and normal biopsies. (Tr. 672, 351, 1397, 1400). Although Plaintiff

reports this impairment sometimes caused him difficulty swallowing 50-percent of the time,

Plaintiff has not suggested or pointed to any evidence showing what work-related limitations result

from this impairment, such as how difficulty swallowing prevents him from performing work as

an addressing clerk, table worker, or document preparer, and it is Plaintiff’s burden to prove his

impairment is severe. Nguyen, 75 F.3d at 430; see also Caviness v. Massanari, 250 F.3d 603, 605

(8th Cir. 2001) (explaining that a claimant bears the burden of showing a severe impairment

significantly limits her ability to perform basic work activities). Thus, the ALJ properly found the

impairment non-severe because the record does not show Plaintiff’s dysphagia prohibits him from

performing “basic work activities.” See 20 C.F.R. §§ 404.1522, 404.1520(c).

3. Headaches/Migraines

The ALJ found Plaintiff’s headaches non-severe because a neurologist opined that his

headaches may be caused by medication overuse and subsequently changed Plaintiff’s

medications.2 Conditions that are controllable or amenable to treatment or medication are not

considered disabling. Kisling v. Chater, 105 F.3d 1255, 1257 (8th Cir. 1997) (“Impairments that

are controllable or amenable to treatment do not support a finding of disability.”); Mabry v. Colvin,

815 F.3d 386, 391–92 (8th Cir. 2016) (citing Brown v. Astrue, 611 F.3d 941, 955 (8th Cir. 2010))

(“If an impairment can be controlled by treatment or medication, it cannot be considered

disabling.”). The ALJ also relied on Dr. Rosamond’s opinion, who considered the headaches and

found Plaintiff remained capable of work.

Besides his subjective complaints, Plaintiff submitted no evidence that his headaches

“significantly” limit his work ability. See 20 C.F.R. § 404.1522; Nguyen, 75 F.3d at 430. As an

example, Plaintiff reported his headaches were debilitating because they require him to lay down,

but he provides no medical evidence of this requirement. See Harris v. Barnhart, 356 F.3d 926,

930 (8th Cir. 2004) (finding whether there is a need to lie down is a medical question requiring

medical evidence; record did not contain any evidence that medical condition required claimant to

lie down for hours each day). While it is true during the relevant period medical records show

Plaintiff self-reported his most severe headaches were often associated with nausea, causing him

to lie down, records also show that he refused medical treatment that would alleviate this pain.3

The ALJ properly considered this information when discounting Plaintiff’s complaints of disabling

2 Although Plaintiff testified at the hearing—15 months after the end date of the relevant period—that his headaches

continued despite the medication change, such evidence does not undermine the ALJ’s opinion. See Turpin v. Colvin,

750 F.3d 989, 993 (8th Cir. 2014) (noting for Title II purposes, the court need “only consider the applicant’s medical

condition as of his or her date last insured.”); Jones v. Callahan, 122 F.3d 1148, 1154 (8th Cir. 1997) (“Additional

evidence showing a deterioration in a claimant’s condition significantly after the date of the [ALJ’s] final decision is

not a material basis for remand.”). And, Plaintiff puts forth no later evidence of a diagnoses related to his headaches

during the relevant period, ie: the time before his insured status expired. See Basinger v. Heckler, 725 F.2d 1166,

1169 (8th Cir. 1984).

3 During the relevant period, evidence showed Plaintiff’s headaches could also be attributed to his sleep apnea, but

Plaintiff refused to use his CPAP machine despite being told that it could help his headaches. (Tr. 637, 639, 1482).

Plaintiff also underwent a nerve block, (Tr. 565), which provided temporary relief for his headaches, (Tr. 598), but

later declined an additional one. (Tr. 600).

headaches. See Milam v. Colvin, 794 F.3d 978, 985 (8th Cir. 2015) (a claimant’s failure to seek

treatment weighs against the reliability of his subjective complaints); see also 20 C.F.R. §

404.1529(c)(3)(v) (considering the claimant’s treatment when evaluating her symptoms);

Chamberlain v. Shalala, 47 F.3d 1489, 1495 (8th Cir.1995) (failing to seek aggressive medical

care is not suggestive of disabling pain). Although Plaintiff puts forth favorable evidence that his

headaches are severe, the ALJ’s finding of a non-severe impairment is also supported by

substantial evidence.4 See Wright v. Colvin, 789 F.3d 847, 852 (8th Cir. 2015) (explaining if the

court finds that the evidence supports two inconsistent positions and one of those positions

represents the ALJ’s findings, the court must affirm the ALJ’s decision); Locher, 968 F.2d at 727

(explaining a court may not reverse merely because substantial evidence would have supported an

opposite decision).

B. The ALJ Properly Considered the Credibility of Plaintiff’s Subjective Symptoms

Next, Plaintiff argues the ALJ improperly discounted his subjective complaints, which the

ALJ must consider when determining a claimant’s RFC. See Goff v. Barnhart, 421 F.3d 785, 790

(8th Cir. 2005). The ALJ cannot discount subjective complaints solely because they are

unsupported by objective medical evidence. Halverson v. Astrue, 600 F.3d 922, 931–32 (8th Cir.

2010) (citing Mouser, 545 F.3d at 638). However, the ALJ may discount complaints if they are

inconsistent with the evidence as a whole. Chaney v. Colvin, 812 F.3d 672, 677–78 (8th Cir.

2016). When analyzing a claimant’s credibility, the ALJ considers various factors.5 See 20 C.F.R.

§ 404.1529; Polaski v. Heckler, 739 F.2d 1320 (8th Cir. 1984) (explaining the factors are (1) the

claimant’s daily activities; (2) the duration, intensity, and frequency of pain; (3) the precipitating

4 Plaintiff also argues the ALJ did not discuss his migraine headaches anywhere in the decision. Doc. [20] at 7.

However, this argument lacks merit; the ALJ discussed Plaintiff’s headaches several times in the decision. (Tr. 88–

89).

5 The ALJ expressly lists these factors in the decision. See (Tr. 86).

and aggravating factors; (4) the dosage, effectiveness, and side effects of medication; and (5) any

functional restrictions); see also Forte v. Barnhart, 377 F.3d 892, 895 (8th Cir. 2004) (“[L]ack of

objective medical evidence is a factor an ALJ may consider.”). The Court defers to the ALJ’s

credibility determination if it is supported by good reasons and substantial evidence. Bryant v.

Colvin, 861 F.3d 779, 782–83 (8th Cir. 2017).

The ALJ provided various reasons for finding Plaintiff’s statements concerning the

intensity, persistence, and limiting effects of his symptoms inconsistent with the evidence in the

record as a whole. The ALJ did not dispute that Plaintiff experienced symptoms but found those

symptoms not to be as limiting as Plaintiff claimed based on (1) objective medical evidence,

including clinical findings during his mental status and other examinations, (2) medical opinions,

(3) aggravating factors, and (4) his daily activities. The Court finds that the ALJ properly

discounted Plaintiff’s subjective complaints based on objective medical evidence, aggravating

factors, daily activities, inconsistencies between medical examinations and subjective complaints,

and the opinions of the state agency consultants, all of which were more consistent with the

medical evidence as a whole. Chaney, 812 F.3d at 677–78 (allowing the ALJ to discount

complaints inconsistent with the evidence as a whole).

First, the ALJ looked at the objective medical evidence. The ALJ found Plaintiff’s claims

of disabling impairments inconsistent with the mostly “unremarkable” or “normal” objective

mental status examinations and “unremarkable” physical exams during the period at issue. The

ALJ properly relied on such evidence when discounting Plaintiff’s subjective complaints. Goff,

421 F.3d at 792 (holding proper the ALJ’s consideration of unremarkable or mild objective

medical findings as one factor in assessing credibility of subjective complaints).

The ALJ also considered Plaintiff’s longitudinal records. While Plaintiff’s mental

symptoms waxed and waned between appointments, the ALJ noted he generally appeared alert,

oriented, neatly groomed with normal speech, and logical and goal-directed thought process with

normal remote memory. The ALJ properly relied on these normal clinical findings when

discounting Plaintiff’s subjective complaints. See Adamczyk v. Saul, 817 F. App’x 287, 291 (8th

Cir. 2020) (discounting a claimant’s subjective statements, in part, based on consistent medical

reports noting well-groomed, clear speech, linear thought process, cognition and memory intact,

and ability to follow and engage in appropriate conversation); Halverson, 600 F.3d at 933 (finding

that appearing alert and oriented with normal speech and thought processes is inconsistent with

claimant’s allegations of disability). Similarly, regarding his physical impairments, although

walking with an antalgic gait was observed in several of Plaintiff’s physical exams, providers

generally noted normal physical and neurological motor examinations, with full strength and intact

sensation and coordination. Inconsistencies between Plaintiff’s alleged extreme symptoms and his

consistent normal clinical findings provide the ALJ a reasonable basis to discount his subjective

statements. Gonzales v. Barnhart, 465 F.3d 890, 895 (8th Cir. 2006) (holding the ALJ may find a

claimant’s subjective pain complaints not credible in light of objective medical evidence to the

contrary). Thus, the Court defers to the ALJ’s well-supported determination that Plaintiff’s

subjective complaints of complete disablement were not wholly credible based on objective

medical evidence to the contrary. Juszczyk v. Astrue, 542 F.3d 626, 632 (8th Cir. 2008) (deferring

to the ALJ’s credibility determination where the objective medical evidence did not support the

claimant’s testimony as to the depth and severity of his physical impairments).

Moreover, the ALJ properly considered the nature of Plaintiff’s treatment. See 20 C.F.R.

§ 404.1529(c)(3)(v) (stating the agency will consider the claimant’s treatment when evaluating his

symptoms). The ALJ noted a pattern of conservative treatment, see Moore, 572 F.3d at 525

(upholding ALJ’s analysis of finding, in part, that relief from conservative treatments were

inconsistent with allegations of disabling symptoms), and his failure to pursue more aggressive

treatment, see Tate v. Apfel, 167 F.3d 1191, 1197 (8th Cir. 1999), as reasons to discount the

reliability of Plaintiff’s debilitating complaints. See also Vanlue v. Astrue, No. 4:11-cv-595-TIA,

2012 WL 4464797, at *12 (E.D. Mo. Sept. 26, 2012) (finding minimal and conservative mental

health treatment weigh against a finding of disability). Also, notably, Plaintiff underwent a

successful surgical excision of the neuroma on the right foot and the record shows no complaints

thereafter. Walker v. Shalala, 993 F.2d 630, 631–32 (8th Cir. 1993) (finding lack of ongoing

treatment inconsistent with complaints of disabling condition); Mabry, 815 F.3d at 391–92.

Second, the ALJ looked at medical opinions assessing Plaintiff’s physical and mental

working capability, and Plaintiff does not contest the validity of those opinions. Two state agency

consultants opined that Plaintiff was not disabled and the ALJ properly relied on these medical

opinions. See Masterson v. Barnhart, 363 F.3d 731, 737–39 (8th Cir. 2004) (holding the ALJ

properly relied on the assessments of a non-examining physicians in determining the claimant’s

physical RFC); Kamann v. Colvin, 721 F3d 945, 951 (8th Cir. 2013) (finding a state agency

psychologist’s opinion supported ALJ’s finding that claimant could work despite his mental

impairments); 20 C.F.R. § 404.1513a (explaining evidence from Federal or State agency medical

or psychological consultants must be considered because those doctors are “highly qualified and

experts in Social Security disability evaluation”); Id. at § 404.1529(b)–(c) (evaluating symptoms

with medical opinions). No medical opinion provides a contrary conclusion of disablement and

despite undergoing physical and mental therapy for his impairments, no treating physicians

imposed greater limitations on Plaintiff than the ALJ. Tennant v. Apfel, 224 F.3d 869, 871 (8th

Cir. 2000) (discrediting Plaintiff’s subjective complaints based on absence of physician-ordered

limitations and the lack of objective medical evidence is proper).

Next, the ALJ discussed aggravating factors. The ALJ acknowledged that Plaintiff’s PTSD

derived from traumatic events while in the military; however, Plaintiff’s PTSD treatment, as well

as the depression and anxiety he experienced, focused on situational stressors, including financial

problems, family and pet deaths, custody of his grandchildren, family conflicts, and frustration

with the VA. As such, the ALJ properly found that Plaintiff’s mental health symptoms were

generally tied to situational stressors, and therefore not completely disabling as alleged. Gates v.

Astrue, 627 F.3d 1080, 1082 (8th Cir. 2010) (finding mental impairment symptoms that are

“situational in nature” not a basis for disability); see also 20 C.F.R. § 404.1509 (requiring

impairment to last for a specific duration). The ALJ further questioned Plaintiff’s credibility

regarding the severity of his symptoms based on his failure to follow treatment advice. For

example, despite alleging disabling diabetes, Plaintiff was non-compliant with his medications and

dietary changes. Non-compliance weighs against credibility. See Julin v. Colvin, 826 F.3d 1082,

1087 (8th Cir. 2016) (noting the “inability to follow a recommended course of treatment also

weighs against [] credibility”); Guilliams v. Barnhart, 393 F.3d 798, 802 (8th Cir. 2005) (noting

that failing to follow a recommended course of treatment weighs against a claimant’s credibility);

Dunahoo v. Apfel, 241 F.3d 1033, 1037 (8th Cir. 2001) (finding claimant’s failure to follow

prescribed course of treatment weighed against credibility when assessing subjective complaints

of pain).

Finally, the ALJ found that Plaintiff was more capable than he alleged based on his daily

activities, notwithstanding his physical and mental ailments.6 Inconsistencies between Plaintiff’s

6 Plaintiff argues that the ALJ’s cited daily activities are insufficient to prove his ability to work. See, e.g., Singh v.

Apfel, 222 F.3d 448, 453 (8th Cir. 2000) (explaining there are cases where a claimant’s ability to engage in certain

subjective complaints and evidence regarding his activities of daily living may raise legitimate

concerns about credibility. Haley v. Massanari, 258 F.3d 742, 748 (8th Cir. 2001); Vance v.

Berryhill, 860 F.3d 1114, 1121 (8th Cir. 2017); Dunahoo, 241 F.3d at 1033 (explaining evidence

of the claimant’s daily activities may be considered in judging the credibility of complaints of

pain). The ALJ discussed Plaintiff’s daily activities—such as driving, handling money,

performing light household chores, performing personal care independently, heating up meals

using the microwave, and using the computer to check emails. Although it is true that Plaintiff’s

daily activities demonstrate some limitations, the ALJ properly found that Plaintiff’s ability to

engage in the cited activities is inconsistent with allegations of debilitating symptoms precluding

all work. Fentress v. Berryhill, 854 F.3d 1016, 1021 (8th Cir. 2017) (explaining that even if a

claimant can point to some evidence that detracts from the [ALJ’s] determination, “good reasons

and substantial evidence on the record as a whole support the [ALJ’s] RFC determination”).

C. The RFC Is Supported By Substantial Evidence

Finally, Plaintiff argues that the RFC is not supported by substantial evidence. The Eighth

Circuit has noted that the ALJ must determine a claimant’s RFC based on all relevant, credible

evidence in the record, including medical records, the observations of treating physicians and

others, and the claimant’s own description of his symptoms and limitations. Goff, 421 F.3d at 793.

“Because a claimant’s RFC is a medical question, an ALJ’s assessment of it must be supported by

some medical evidence of the claimant’s ability to function in the workplace.” Hensley, 829 F.3d

at 932 (8th Cir. 2016) (citing Cox, 495 F.3d at 619). The ALJ considers all of a claimant’s

personal activities does not constitute substantial evidence that he has the RFC to work). However, the ALJ cited

Plaintiff’s daily activities as evidence inconsistent with Plaintiff’s subjective complaints—not as evidence that his

daily activities demonstrated an ability to work.

impairments—severe and non-severe—in determining the claimant’s RFC. See 20 C.F.R.

§§ 404.1520(e), 404.1545(a)(2).

1. RFC Physical Limitations

The RFC reflects limitations from Plaintiff’s non-severe7 left knee impairment and severe

physical impairments of diabetes mellitus with neuropathy and neuroma of the right foot.

Regarding Plaintiff’s knee, neuropathy, and right foot neuroma, the record indicates those

impairments prevented him from standing, walking, or sitting for extended periods; with reported

difficulty lifting, squatting, bending, reaching, kneeling, stair climbing, and doing anything active.

To aid these functional limitations, Plaintiff uses a knee brace and a cane. Consistent with that

evidence, the ALJ limited Plaintiff to “sedentary work,” which is defined in part, as a job where

“walking and standing are required occasionally.” 20 C.F.R. § 404.1567(a). To account for

Plaintiff’s other functional limitations, the RFC also limited work to use of a cane, the option to

stand every two hours for two minutes before returning to a seated position, and other postural

limitations. Notably, Plaintiff points to no medical evidence imposing greater work-related

limitations than the RFC. Ponder v. Colvin, 770 F.3d 1190, 1195 (8th Cir. 2014) (holding proper

the ALJ considered the fact that no physician-imposed work restrictions during the time period

relevant to Plaintiff’s claim); Goff, 421 F.3d at 790 (“A disability claimant has the burden to

establish her RFC”).

7 As the Court discussed supra, the ALJ found Plaintiff’s headaches and dysphagia “non-severe” impairments.

Nonetheless, the ALJ must still account for these impairments in the RFC. 20 C.F.R. § 404.1545(a)(2). However, no

medical evidence suggests these impairments cause any work-related limitations. Hensley v. Colvin, 829 F.3d 926,

932 (8th Cir. 2016) (explaining an RFC must be supported by some medical evidence of the claimant’s ability to

function in the workplace); Ponder v. Colvin, 770 F.3d 1190, 1195 (8th Cir. 2014) (holding proper the ALJ considered

the fact that no physician-imposed work restrictions during the time period relevant to Plaintiff’s claim). Rather,

Plaintiff self-reported limitations, but, as discussed supra, the ALJ engaged in a proper credibility analysis and then

“properly limited [the] RFC determination to only the impairments and limitations [the ALJ] found credible based on

[] evaluation of the entire record.” McGeorge v. Barnhart, 321 F.3d 766, 769 (8th Cir. 2003); see also Goff, 421 F.3d

at 793 (explaining the RFC is based on all “credible evidence”).

Despite these limitations, the ALJ found Plaintiff able to engage in sedentary work based

on consistent clinical findings that Plaintiff exhibited normal muscle bulk, tone, strength, and

psychomotor activity; ability to move all four extremities spontaneously; no involuntary motion

of the hands or head at rest; no en bloc turning when using a cane; and no evidence of neurological

deficits. The ALJ properly relied on this evidence. Hensley, 829 F.3d at 934 (affirming RFC

based on treating providers clinical findings of physical ability); Flynn v. Astrue, 513 F.3d 788,

793 (8th Cir. 2008) (same); see also 20 C.F.R. §§ 404.1545(a)(3) (considering “descriptions and

observations” of a claimant’s limitations from an impairment in RFC assessment). The ALJ also

considered Dr. Rosamond’s medical opinion of Plaintiff’s physical working capability that opined

he could perform a range of “light work” with some postural and environmental limitations.

Medical opinions are proper evidence the ALJ may use when determining a claimant’s RFC. See

20 C.F.R. §§ 404.1545(a)(3) (considering evidence in RFC assessment); 404.1527 (evaluating

opinion evidence), 404.1513a (evaluating evidence from Federal or State agency medical or

psychological consultants). The ALJ gave her opinion “partial” weight because Dr. Rosamond

did not review all of the later records but did possess disability program knowledge and expertise.

The ALJ reached this conclusion in accordance with the Commissioner’s regulations, 20 C.F.R.

§§ 404.1513a and 404.1527(c), and the evidence of record. Thus, the ALJ limited Plaintiff to

sedentary work instead of light work as Dr. Rosamond opined.

As to Plaintiff’s diabetes, the ALJ did acknowledge Plaintiff’s high A1C levels at various

times during the relevant period. However, the ALJ noted the high levels were mostly due to

noncompliance with prescribed treatments, such as medication and diet changes. Mabry, 815 F.3d

at 391–92 (“If an impairment can be controlled by treatment or medication, it cannot be considered

disabling.”); Roth v. Shalala, 45 F.3d 279, 282 (8th Cir. 1995) (“Failure to follow a prescribed

course of remedial treatment without good reason is grounds for denying an application for

benefits.”). Further, the ALJ found that Plaintiff’s diabetes did not cause functional limitations,

as evidenced by the numerous “unremarkable” objective status exams and the lack of medically

necessary restrictions, restrictions on his daily activities, or functional limitations of record. Brown

v. Chater, 87 F.3d 963, 964–65 (8th Cir. 1996) (finding lack of significant medical restrictions

imposed by treating physicians supported the ALJ’s decision of no disability).

2. RFC Mental Limitations

The RFC also reflects limitations from Plaintiff’s mental impairments of PTSD, major

depressive disorder, and generalized anxiety disorder. Based on record evidence, the ALJ found

Plaintiff had moderate limitations in understanding, remembering, and applying information;

interacting with others; and concentrating, persisting, or maintaining pace. Consistent with those

findings, the ALJ limited Plaintiff to “simple” work with occasional social interaction and

environmental limitations, such as no exposure to hazards and heights.

Despite Plaintiff’s limitations, the ALJ found him able to work based on consistent clinical

observations that Plaintiff exhibited logical thought process, fair fund of knowledge, adequate

attention and concentration, intact memory, appropriate speech, and was alert and oriented.

Moreover, providers generally reported Plaintiff’s PTSD symptoms as “moderate” or “moderate

to marked” severity without ever reporting, noting, or opining that his symptoms were disabling

or caused work-related issues. Young v. Apfel, 221 F.3d 1065, 1069 (8th Cir. 2000) (finding it

significant that no examining physician submitted medical conclusion that claimant is disabled or

unable to work). And the RFC need only include the limitations supported by the record. See

Tindell v. Barnhart, 444 F.3d 1002, 1007 (8th Cir. 2006).

The ALJ also gave Dr. Scher’s opinion “great weight” reasoning the opinion was consistent

with medical evidence as a whole. 20 C.F.R. § 404.1527(c)(4) (“Generally, the more consistent a

medical opinion is with the record as a whole, the more weight we will give to that medical

opinion.”); Casey v. Astrue, 503 F.3d 687, 694 (8th Cir. 2007) (finding ALJ did not err in

considering a state agency psychologist’s opinion along with the medical evidence as a whole).

Dr. Scher opined that Plaintiff could perform short and simple instructions, make simple work-

related decisions, and could work with others, but would do best with limited public contact. Thus,

the RFC permitting Plaintiff to perform simple instructions and make simple work-related

decisions is supported by substantial evidence.

The ALJ also looked at Plaintiff’s longitudinal records that showed no evidence of thought

disorder or delusions and Plaintiff mostly denied suicidal ideations. Mabry, 815 F.3d at 391

(finding no delusions, hallucinations, or suicidal ideations as medical evidence inconsistent with

disablement). The ALJ also noted the conservative nature of Plaintiff’s medical treatment prior to

the expiration of his insured status. Gowell v. Apfel, 242 F.3d 793, 796 (8th Cir. 2001) (noting an

ALJ may consider a plaintiff’s conservative course of treatment as indicative that his symptoms

are not disabling); Mabry, 815 F.3d at 392 (finding lack of hospitalization weighs against severity

of symptoms). The ALJ did recognize that in 2017—after Plaintiff’s last insured date—he was

hospitalized for suicidal thoughts.8 Although the record may indicate Plaintiff’s mental health

worsened in subsequent years, such later evidence does not demonstrate disability during the

period relevant to his claim. See Thomas v. Sullivan, 928 F.2d 255, 260-261 (8th Cir. 1991)

(explaining that a claimant’s worsening condition, which deteriorated after the ALJ’s decision,

could not act as the basis of determining claimant’s condition at the time he was eligible for

8 The record also shows that Plaintiff’s anxiety and depression may have worsened post-insured date.

benefits); Turpin v. Colvin, 750 F.3d 989, 993 (8th Cir. 2014) (noting for Title II purposes, the

court need “‘only consider the applicant’s medical condition as of his or her date last insured”).

Thus, the ALJ properly found Plaintiff's medical treatment and symptoms prior to the expiration

of his insured status did not support including greater limitations into the RFC finding.

The ALJ is not required to list and reject every possible limitation. McCoy v. Astrue, 648

F.3d 605, 615 (8th Cir. 2011). In the instant case, the ALJ made clear which of Plaintiff's alleged

physical and mental limitations were supported by the record and, which were not, and accounted

for them in the RFC. The findings in this case, as discussed above, demonstrate the ALJ’s opinion

is supported by substantial evidence.

CONCLUSION

For the foregoing reasons, the Court finds that the ALJ’s determination is supported by

substantial evidence on the record as a whole.

Accordingly,

IT IS HEREBY ORDERED that the decision of the Commissioner is AFFIRMED.

A separate Judgment shall accompany this Memorandum and Order.

Dated this 4th day of February 2022. _

ug] □□

TTHEW T. SCHELP

UNITED STATES DISTRICT JUDGE

30