STEPHANIE M. ROSE, District Judge.
Plaintiff Brenda L. Prevett seeks judicial review of a decision of an administrative law judge ("ALJ") denying her application for Social Security disability benefits. [ECF No. 1]. For the reasons set forth below, the Court reverses and remands for further proceedings.
In reviewing the decision of an ALJ denying social security benefits, a court must first "determine whether the ALJ's decision complies with the relevant legal requirements." Hesseltine v. Colvin, 800 F.3d 461, 464 (8th Cir. 2015) (internal quotation marks omitted). When evaluating disability claims, the ALJ uses a "five-step sequential evaluation process." 20 C.F.R. § 404.1520(a)(4) (2014); Goff v. Barnhart, 421 F.3d 785, 790 (8th Cir. 2005). Steps two through five are relevant to this case. At step two, the ALJ determines whether the claimant has a severe impairment. 20 C.F.R. § 404.1520(a)(4)(ii). At step three, the ALJ considers whether the claimant's impairment meets or equals one listed in the appendix to the applicable regulations. 20 C.F.R. § 404.1520(a)(4)(iii). "If the claimant wins at the third step (a listed impairment), she must be held disabled, and the case is over." Jones v. Barnhart, 335 F.3d 697, 699 (8th Cir. 2003). If the claimant's impairment is not listed in the relevant appendix, the ALJ proceeds to step four and considers whether the claimant can engage in past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv).
During step four, the ALJ must determine the claimant's residual functioning capacity ("RFC"). Id.; Goff, 421 F.3d at 790. The RFC reflects what a claimant can do despite her limitations. Goff, 421 F.3d at 790. The ALJ then uses the RFC to consider whether the claimant can engage in past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant proves she cannot perform past relevant work, the ALJ continues to the fifth step and, again using the RFC, considers whether the claimant's impairments prevent her from doing other work. Id.; Steed v. Astrue, 524 F.3d 872, 874 n.3 (8th Cir. 2008). At this point, the burden shifts to the Social Security Commissioner to prove that jobs exist in the national economy that the applicant could perform. Steed, 524 F.3d at 874 n.3. "The testimony of a vocational expert is required when a claimant has satisfied his initial burden of showing that he is incapable of performing his past relevant work." Pickney v. Chater, 96 F.3d 294, 296 (8th Cir. 1996). If no jobs exist that a claimant could perform, the claimant is disabled; if jobs do exist, the claimant is not disabled.
The ALJ's decision will be upheld if it is supported by substantial evidence on the record as a whole. Weiler v. Apfel, 179 F.3d 1107, 1109 (8th Cir. 1999). "Substantial evidence is less than a preponderance, but enough that a reasonable mind might accept as adequate to support a conclusion." Renstrom v. Astrue, 680 F.3d 1057, 1063 (8th Cir. 2012) (internal quotation marks omitted). "In determining whether substantial evidence supports the ALJ's decision, [the court] must consider evidence in the record that supports the ALJ's decision as well as evidence that detracts from it." Harwood v. Apfel, 186 F.3d 1039, 1042 (8th Cir. 1999). The court "appl[ies] a balancing test to evidence which is contradictory." Minor v. Astrue, 574 F.3d 625, 627 (8th Cir. 2009) (internal quotation marks omitted). The court defers to an ALJ's credibility findings if they are supported by "good reasons and substantial evidence." Turpin v. Colvin, 750 F.3d 989, 993 (8th Cir. 2014) (internal quotation marks omitted). The court may not reweigh the evidence, and may not reverse "merely because substantial evidence also exists that would support a contrary outcome, or because [it] would have decided the case differently." Id. (internal quotation marks omitted). But "[t]he standard requires a scrutinizing analysis, not merely a rubber stamp" of the ALJ's decision. Cooper v. Sec'y of Health & Human Servs., 919 F.2d 1317, 1320 (8th Cir. 1990) (internal quotation marks omitted).
Plaintiff filed for disability on March 8, 2012, alleging impairments of fibromyalgia, anxiety, bursitis, arthritis, and degenerative disk disease. [ECF No. 5-6 at 14]. She later amended her application to add a recent diagnosis of post-traumatic stress disorder ("PTSD"). Id. at 42. Plaintiff is currently age fifty and lives on a small acreage in the country with her mother and her son. [ECF No. 5-2 at 51-52]. She holds a high school diploma, and has previously worked as a home health care aide and as a cashier at a gas station and Wal-Mart. [ECF Nos. 5-6 at 15; 5-7 at 55]. For a period while her disability application was pending, Plaintiff worked in home health care.
In a decision dated October 28, 2013, an ALJ found Plaintiff has severe impairments of lumbar degenerative disc disease, fibromyalgia, cervical degenerative disc disease, PTSD, and adjustment disorder. [ECF No. 5-2 at 17]. In determining Plaintiff's RFC, the ALJ "afforded little weight" to the opinion of Plaintiff's primary care physician, Dr. Djonggi Situmeang, MD. Id. at 24. The ALJ also discounted Plaintiff's description of her functional limitations, finding her not fully credible. Id. at 28. The ALJ concluded that Plaintiff could perform sedentary work, with several restrictions, and that those restrictions did not preclude her from employment. Id. at 31.
On appeal, Plaintiff argues the ALJ should have provided greater weight to Dr. Situmeang's opinion. [ECF No. 7 at 12-22]. She further contends the ALJ's credibility finding was not supported by substantial evidence. Id. at 24-26. Finally, she asserts the ALJ failed to fully and fairly develop the record. Id. at 22-24. Defendant disputes each of these contentions. [ECF No. 8].
Due to the nature of Plaintiff's arguments, an exhaustive review of the record is necessary.
A rheumatologist diagnosed Plaintiff with fibromyalgia in May 2008. At the time of her diagnosis, Plaintiff's symptoms included "pain all over," swelling in her hands, anxiety, worsening memory, difficulty sleeping, and fatigue. [ECF No. 5-7 at 143, 148]. She had sixteen of eighteen tender points. Id. at 149. Plaintiff reported that the pain had increased over the past year and led her to quit working at Wal-Mart. Id. at 143. The rheumatologist noted Plaintiff exhibited "fibromyalgia with the typical signs and symptoms of point tenderness in the classic areas, difficulties with sleeping, and fatigue." Id. at 149. Plaintiff was prescribed Amitriptyline to help her sleep, with the hope her pain would improve if she were able to sleep better. Id. She was also instructed to exercise: "Start out easy at 10-15 min a day and then gradually increase. Can try walking, bicycling, or water aerobics." Id. at 149.
After her diagnosis from the rheumatologist, Plaintiff resumed regular care with Dr. Situmeang, her primary care physician. In January 2009, Plaintiff reported pain in her forearm, right shoulder, and upper back. [ECF No. 5-7 at 52]. Plaintiff additionally described swelling in her hand and numbness in all of her fingers, though her work did not involve repetitive hand motion. Id. Dr. Situmeang ordered a bone scan and opined that if the bone scan was negative, Plaintiff had most likely suffered a strain. Id. at 53. No follow-up on this issue is reflected in Plaintiff's charts.
In February 2009, Plaintiff visited Dr. Situmeang for her hypertension. She reported no fatigue and her fibromyalgia was not discussed. Id. at 49-50.
Plaintiff next visited Dr. Situmeang in August 2009, and they discussed her fibromyalgia. Plaintiff was not sleeping well at night and Dr. Situmeang increased her Amitriptyline prescription. Id. at 47. Dr. Situmeang noted that if Plaintiff did not see improvement, she would need to visit her rheumatologist. Id.
In February 2010, Plaintiff sought care from Dr. Situmeang for worsening depression. Id. at 45. She reported crying all of the time and wanting to withdraw socially. Id. Plaintiff stated she was taking her medications as directed and her fibromyalgia remained about the same. Id. Dr. Situmeang prescribed Plaintiff Cymbalta, which he commented "[m]ight help her fibromyalgia." Id.; see also U.S. National Library of Medicine, Duloxetine, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a604030.html (noting Cymbalta—the brand name for Duloxetine—is used to treat both depression and fibromyalgia).
Plaintiff returned to Dr. Situmeang in April 2010, reporting "[e]motionally and from the standpoint of fibromyalgia doing a lot better on the Cymbalta." Id. at 41. Plaintiff stated she was doing well and had no problems. Id.
Not long after, in May 2010, Plaintiff visited Dr. Situmeang because she had been experiencing moderate to severe low back pain for several weeks. Id. at 39. Plaintiff's chart reflects that the pain radiated to her hip and leg and that Plaintiff experienced weakness and discomfort with motion. [ECF No. 5-7 at 39]. An MRI found paracentral disc herniation at L5-S1 with associated spinal stenosis resulting in nerve root compression. Id. at 37. Plaintiff consulted an orthopedic surgeon, who attempted to treat Plaintiff with nonoperative modalities but ultimately opted for surgical intervention. Id. at 8, 12. On June 24, 2010, the surgeon excised Plaintiff's disk herniation, removing several fragments of loose herniated disk material. Id. at 9.
Post-surgery, Plaintiff reported that she no longer had pain down her legs, though her chronic numbness in her left foot persisted. Id. at 5. She was anxious to return to work, providing home health care for two of her friends. Id. The surgeon authorized Plaintiff to return to light duty work, with no lifting greater than 25 pounds, no repetitive bending, and no twisting at the waist. Id. At a later check-up in August 2010, Plaintiff again reported "doing excellent" and that her left leg felt "great." Id. at 4. The surgeon encouraged Plaintiff to remain active and complete physical therapy exercises at home. Id.
Again in November 2010, Plaintiff visited Dr. Situmeang reporting her fibromyalgia was worse. Id. at 34. Dr. Situmeang found Plaintiff was "[t]ender in all the spots consistent with fibromyalgia." He further noted Plaintiff exhibited a depressed affect. Id. at 35. Concluding Plaintiff's fibromyalgia condition had deteriorated, Dr. Situmeang ordered Plaintiff to taper off Cymbalta and begin Savella. Id. at 36.
At a follow-up visit later that month, Plaintiff told Dr. Situmeang her fibromyalgia had improved by "at least 50% if not more." Id. at 31. She did, however, report increased anxiety and moodiness, which she thought may be related to menopause. Id. Dr. Situmeang added Buspirone to Plaintiff's medication list to treat her anxiety. Id. at 32.
Plaintiff next visited Dr. Situmeang in February 2011 due to marital difficulties. [ECF No. 5-7 at 27]. Dr. Situmeang offered Plaintiff counseling but did not alter her prescriptions because he viewed her increased anxiety and depression as situational. Id.
In April 2011, Plaintiff sought care for back pain. Id. at 24. Plaintiff explained that "[h]er new job consists of some lifting and she knew within two days that it was not the right job for her." Id. Dr. Situmeang agreed. Id. Plaintiff and Dr. Situmeang also discussed her anxiety. Id. Plaintiff was under stress due to her marital situation and had suffered some panic attacks. Id. Dr. Situmeang noted Plaintiff had maxed out her anxiety medication, but gave her medication for panic attacks and recommended counseling. Id. Despite her mental difficulties, Plaintiff reported that her fibromyalgia medication was working well. Id.
Plaintiff next saw Dr. Situmeang in August 2011. Id. at 21. She reported continued stress and anxiety, and Dr. Situmeang noted her depressed affect. Id. at 21-22. Plaintiff also stated that she had gotten a new job where she had to stand all the time, and that this was causing her back pain. Id. at 21. Dr. Situmeang documented slight tenderness in Plaintiff's lower back, with "[s]ome inflammatory nodules." Id. at 22. Dr. Situmeang instructed Plaintiff to take Ibuprofen three times daily for her back pain and prescribed her Gabapentin. Id. Dr. Situmeang discussed the possibility of a tens unit, but Plaintiff felt she could not afford it. Id.
Plaintiff returned to Dr. Situmeang in February 2012 to discuss her fibromyalgia. Id. at 20. Plaintiff felt her anxiety had worsened, along with her short-term memory. Id. She said she did well on Savella, but had recently ceased taking it on the advice of another physician. Id. at 20. Plaintiff did not feel that Buspirone helped much. Id. Dr. Situmeang recommended Plaintiff continue Savella and taper off Buspirone. Id.
The next medical professional Plaintiff visited was a psychologist—for purposes of a social security disability evaluation. [ECF No. 5-7 at 55]. Plaintiff told the psychologist, Richard Martin, Ph.D, that she has fibromyalgia, but this diagnosis was not discussed at any length in the psychologist's report. Id. at 56. The report, issued in June 2012, documented "mild pain presentation/discomfort while seated" and noted that Plaintiff "exhibited increased pain while walking." Id. Dr. Martin found Plaintiff's attention and concentration to be fair, and Plaintiff's memory to be intact. Id. Plaintiff's mood was depressed, and she reported multiple anxiety symptoms. Id. Plaintiff told Dr. Martin that she was able to complete most self-care tasks independently on her own, but that she does so more slowly than in the past. Id. at 58. Plaintiff explained that she sometimes needed help lifting, and that she sometimes did not drive because she feels "fuzzy" or "off." Id.
Dr. Martin found Plaintiff to be "a reliable informant." Id. at 55. He diagnosed Plaintiff with panic disorder, depression, and PTSD. Id. at 58. Dr. Martin further commented, "An underlying somatoform disorder is also strongly suspected. However, [Plaintiff's] history of poor coping skills makes diagnostic specification somewhat difficult." Id. Dr. Martin concluded Plaintiff possesses the cognitive abilities to work within a wide range of simple unskilled vocational situations, but noted Plaintiff's concentration/attention and memory abilities "may vary depending on her overall emotional (and physical) functioning." Id.
Plaintiff next saw Dr. Situmeang in August 2012. Id. at 81. She presented with anxiety, and complained she had not been sleeping well the last month and a half. Id. Dr. Situmeang added Buspirone back to Plaintiff's medication list and directed Plaintiff to taper off Amitriptyline and begin taking Doxepin. Id. at 82.
Later in August, Plaintiff sought counseling from Dr. Situmeang regarding abuse she had suffered as a child. [ECF No. 5-7 at 79]. Dr. Situmeang prescribed Plaintiff Risperdone and recommended counseling. Id.
In September 2012, Plaintiff visited Dr. Situmeang because she had been riding a horse earlier in the month and hurt her knee. Id. at 151. Plaintiff reported that Risperadone was "really helping," and thought that she could benefit from a higher dose. Id. She stated she was sleeping much better. Id. Dr. Situmeang noted in Plaintiff's chart that she was exercising seven days a week by walking one mile. Id. at 152. Plaintiff denied joint pain and anxiety, and Dr. Situmeang noted her mood, attention span, and concentration were normal. Id. at 152-53.
Plaintiff again saw Dr. Martin in October 2012. Id. at 84. His findings remained largely the same, and he again noted Plaintiff was a reliable informant, appeared to be in pain while seated, and demonstrated increased pain while walking. Id. at 84, 86. Dr. Martin supplemented his impressions with the statement, "Given samples of [Plaintiff's] written product, an underlying learning disorder in written expression appears possible." Id. at 87.
Plaintiff returned to Dr. Situmeang in January 2013 due to issues with her medications. Id. at 156. Plaintiff was tearful and anxious during the visit. Id. at 157. She told Dr. Situmeang her depression was worse; she was short with people and irritable. Id. at 156. She also reported being anxious and forgetful all the time. Id. Dr. Situmeang wrote, "Clearly her anxiety is worse." Id. at 157. He recommended increasing her Buspirone and tapering her off Savella. Id. Dr. Situmeang explained that, even though Savella "did help with her fibromyalgia," he was "more focused on treating her anxiety at this time." Id. at 158. Dr. Situmeang further stated that Plaintiff might need to increase her Risperdal prescription if she did not sleep better. Id. at 157. Plaintiff's chart reflects that she was walking one mile seven days a week. Id.
Plaintiff was back in to see Dr. Situmeang only two weeks later. [ECF No. 5-7 at 159]. She felt she was experiencing side effects from taking Gabapentin and wished to cease taking that medication. Id. Plaintiff additionally sought to re-start her Savella prescription because she felt "like it has made her tired being off of it [and] her anger and depression have gotten worse." Id. Dr. Situmeang noted that Plaintiff seemed fatigued. Id. at 160. Plaintiff told Dr. Situmeang she felt she was going through menopause. Dr. Situmeang commented, "I cannot agree with her more." Id. at 159. Dr. Situmeang prescribed Plaintiff both Savella and Topamax. Id. at 160.
Plaintiff appeared three months later, in May 2013, for a follow-up visit with Dr. Situmeang. Id. at 162. She reported her depression, anxiety, and sleep problems had greatly improved—although Dr. Situmeang noted she appeared fatigued. Id. at 162-63. Plaintiff complained, however, of difficulty concentrating, indigestion, nausea, joint pain, back pain, and muscle aches. Id. at 163. Dr. Situmeang counseled Plaintiff to cease smoking, exercise regularly, and lose weight. Id. at 164. He added Ibuprofen to Plaintiff's medication list, to help with her fibromyalgia. Id.
In June 2013, Plaintiff visited Dr. Situmeang due to acute shoulder pain. Id. at 166. Plaintiff told Dr. Situmeang that the pain started on her right side and then spread to her left side a week later. Id. Dr. Situmeang believed Plaintiff had suffered a strain and prescribed heat, massage, and rest. Id. at 167. Plaintiff returned in July 2013. Id. at 168. She informed Dr. Situmeang that her shoulder pain had been improving, but that she had reinjured her shoulders in a recent fall. Id.
Also at the July 2013 visit, Dr. Situmeang reviewed Plaintiff's fibromyalgia diagnosis and filled out Plaintiff's disability paperwork. He again found Plaintiff "has multiple tender spots consistent with fibromyalgia." Id. In the "Fibromyalgia Medical Source Statement" completed by Dr. Situmeang, he wrote Plaintiff exhibited eighteen of eighteen possible tender points. Dr. Situmeang checked boxes indicating Plaintiff experienced pain in her spine, chest, shoulders, arms, hips, and legs, but did not describe the nature, frequency, or severity of her pain. [ECF No. 5-7 at 94]. He listed changing weather, fatigue, cold, hormonal changes, stress, sleep problems, and static position as factors precipitating Plaintiff's pain. Id.
For Plaintiff's symptoms, Dr. Situmeang listed: 1) Allodynia—hypersensitivity to touch; 2) fatigue; 3) chronic widespread pain; 4) sleep disturbance; 5) subjective swelling—feet and knees; 6) joint stiffness; 7) muscle spasms; 8) morning stiffness; 9) Temporomandibular Joint Dysfunction (TMJ); 10) cognitive dysfunction ("fibro fog"); 11) PTSD; 12) numbness and tingling; 13) Raynaud's Phenomenon; 14) dizziness; 15) Chronic Fatigue Syndrome; 16) Myofascial Pain Syndrome; 17) GERD; 18) anxiety; 19) panic attacks; and 20) depression. Id. at 93. Dr. Situmeang opined Plaintiff's "emotional factors contributed to the severity of [her] symptoms and functional limitations." Id. Dr. Situmeang rated Plaintiff's prognosis poor. Id.
For Plaintiff's functional limitations, Dr. Situmeang determined Plaintiff could sit for 30 minutes at a time before needing to get up, and could stand for 45 minutes before needing to sit or walk. Id. at 94. He felt Plaintiff could stand or walk for less than two hours a day, and sit for about four hours. Id. Dr. Situmeang also indicated Plaintiff would need a job that permitted shifting positions—between sitting, standing, and walking away from the work station—at will. Id. He opined that Plaintiff would need to take unscheduled breaks every 30 minutes, to allow her to lie down for 10 minutes. Id. at 95. According to Dr. Situmeang, Plaintiff would be off task for 25% of the day due to limitations with her attention and concentration, and would miss more than four days of work every month. Id. at 96.
Dr. Situmeang supplemented the check-list-style source statement with a letter dated September 12, 2013. In his letter to the ALJ, Dr. Situmeang explained that Plaintiff had been his patient for over fifteen years. [ECF No. 5-7 at 177]. He wrote:
Id.
The last medical records found in Plaintiff's Social Security file is a set of MRIs conducted on August 27 and September 4, 2013. Id. at 169-72. The first MRI documented minimal disc space narrowing at C6-C7. Id. at 171. The second found "very minimal early degenerative disc signal change at several levels" and a herniated disc at C6-C7. Id. at 169. A surgical consultation was recommended. Id.
Plaintiff completed a function report and pain/fatigue questionnaire in March 2012. She described her functional restrictions as:
[ECF No. 5-6 at 29]. Plaintiff explained it takes about two hours in the morning for her to be able to move well. Id. at 30. Plaintiff described taking several breaks when working for her clients. Id.
Plaintiff did not describe many limitations relating to personal care; only that she cannot hold her arms up for very long to fix her hair and sometimes she does not want to get out of bed due to depression. [ECF No. 5-6 at 30]. She remained able to prepare simple meals, do light cleaning, shop for groceries, visit friends and family, and attend church. Id. at 31-33. She reported that she goes outside ten times a day in good weather and is able to drive a car. Id. at 32.
At the hearing held September 13, 2013, Plaintiff further explained that she has trouble lifting and holding items in her hands; her hands will sometimes give out and she will drop items. [ECF No. 5-2 at 46-48]. She testified that her fibromyalgia causes her constant pain, at a level of six or seven out of ten. Id. at 64. When asked why she did not believe she would able to work even a simple, easy job, Plaintiff responded:
Id. at 47. She later elaborated, "I would have problems with fatigue during the day and . . . when I have fatigue that bothers my concentration . . . the more tired I am it bothers my memory worse than it already is." Id. at 62.
Plaintiff also reported that she was scheduled for surgery on the Monday following her hearing. Id. at 56. Plaintiff explained that the purpose of the surgery was to treat a herniated disc in her neck. Id. The plan was to take a piece of bone from Plaintiff's hip and graft it onto the disk in her neck. Id.
Plaintiff's home health care client and friend, Linda Merrill, completed a function report on Plaintiff's behalf. Merrill indicated Plaintiff's impairments limit her ability to work in that Plaintiff 1) is not able to lift more than ten pounds; 2) tires easily; 3) becomes emotionally upset easily; 4) has leg and foot problems; and 5) tends to have problems with her hands, dropping things occasionally. [ECF No. 5-6 at 21, 26]. Merrill confirmed that Plaintiff rests throughout the day between chores. Id. at 23.
Plaintiff's mother, Ruth Bruegge, also completed a function report. Bruegge lives with Plaintiff. Id. at 56. Bruegge stated that Plaintiff is limited in her ability to work due to her inability to sit or stand for long periods of time, but that Plaintiff is not limited with respect to her personal care. Id. at 56-57. In Bruegee's opinion, Plaintiff can pay attention for an hour at the most. Id. at 61.
The first non-examining medical source to review Plaintiff's records was Marlene Gernes, D.O. In a report signed April 2012, Dr. Gernes found fibromyalgia to be Plaintiff's primary impairment. [ECF No. 5-3 at 7]. Dr. Gernes found Plaintiff's reported sitting and standing limitations were not supported by her medical records, and were inconsistent with Plaintiff's reported ability to shop twice a month for three to four hours at a time. Id. at 9. Dr. Gernes found Plaintiff's mental health complaints credible, however. Id. Dr. Gernes concluded Plaintiff could sit for six hours a day and could stand for six hours a day. Id. Dr. Gernes further opined Plaintiff had no manipulative limitations. Id. at 10.
Plaintiff's application was reevaluated in November 2012 by John May, MD, after Plaintiff amended her application to include PTSD. Dr. May reached the same conclusions as Dr. Gernes and again found Plaintiff not disabled. Id. at 46.
As mentioned at the outset, the ALJ assigned little weight to Dr. Situmeang's opinion. The ALJ delineated several reasons for discounting Dr. Situmeang's opinion. In the ALJ's view, the objective medical findings failed to support Plaintiff's allegations. [ECF No. 5-2 at 20]. Namely, Plaintiff sought relatively minimal treatment concerning her fibromyalgia, back pain, and neck pain. Id. In addition, Plaintiff's back pain was relieved by surgery and her fibromyalgia pain was well controlled by medication. Id. at 21. The ALJ characterized Plaintiff's physical problems, as documented in her medical records, as "rather benign." Id. at 25. The ALJ also emphasized that Plaintiff reported riding horses in September 2012 and walking one mile on a daily basis. Id. at 24-25. The ALJ thus concluded Dr. Situmeang's opinion of Plaintiff's functional limitations was due to Dr. Situmeang "blindly accept[ing] [Plaintiff's] subjective allegations concerning the nature and severity of her alleged limitations." Id. at 25.
Likewise, the ALJ found Plaintiff's "statements concerning the intensity, persistence and limiting effects of [her] symptoms are not credible to the extent they are inconsistent with the [assigned RFC]." Id. at 28. The ALJ reiterated that Plaintiff's medical records do not support her allegations of disabling symptoms and limitations; the ALJ believed Plaintiff's medical records showed her conditions were well controlled with medication. Id. The ALJ cited the psychological evaluation, which showed Plaintiff was within normal ranges with respect to her memory. Id. The ALJ also commented, "there was no medical evidence that the claimant was scheduled to undergo any further surgical procedure as she alleged during the hearing." Id. And the ALJ viewed Plaintiff's daily activities as inconsistent with disability, pointing to Plaintiff's ability to perform personal care tasks independently, prepare meals, clean, do laundry, go outside, shop, work for Linda Merrill, ride a horse, and socialize. Id.
Having discounted the evidence from Plaintiff and Dr. Situmeang, the ALJ assigned great weight to the opinions from the non-examining medical sources. The ALJ did not, however, detail what those opinions were or the basis for those opinions. Rather, the ALJ simply stated "the State [A]gency opinions are internally consistent and consistent with the evidence as a whole." [ECF No. 5-2 at 29].
Having accepted that Plaintiff's lumbar degenerative disc disease, fibromyalgia, cervical degenerative disc disease, PTSD, and adjustment disorder were severe impairments, the ALJ concluded Plaintiff could perform sedentary work, with the following additional restrictions:
Id. at 19. The ALJ accepted a vocational expert's testimony that an individual with the above RFC would be able to work as a document preparer, touch up screener, or order clerk. Id. at 31. The ALJ therefore found Plaintiff not disabled. Id.
Plaintiff now challenges the ALJ's decision to afford little weight to Dr. Situmeang's opinion. Plaintiff argues that the ALJ should have assigned controlling weight to Dr. Situmeang's opinion or, at a minimum, substantial weight. The weight assigned to Dr. Situmeang's opinion is significant because, as the ALJ commented, the limitations described by Dr. Situmeang "are significantly restricting and no doubt would preclude sustained work activity." [ECF No. 5-2 at 24].
"The opinion of a treating physician is accorded special deference under the social security regulations. Such an opinion is normally entitled to great weight." Vossen v. Astrue, 612 F.3d 1011, 1017 (8th Cir. 2010) (internal quotation marks and citation omitted). This is because treating physicians "`are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations.'" Papesh v. Colvin, 786 F.3d 1126, 1132 (8th Cir. 2015) (quoting 20 C.F.R. § 404.1527(c)(2)).
So long as a treating source's opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence," such an opinion should be given controlling weight. 20 C.F.R. § 404.1527(c)(2). "`Not inconsistent . . . is a term used to indicate that a well-supported treating source medical opinion need not be supported directly by all of the other evidence (i.e., it does not have to be consistent with all the other evidence) as long as there is no other substantial evidence in the case record that contradicts or conflicts with the opinion.'" Papesh, 786 F.3d at 1132 (quoting S.S.R. 96-2p, Policy Interpretation Ruling, Titles II and XVI: Giving Controlling Weight to Treating Source Medical Opinions, 1996 WL 374188 (July 2, 1996) [hereinafter S.S.R. 96-2p]).
If a treating source's opinion does not deserve controlling weight, an adjudicator must then consider several factors in deciding how much weight is due the opinion:
Even when a treating source medical opinion is not entitled to controlling weight, it is "still entitled to deference and must be weighed using all of the factors [listed above.]" S.S.R. 96-2p, 1996 WL 374188. "In many cases, a treating source's medical opinion will be entitled to the greatest weight and should be adopted, even if it does not meet the test for controlling weight." Id.
Finally, an ALJ is entitled to assign a treating source's opinion little weight if the opinion provides conclusory statements only, is internally contradictory, is inconsistent with the record, or is belied by better-supported medical assessments. Papesh, 786 F.3d at 1132.
The Court now considers the reasons given by the ALJ for discounting Dr. Situmeang's opinion, to determine if Dr. Situmeang's opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence." 20 C.F.R. § 404.1527(c)(2). A brief overview of fibromyalgia is warranted at the outset. Fibromyalgia is "pain in the fibrous connective tissue components of muscles, tendons, ligaments, and other white connective tissues." Cline v. Sullivan, 939 F.2d 560, 563 (8th Cir. 1991). It "often leads to a distinct sleep derangement which contributes to a general cycle of daytime fatigue and pain." Id. The United States Court of Appeals for the Sixth Circuit has further elaborated on this diagnosis:
Preston v. Sec'y of Health & Human Servs., 854 F.2d 815, 817-18 (6th Cir. 1988) (per curiam). Fibromyalgia is a degenerative condition that worsens over time. Cline, 939 F.2d at 566.
Both Dr. Situmeang and a rheumatologist found Plaintiff exhibits tender points warranting a fibromyalgia diagnosis. According to Dr. Situmeang, Plaintiff's anxiety, depression, and fatigue are all symptoms of her fibromyalgia. Dr. Situmeang believed that, due to fatigue and pain, Plaintiff would need to be able to shift positions at will and take 10 minute breaks every 30 minutes. [ECF No. 5-7 at 94-95]. He opined that Plaintiff could sit for only 30 minutes at a time and stand for only 45 minutes at a time. Id. at 94. Finally, in Dr. Situmeang's opinion, Plaintiff would be off task for 25% of the day and would miss more than four days of work every month. Id. at 96.
The ALJ's primary critiques of Dr. Situmeang's opinion stemmed from the ALJ's opinion that Plaintiff's fibromyalgia was controlled with medication and that Plaintiff's activities of daily living were inconsistent with disability. Plaintiff's fibromyalgia diagnosis is not in doubt; the ALJ doubted only the symptoms associated with Plaintiff's fibromyalgia.
The Court finds Dr. Situmeang's opinion deserved greater weight than the ALJ gave it. Dr. Situmeang's opinion is supported by diagnostic techniques: Plaintiff's fibromyalgia diagnosis is valid and fatigue, pain, and psychological disorders are commonly associated with that diagnosis. Dr. Situmeang and Martin both diagnosed Plaintiff with anxiety and depression. And Dr. Situmeang's opinion is not inconsistent with the objective medical evidence. The ALJ correctly noted that Plaintiff periodically reported improvement in her symptoms. But between 2009 and 2013, Dr. Situmeang explored multifaceted approaches to Plaintiff's symptoms, tweaking her medication to address whichever of her symptoms was bothering her at present— depression, anxiety, fatigue, pain. Cf. Forehand v. Barnhart, 364 F.3d 984, 987 (8th Cir. 2004) ("On some occasions, Forehand[, who suffered from fibromyalgia,] would feel better than others, but Dr. Quevillon's basic diagnosis remained the same throughout his treatment of her. Clearly, Dr. Quevillon's opinion letter was . . . supported by his own medical observations[.]"). Plaintiff's medical records also reflect that her pain forced her to quit three jobs. [ECF No. 5-7 at 143 (Wal-Mart in 2009), 24 (job requiring lifting in April 2011), 21 (job requiring standing in August 2011)]. At most, the objective medical evidence is inconclusive—not inconsistent. Plaintiff's medical records never speak directly to the impact her pain and fatigue have on her functional abilities. Cf. Green-Younger v. Barnhart, 335 F.3d 99, 108-09 (2d Cir. 2003) (noting a "relative lack of physical abnormalities" and examinations yielding normal results are to be expected with a fibromyalgia diagnosis).
Moreover, whatever Plaintiff's progress, Dr. Situmeang did not believe Plaintiff had the functional abilities to maintain full employment. As Plaintiff's primary care physician for over fifteen years, Dr. Situmeang is in by far the best position to evaluate Plaintiff's impairments. Plaintiff visited Dr. Situmeang at least eighteen times between 2009 and 2013. Certainly, Dr. Situmeang is best equipped to provide a longitudinal picture of Plaintiff's impairments. See 20 C.F.R. § 404.1527(c)(2). He is also likely to provide additional information beyond that which is contained in Plaintiff's charts. Id. This is particularly important in a case such as this, where the chart notes leave room for interpretation.
The Court also disagrees with the ALJ that Plaintiff's activities of daily living justified disregarding Dr. Situmeang's opinion. The United States Court of Appeals for the Eighth Circuit has repeatedly recognized that individuals suffering from fibromyalgia often are able to carry on with normal daily activities, to a certain extent, but that this does not render them able to maintain full-time employment. For instance, in Cline, the Eighth Circuit held the claimant's "ability merely to perform the limited service of pouring coffee or removing the excess plates from a table on an occasional basis does not compel a conclusion that a claimant is capable of performing the full range of sedentary work on a sustained basis." 939 F.2d at 565. The Court admonished the ALJ not to "penalize a claimant who, prior to an award of benefits, attempts to make ends meet by working in a modest, part-time job." Id. at 565-66. In Forehand, the Eighth Circuit reiterated that "to determine whether a claimant has the residual functional capacity necessary to be able to work we look to whether she has the ability to perform the requisite physical acts day in and day out, in the sometimes competitive and stressful conditions in which real people work in the real world." 364 F.3d at 988 (internal quotation marks omitted) (fibromyalgia decision finding claimant's activities, "such as caring for her personal needs and hygiene, doing laundry and other housework, and once moving furniture," were not inconsistent with her allegations of limitation); see also Brosnahan v. Barnhart, 336 F.3d 671, 677 (8th Cir. 2003) ("[W]e have held, in the context of a fibromyalgia case, that the ability to engage in activities such as cooking, cleaning, and hobbies, does not constitute substantial evidence of the ability to engage in substantial gainful activity.").
Here, Plaintiff testified that she took frequent breaks throughout the day to rest. As such, her ability to perform personal care tasks independently, prepare meals, clean, do laundry, go outside, shop, work for Linda Merrill, ride a horse, and socialize is not inconsistent with her claim that she is unable to perform full-time work due to fatigue. See Lewis v. Astrue, No. 4:09CV3218, 2010 WL 3523014, at *7 (D. Neb. Sept. 2, 2010) (unpublished) ("The record demonstrates that plaintiff is capable of performing several daily activities, including household work, driving to run errands, and caring for her grandchildren two afternoons a week, but plaintiff claims that she takes frequent breaks while performing housework, watches her grandchildren sleep and play with toys, and rests for two hours each afternoon. These activities are not necessarily inconsistent with her claim that [fibromyalgia renders her] unable to perform full-time work, let alone full-time light work, which requires the ability to stand/walk for 6-hours out of an 8-hour day.").
Also important to the Court's conclusion on this matter is the fact that the only other medical evidence in Plaintiff's file regarding fibromyalgia is from non-examining medical sources. Despite having never examined Plaintiff, these sources concluded Plaintiff could sit and walk as required by sedentary work. [ECF No. 5-3 at 9, 22]. What is more, these sources issued their opinions in April and November of 2012. Consequently, these sources never saw any of Plaintiff's 2013 records or Dr. Situmeag's opinion. These reports therefore "`deserve little weight in the overall evaluation of disability,'" Nelson v. Heckler, 712 F.2d 346, 348 (8th Cir. 1983), yet the ALJ assigned them great weight. See also id. ("[T]o attempt to evaluate disability without personal examination of the individual and without evaluation of the disability as it relates to the particular person is medical sophistry at its best." (internal quotation marks omitted)). The non-examining medical source opinions in this case surely do not deserve greater weight than the opinion of Plaintiff's long-term treating physician.
In sum, the record does not contain substantial evidence establishing Plaintiff's pain and fatigue were resolved to the point they did not impact her ability to work. The Court therefore finds the ALJ was not justified in assigning little weight to Situmeang's opinion.
The Court recognizes, however, that Dr. Situmeang did not provide a detailed explanation for his source statement. The Court therefore concludes that this is a case where remand is necessary for additional development of the record. As explained in a Social Security Ruling, sometimes "additional development required by a case—for example, to obtain more evidence or to clarify reported clinical signs or laboratory findings—may provide the requisite support for a treating source's medical opinion that at first appeared to be lacking or may reconcile what at first appeared to be an inconsistency between a treating source's medical opinion and the other substantial evidence in the case record." S.S.R. 96-2p, 1996 WL 374188; see also Bowman v. Barnhart, 310 F.3d 1080, 1085 (8th Cir. 2002) (faulting ALJ for relying on non-examining consultant opinion instead of contacting treating provider for clarification of cursory charts notes). On remand, the ALJ is directed to contact Dr. Situmeang and request documentation detailing the basis for his opinion, with citation to objective indicators justifying his opinion, if available. If Dr. Situmeang is unable to provide a satisfactory report, the ALJ should obtain a consultative medical examination to determine the functional restrictions associated with Plaintiff's fibromyalgia condition. In the face of Dr. Situmeang's treating opinion, the opinions of non-treating, non-examining medical consultants will not be sufficient to justify a denial of benefits. See Nevland v. Apfel, 204 F.3d 853, 858 (8th Cir. 2000) ("The opinions of doctors who have not examined the claimant ordinarily do not constitute substantial evidence on the record as a whole. . . . `An administrative law judge may not draw upon his own inferences from medical reports.'").
In evaluating a claimant's credibility, "[t]he adjudicator must give full consideration to all of the evidence presented relating to subjective complaints, including the claimant's prior work record, and observations by third parties and treating and examining physicians relating to such matters as:"
Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984) (internal quotation marks omitted).
As discussed above, the Court finds the ALJ erred both in concluding Plaintiff's medical records contradict her description of her limitations and in concluding Plaintiff's daily activities are inconsistent with her allegations. Brosnahan, 336 F.3d at 677 (finding activities of daily living analogous to Plaintiff's do not justify discounting claimant's credibility); Cline, 939 F.2d at 565 (disagreeing with ALJ's credibility assessment of claimant with fibromyalgia; commenting "we can not say that fairness is obtained by denying appellant's claim merely because the objective medical evidence in favor of her claim could have been stronger"); see also Flanery v. Chater, 112 F.3d 346, 350 (8th Cir. 1997) ("A patient's report of complaints, or history, is an essential diagnostic tool."). The Court additionally notes that neither Dr. Situmeang nor Dr. Martin indicated Plaintiff was a malingerer or less-than-credible; Dr. Martin expressly found Plaintiff to be a "reliable informant." [ECF No. 5-7 at 55, 84]; cf. Orr v. Chater, 956 F.Supp. 861, 873 (N.D. Iowa 1997) (rejecting ALJ's finding that claimant was incredible when "[n]one of the twelve doctors who examined [claimant] or reviewed her test results questioned [her] subjective complaints of pain"). The ALJ is directed, upon remand, to re-evaluate Plaintiff's credibility consistent with this ruling.
Plaintiff argues the ALJ should have further developed the record regarding Martin's rule-out diagnoses of somatoform disorder and learning disorder. The Court finds no error. Despite the rule-out diagnoses Dr. Martin mentioned, he found Plaintiff possessed the cognitive ability to work in a wide range of simple, unskilled jobs. Accordingly, no further clarification on this issue was needed. See Grable v. Colvin, 770 F.3d 1196, 1201 (8th Cir. 2014) (finding development of record unnecessary where no crucial issue was undeveloped).
Plaintiff additionally argues the ALJ should have acquired the medical records relating to Plaintiff's anticipated neck surgery. On remand, the record should be supplemented with Plaintiff's recent medical records.
For the above-stated reasons, the Commissioner's decision denying Plaintiff's claim for disability insurance benefits under Title II of the Social Security Act is REVERSED and this matter is REMANDED to the Commissioner for further proceedings consistent with this opinion. The ALJ is directed upon remand to:
IT IS SO ORDERED.
