United States District Court, D. Minnesota
Dana
W. Duncan, Jennifer G. Mrozik, Hoglund, Chwialkowski &
Mrozik, PLLC, for Plaintiff Meshetnaglee S.
Elvi
D. Jenkins, Social Security Administration, for Andrew Saul,
Commissioner of Social Security.
AMENDED ORDER [1]
HILDY
BOWBEER, UNITED STATES MAGISTRATE JUDGE.[2]
Pursuant
to 42 U.S.C. § 405(g), Plaintiff Meshetnaglee S. seeks
judicial review of a final decision by the Commissioner of
Social Security, denying his applications for social security
disability insurance benefits (DIB) and supplemental security
income (SSI). The matter is before the Court on the
parties' cross-motions for summary judgment [Doc. Nos.
13, 15]. For the reasons set forth below, the Court denies
Plaintiff's motion for summary judgment and grants the
Commissioner's motion for summary judgment.
I.
Procedural Background
Plaintiff
applied for DIB and SSI on July 25, 2016, alleging disability
which began on November 10, 2014. (See R.
19.)[3]
The claims were denied on January 19, 2016, and denied again
on reconsideration on February 6, 2017. (Id.)
Plaintiff requested a hearing to review the denial of his
claims on March 1, 2017. (Id.) On August 10, 2017,
an administrative law judge (“ALJ”) held a
hearing wherein Plaintiff and David Russell, a vocational
expert, appeared and testified. (Id.) The ALJ
analyzed Plaintiff's claims under the Social Security
Administration's five-step sequential evaluation
procedure. 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). The ALJ issued a written opinion on October 6,
2017, finding that Plaintiff was not disabled under §
216(i) and 223(d) of the Social Security Act. (R. 21-34.)
At step
one, the ALJ concluded that Plaintiff had not engaged in
substantial gainful activity since November 10, 2014, the
alleged date of disability onset. (R. 21.) At step two, the
ALJ concluded that Plaintiff had the following severe
impairments: hearing loss on the right side, headaches,
obesity, degenerative disc disease, left hip sclerosis, major
depression, borderline personality disorder, posttraumatic
stress disorder, and panic disorder. (R. 22.) However, at
step three, the ALJ found that Plaintiff did not have an
impairment or combination of impairments that met or
medically equaled the severity of an impairment listed in 20
C.F.R. part 404, subpart P, appendix 1. (R. 22-25.)
At step
four, the ALJ assessed Plaintiff's residual functional
capacity (“RFC”). (R. 25-33.) As part of that
assessment, the ALJ analyzed whether the intensity,
persistence, and limiting effects of Plaintiff's symptoms
were as severe as he claimed. (R. 26-27, 29.) The ALJ also
analyzed and assigned evidentiary weight to three medical
sources who opined on Plaintiff's RFC. (R. 29-32.) Two of
these sources were treating sources (Dr. Kirk Mueller, Ph.D.,
and Dr. Brandon Dugan, Psy.D), and one opinion was from a
non-treating Social Security Administration consultant, Dr.
Donald Wiger, Ph.D. (Id.) Ultimately, the ALJ relied
on the opinions of two non-examining, non-treating agency
physicians, and based his RFC assessment on their opinions,
with modifications derived from the ALJ's findings. (R.
32.)
The ALJ
concluded Plaintiff could perform medium work with some
excluded tasks, which were enumerated in
detail.[4] The ALJ found that Plaintiff was capable
of simple, routine, repetitive tasks with occasional, brief,
and superficial contact with coworkers, supervisors, and the
public. (R. 25.) The ALJ noted that Plaintiff had no past
relevant work and therefore did not determine the
transferability of his job skills. (R. 33.)
At step
five, the ALJ considered the limitations impeding
Plaintiff's RFC as well as his age, education, and work
experience. (R. 33-34.) Turning to the testimony of the
vocational expert, the ALJ concluded that Plaintiff could
successfully adjust to work including positions such as
packager, assembler, and cleaner. (Id.) Because
those positions exist in significant numbers in the national
economy, the ALJ decided that Plaintiff was not disabled.
(Id.) Plaintiff sought review by the Appeals
Council, which denied her request. (R. 3.) The ALJ's
decision therefore became the final decision of the
Commissioner. (See R. 3.)
In this
action for judicial review, Plaintiff contends that the ALJ
did not afford appropriate weight to the treating source
opinions during step four of the analysis. (Pl.'s Br.
Supp. Mot. Summ. J. at 15-34 [Doc. No. 14].)[5] Plaintiff argues
that the ALJ improperly discounted the opinions of Drs.
Mueller, Dugan, and Wiger, and afforded disproportionate
weight to the opinions of non-examining state agency
physicians. (Id. at 15-16.)
II.
Medical Background
The
Court has reviewed the entire administrative record, and
given particular attention to the facts and records cited by
the parties. The Court will recount the facts of record only
to the extent they are helpful for context or necessary for
resolution of the specific issues presented in the
parties' motions.
During
the relevant time period, Plaintiff received medical care at
three locations: the Mayo Clinic in Austin, Minnesota; Sioux
Trails Mental Health Center; and Eunoia Family Resource
Center in Mankato, Minnesota.
A.
Mayo Clinic
At the
Mayo Clinic, Plaintiff was first seen by Joanne M. McGaffey,
a certified nurse practitioner, on November 3 and 17, 2014,
for a musculoskeletal injury he claimed to have incurred at
work. (R. 419-23.) Initial examination found an abnormal gait
and paraspinous tenderness to palpation without signs of
radiculopathy. (R. 421-23.) X-ray studies showed
“trace” degenerative disc disease, which the
radiologist reported to be common in asymptomatic patients.
(Id.) On follow up, McGaffey noted Plaintiff
reported improvement, and his physical examination showed
improvement as well. (R. 419-20.)
Plaintiff's
psychological illness was first noted on January 29, 2016, by
Dr. Bryan M. Cairns, M.D., a family practitioner. (R.
415-18.) Dr. Cairns noted Plaintiff engaged in self-harm
(“cutting”) in the past year after several fights
with his father. (Id.) However, Dr. Cairns reported
Plaintiff's mental status examination was largely normal.
(Id.) Repeat x-ray studies of his left hip and left
knee were unchanged since 2012 and remained within normal
limits. (R. 417-18.)
On
February 17, 2016, Plaintiff treated with Dr. Alberto
Marcelin, M.D., a family practitioner. (R. 406-08.) Plaintiff
discussed many complaints with Dr. Marcelin. (Id.)
In addition, Plaintiff's significant other reported odd
behavior, specifically, that he had recently been
“giggly.” (Id.) Due to Plaintiff's
history of cutting and childhood meningitis, Dr. Marcelin
ordered consultation with psychiatry and neurology and
started him on an antidepressant. (Id.)
Plaintiff
was seen by a psychiatrist, Dr. Fatma Reda, M.D., on March 7,
2016. (R. 398-400.) She noted a past history of
“non-serious” suicide attempts prior to 2010,
“very superficial” self-injurious behavior,
depression, post-traumatic stress disorder, and anxiety.
(Id.) Plaintiff's depressive symptoms were
improving after three weeks on fluoxetine, however, and his
mental status examination was grossly normal. (Id.)
Dr. Reda ordered an increased dose of antidepressants and a
Millon Clinical Multiaxial Inventory-III
(“MCMI-III”) to further assess Plaintiff's
psychological condition. (Id.) Dr. Kirk H. Mueller,
Ph.D., a psychologist, administered the MCMI-III on April 6,
2016; the results were confounded, however, by exceedingly
high scores suggestive of “self-depreciation” and
“vulnerability.” (R. 397.) On April 6, 2016, Dr.
Reda continued to report a normal mental status examination
but noted self-reported agitation that she attributed to an
increased antidepressant dose. (R. 395-96.)
Plaintiff
received psychotherapeutic care from Dr. Mueller on three
occasions between May 2, 2016, and July 12, 2016. (R. 385,
388, 392.) Dr. Mueller's mental status examinations noted
marginal grooming with body odor, depressed mood with
congruent affect, intact insight and judgment, and thoughts
of self-harm without suicidal ideation or intent.
(Id.) Dr. Mueller opined that Plaintiff's
thoughts of self-harm were secondary to family trauma and
caring for his significant other who suffered from
depression. (R. 388.) Dr. Mueller observed improvement with
psychotherapeutic and medical interventions. (R. 386.) Dr.
Mueller completed a medical source statement on October 30,
2016. (R. 429-30.)
On June
8, 2016, Plaintiff saw Dr. Marcelin for worsening symptoms of
depression over the prior three to four days that he
attributed to a complicated relationship with his significant
other. (R. 387.) Dr. Marcelin recommended hospitalization,
but Plaintiff refused. (Id.) Shortly thereafter,
Plaintiff was seen in the emergency department. Following an
argument with his girlfriend he made
“superficial” cuts on his right arm and had a
panic attack. (R. 376.) The emergency department physician
noted “appropriate mood [and] affect, [and] normal
judgment.” (R. 379.) He elaborated that Plaintiff
“looks ok[ay], he is smiling, has good eye contact . .
. [and] does not feel suicidal.” (R. 380.)
On
follow up, Dr. Marcelin noted that Plaintiff had been
noncompliant with his Zoloft regimen; therefore, Dr. Marcelin
changed his antidepressant course. (R. 386). On August 3,
2016, Plaintiff's girlfriend reported his mood had
improved with the new antidepressant. (R. 383-84.)
On
September 7, 2016, Plaintiff saw another family medicine
practitioner, Dr. Kristen L. Holland, M.D., to request
disability documentation. (R. 441-43.) When asked why he was
disabled, Plaintiff answered it is “probably . . .
related to his psychiatric diagnoses.” (R. 442.) Dr.
Holland declined to provide a medical source opinion given
Plaintiff was just establishing care with her. (R. 445.) Dr.
Holland reported that Plaintiff's depression began in
2011. (R. 442.) She found his psychological symptoms were
related to his living situation with his parents.
(Id.) Plaintiff reported being unemployed after
August, 2016, when he moved to Saint Peter, Minnesota.
(Id.) While living in St. Peter he continued to work
at his family's store. (Id.) Dr. Holland's
psychiatric examination revealed neutral mood and affect.
(Id.) On follow up, Dr. Holland observed a normal
affect, and recommended that Plaintiff disentangle himself
from his “toxic family” relationships. (R.
434-35.)
Plaintiff
saw Dr. Holland on three more occasions from September 2016
to April 2017 for a variety of complaints including pain and
numbness, gastrointestinal symptoms, and a cough. (R. 447-50,
541-44, 545-47.) During this time, he began treating at Sioux
Trails Mental Health Center. Plaintiff consistently reported
only occasional alcohol use throughout his time at the Mayo
Clinic. (See, e.g., R. 443.)
B.
Sioux Trails Mental Health Center
Plaintiff
treated at Sioux Trails Mental Health Center from October
2016 through February 2017. (R. 459-73.) During that time he
was seen by psychologist Dr. Mark E. Kleiman, Ph.D., on ten
occasions, and psychiatrist Dr. Nora Bammidi, M.D., twice.
(Id.) Dr. Kleiman noted that Plaintiff's
euthymic mood was incongruent with the severity of his
subjective symptoms. (R. 470.) Plaintiff reported binge
drinking until he blacked out. (See, e.g., R. 464,
467.) Dr. Kleiman consistently reported improvement with
psychotherapy. (R. 463, 468.) He also observed that Plaintiff
started seeking mental health care around the time of his DIB
application. (See R. 462.)
Dr.
Kleiman repeatedly attributed exacerbations in
Plaintiff's anxiety, self-harm, and depression to family
stressors including confrontations with his father and his
girlfriend. (See R. 463, 466.) Dr. Kleiman noted
symptoms of sleep disturbance, hyperactivity, and aggression
associated with changes in medication; however, he did not
observe any other symptoms of mania. (R. 458, 463.) Plaintiff
reported ...