United States District Court, E.D. Arkansas, Little Rock Division
JULIA A. WILLFOND PLAINTIFF
NANCY A. BERRYHILL, Deputy Commissioner for Operations, performing the duties and functions not reserved to the Commissioner of Social Security Administration DEFENDANT
following Recommended Disposition
(“Recommendation”) has been sent to United States
District Judge J. Leon Holmes. You may file written
objections to all or part of this Recommendation. If you do
so, those objections must: (1) specifically explain the
factual and/or legal basis for your objection; and (2) be
received by the Clerk of this Court within fourteen (14) days
of this Recommendation. By not objecting, you may waive the
right to appeal questions of fact.
Willfond (“Willfond”) applied for social security
disability benefits with an alleged disability onset date of
February 19, 2015. (R. at 65). The administrative law judge
(“ALJ”) held a hearing and denied her
applications. (R. at 21). The Appeals Council denied review.
(R. at 1). Willfond has requested judicial review.
reasons stated below, the Court recommends reversing and
remanding the Commissioner's decision.
found that Willfond had the severe impairments of bulging
disk and chronic back pain, which left her with the residual
functional capacity (“RFC”) to perform light
work. (R. at 13). Specifically, the ALJ found Willfond could
lift and/or carry twenty pounds occasionally and ten pounds
frequently; stand and/or walk six hours in an eight-hour
workday with normal breaks; sit six hours in an eight-hour
workday with normal breaks; push and pull with the same
limitations as lift and/or carry; occasionally balance,
stoop, kneel, crouch, crawl, and climb ramps, stairs,
ladders, ropes, and scaffolds; and perform jobs that do not
require written communication or math computation skills
beyond a sixth grade level. (R. at 15).
on testimony from a vocational expert (“VE”), the
ALJ found that Willfond could return to her past relevant
work as a plastic molding machine tender, hand packager, or
conveyor feeder. (R. at 20-21). Thus, the ALJ held that
Willfond was not disabled. (R. at 21).
argues that the ALJ failed to fully and fairly develop the
record; failed to find her depression to be a severe
impairment; erred in the RFC determination; and failed to
resolve conflicts in the VE's testimony. Because the
Court agrees that the ALJ failed to fully and fairly develop
the record, the Court recommends that the Commissioner's
decision be reversed.
Court's function on review is to determine whether the
Commissioner's decision is supported by substantial
evidence on the record as a whole and whether it is based on
legal error. Miller v. Colvin, 784 F.3d 472, 477
(8th Cir. 2015); see also 42 U.S.C. § 405(g).
argues she requested the ALJ to order a consultative
examination based on her medically documented history of
serious depression. The ALJ failed to order that a mental
health specialist perform a consultative mental health
evaluation of Willfond's problems with depression, and,
instead, relied on the opinions of non-examining reviewing
physicians who did not examine the entire record to reach the
conclusion Willfond's depression was not a severe mental
has a duty to fully and fairly develop the record independent
of the claimant's burden to prove his or her case,
especially where the missing medical evidence relates to an
important but under-developed medical issue. Combs v.
Berryhill, 878 F.3d 642, 646 (8th Cir. 2017);
Martise v. Astrue, 641 F.3d 909, 926-27 (8th Cir.
gave significant weight to the opinions of the non-examining
reviewing physicians, even though it is clear they did
not review all of the medical evidence. (R. at 18).
Rather, those physicians only reviewed exhibits up to and
including a physical consultative examination by Ted
Honghiran, M.D. (R. at 66- 69, 78-81, 92-96, 106-10, 404-07).
However, they did not review a medical source
statement from Willfond's treating physician, nor did
they consider any of the other medical records received
after Dr. Honghiran's report. (R. at 66-69, 78-
81, 92-96, 106-10, 393-97, 408-617). While some of those
records are duplicative (compare R. at 343-68
with R. at 483-530 and R. at 546-93),
others reflect additional medical treatment and contain
opinions from treating providers that the reviewing
physicians failed to consider in arriving at their
conclusions. Finally, notwithstanding Willford's history
of depression, including anxious and depressed mood or
affect, and fleeting suicidal thoughts (R. at 319, 348, 349,
350, 353, 355, 357, 359, 362, 363, 485, 503), the ALJ refused
a psychiatric consultative examination. (R. at 10). The
ALJ's stated basis for disregarding Willfond's
depression were notes that showed she was “alert and
oriented” and “in no apparent mental
distress.” (R. at 13, 315, 348, 374, 411, 482, 615).
However, “alert and oriented” does not
indicate a lack of depressive symptoms. Two of the records
cited by the ALJ even indicate “anxious,
depressed” mood or affect. (R. at 348, 615).
also disregarded Willfond's depression because records
indicated that she reported improvement with Zoloft. (R. at
13). This improvement still left her feeling “a
moderate degree of depression” (R. at 347), a clear
indication the Zoloft did not eliminate her symptoms. In
fact, she reported worsening symptoms on December 30, 2015
and February 1, 2016 and received an additional prescription
for Risperdal. (R. at 606, 609-10). She continued to present
with moderate depression on March 4, 2016. (R. at 614). She
testified that she continued to deal with depression and that
she had recently begun seeing a psychiatrist. (R. at 44-45).
She testified that she had suicidal thoughts daily. (R. at
evidence of Willfond's depression was sufficient to put
the ALJ on notice of a real condition that requires further
development by ordering a consultative mental health
evaluation. Without such an evaluation, the ALJ's ...