United States District Court, D. South Dakota, Southern Division
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY, UNITED STATES MAGISTRATE JUDGE.
Richard Lee Springer, seeks judicial review of the
Commissioner's final decision denying his application for
social security disability benefits under Title II of the
Social Security Act.
Springer has filed a complaint and has requested the court to
reverse the Commissioner's final decision denying him
disability benefits and to remand the matter to the Social
Security Administration for further proceedings.
appeal of the Commissioner's final decision denying
benefits is properly before the court pursuant to 42 U.S.C.
§ 405(g). The parties have consented to this magistrate
judge handling this matter pursuant to 28 U.S.C. §
Statement of the Case
action arises from plaintiff Richard Lee Springer's
application for Title II disability benefits filed on March
30, 2016, alleging disability since October 5, 2015, due to
social anxiety, depression, stress, sleep apnea, dizzy
spells, high blood pressure, lack of focus, short and long
term memory loss, obesity, and cerebral palsy, including lack
of hand-eye coordination, lack of muscle strength and
dexterity, slowness and restriction in movement, all more
affected on the right side. AR181-190, 221, 257, 261, 285
(citations to the appeal record will be cited by
“AR” followed by the page or pages).
Springer's claim was denied initially and upon
reconsideration. AR143, 149. Mr. Springer then requested an
administrative hearing. AR156.
Springer's administrative law judge (ALJ) hearing was
held on March 15, 2018, by ALJ Jeffrey N. Holappa. AR76-112.
Mr. Springer was represented by a non-attorney representative
at the hearing, and an unfavorable decision was issued on May
4, 2018. AR8-27, 79.
One of the evaluation, the ALJ found that Mr. Springer was
insured for benefits through September 30, 2020, and that he
had not engaged in substantial gainful activity
(“SGA”) since October 5, 2015, the alleged onset
of disability date. AR13.
Two, the ALJ found that Mr. Springer had severe impairments
of cerebral palsy with right spastic hemiparesis,
generalized anxiety disorder, major depressive disorder,
personality disorder, panic disorder, and social anxiety
disorder, finding that each of those medically determinable
impairments significantly limited Mr. Springer's ability
to perform basic work activities as required by Social
Security Ruling (SSR85-28). AR13.
found that Mr. Springer also had a medically determinable
impairment of urinary frequency, but found that it was not
severe because the treatment note reflected that Mr. Springer
reported, “good bowel and bladder control, ” as
of March, 2016, and he has not sought any further evaluation
or treatment for this symptom. AR13.
found that Mr. Springer also had medically determinable
impairments of sleep apnea, hypersomnia, and a deviated
septum. AR14. The ALJ found that Mr. Springer underwent
continuous positive airway pressure (CPAP) titration, which
determined that proper adaptive servo-ventilation (ASV)
therapy would control the majority of Mr. Springer's
respiratory events and snoring. AR14. In addition, while Mr.
Springer complained of daytime fatigue and sleepiness through
March, 2016, these complaints do not reappear in his
treatment records from 2017. AR14. Given the brevity of Mr.
Springer's complaints of these symptoms to medical
providers and the documented efficacy of proposed treatment,
the ALJ determined Mr. Springer's sleep apnea,
hypersomnia and deviated septum are not severe impairments.
found that Mr. Springer also had medically determinable
impairments of obesity with a BMI ranging from 37.3 to 40.3.
AR14. The ALJ found there is no persuasive evidence that Mr.
Springer's obesity significantly affects or exacerbates
his physical impairment. AR14. The ALJ also found that Mr.
Springer had not undergone any special treatment for weight
loss and does not make any significant allegations that his
weight causes, or contributes to, any degree of functional
limitations. AR14. Therefore, the ALJ found Mr.
Springer's obesity is non-severe. AR14.
3, the ALJ found that Mr. Springer did not have an
impairment, or combination of impairments, that met or
medically equaled one of the listed impairments in 20 CFR
404, Subpart P, App 1 (hereinafter referred to as the
“Listings”). AR14. The ALJ considered the
cerebral palsy impairment under Listing 11.07 and found there
is no persuasive evidence of disorganization of motor
function in two extremities (see 11.00D1) resulting
in extreme limitation (see 11.00D2) in the ability
to stand up from a seated position, balance while standing or
walking, or use the upper extremities. AR14. There is also no
persuasive evidence of a marked limitation (see
11.00G2) in understanding, remembering, or applying
information; interacting with others; concentrating,
persisting, or maintaining pace; or adapting or managing
also considered the mental impairments under Listings 12.04
and 12.06 and considered whether the “paragraph
B” criteria are satisfied. AR15. The ALJ found that Mr.
Springer had mild limitations in understanding, remembering
or applying information because Mr. Springer had an overall
mental status exam score of 27/30, which is in the average
found Mr. Springer had moderate limitations in interacting
with others because his mental status exams reveal normal
dress, behavior, appearance, and speech. AR15. The ALJ noted
that Mr. Springer's mental status exams revealed extreme
anxiety at times. AR15. The ALJ found Mr. Springer had
moderate limitations with concentration, persistence or
maintaining pace because although his mental status exams
have occasionally shown depressed mood, anxious affect, and
agitated presentation, many mental status exams have revealed
normal findings, and Mr. Springer was able to accurately
perform serial seven calculations. AR15.
found Mr. Springer had mild limitations in adapting or
managing oneself because Mr. Springer has not shown evidence
of decompensation, despite having undergone major life
changes; while Mr. Springer has developed depression while
adapting to such changes, there has not been a significant
disruption in his ability to adapt to changes; nor is he
regularly observed to be malodorous, unkempt, disheveled or
otherwise display indicia of an inability to manage oneself.
AR15. Therefore, Mr. Springer did not meet a Listing.
determined that Mr. Springer had the residual functional
capacity (“RFC”) to perform:
light work as defined in 20 CFR 404.1567(b) except that the
claimant can lift and carry up to 20 pounds occasionally and
10 pounds frequently; can sit for six hours in an eight-hour
day; can stand for six hours in an eight-hour day; can walk
for six hours in an eight-hour day; can occasionally push and
pull with the right upper and lower extremity; can
occasionally climb ramps and stairs; can never climb ladders
or scaffolds; can occasionally balance, stoop, kneel, crouch
and crawl; can frequently reach (both overhead and all other
directions) with the right upper extremity; and can
frequently handle, finger and feel with the right hand. The
claimant cannot tolerate exposure to unprotected heights or
moving mechanical parts. The claimant would need hourly
bathroom breaks lasting five minutes in duration. Finally,
the claimant is capable of only simple, routine tasks, with
simple work-related decisions, and occasional interactions
with supervisors, co-workers and the general public.
noted Mr. Springer testified, in part, as follows:
The claimant testified that he was unable to work due to
panic, anxiety, depression, fatigue, sleepiness, and
difficulty with right hemiparesis and spasticity. The
claimant testified that he has problems with right hand
dexterity due to cerebral palsy. This has caused problems for
him when he worked at Pizza Hut mixing dough. The claimant
has sought out work where such dexterity is not required. The
claimant has worked at Esurance, but developed anxiety due to
the failing health of his mother. The claimant had worked and
been successful after transferring. He was able to work
[from] home. The claimant then had an out-of-state manager,
and he did not get along with this person. The claimant's
manager wanted him to cease working at home. The claimant
indicated he could not do this because of his social anxiety
and depression. . . . The claimant has not taken sertraline
for over a year. He does not have health insurance. . . . He
does not do a lot of laundry. He can physically perform the
light household tasks in his apartment. The claimant goes
shopping at night to avoid crowds. He becomes too anxious to
effectively shop there during the day. The claimant feeds his
cats. The claimant gets anxiety attacks.
ALJ's subjective symptom finding was that Mr.
Springer's medically determinable impairments could
reasonably be expected to produce the symptoms he alleged,
but his statements concerning the intensity, persistence and
limiting effects of his symptoms were not “entirely
consistent with the medical evidence and other evidence in
the record for the reasons explained in this decision.”
considered a January, 2016, MRI of the brain that revealed
findings consistent with cerebral palsy. AR17. The ALJ found
that the MRI findings may account for Mr. Springer's
right sided symptoms, but the mere presence of objective
abnormalities does not, in and of itself, equate to a
specific functional limitation, nor does it necessarily
indicate the frequency or severity of symptoms caused by the
also found that Mr. Springer's exam findings do not
support the presence of disabling symptoms, noting:
Exams have revealed a boutonniere-type deformity of the right
hand; spasticity, weakness and immobility of the right hand;
atrophy of the right upper and lower extremities hemi-paretic
gait; right spastic hemiparesis; 4-5/right foot strength; and
hyperreflexia in the right lower extremity. Exh. 3F, pp. 3,
24; Exh. 6F, pp. 6, 7; Exh. 7F, p. 6. These findings are
consistent with some degree of difficulty lifting and
carrying heavy objects, engaging in constant postural
activity, or engaging in constant activity with the right
upper and lower extremity. However, the claimant's exams
have also revealed normal strength; stable gait; normal
sensation; and normal range of motion. Exh. 1F, p. 3; Exh.
3F, pp. 10, 20; Exh. 7F, p. 3. These findings demonstrate
sufficient strength to lift and carry up to 20 pounds
occasionally; occasionally push and pull with the right upper
and lower extremity; frequently handle, reach, feel, and
reach in all direction with the right arm; and occasionally
engage in most postural activity.
considered Mr. Springer's treatment history and found it
inconsistent with the presence of disability impairments. The
While he has sought some treatment for sleep apnea and
hypertension, he does not require any treatment to manage his
symptoms of cerebral palsy. He does not require any assistive
treatment devices. He does not use any braces. Therefore,
while the claimant's treatment history is consistent with
some degree of limitation, it is not consistent with a
disabling degree of limitation.
The claimant has been diagnosed with social anxiety disorder,
personality disorder, major depressive disorder, and panic
disorder. Exh. 2F. The claimant has been prescribed
medications such as Fluoxetine, Wellbutrin, and sertraline.
Exh. 6F, p. 3.
This degree of treatment is consistent with some degree of
mental limitation. However, the undersigned notes that the
claimant has not been psychiatrically hospitalized. Nor has
he been seen in the ER for symptoms of a panic or anxiety
attack. Although he has been on medications in the past, he
reported that he took no medications for depression or
anxiety currently. The undersigned also notes that when the
claimant presented for a mental health intake in March 2016,
he indicated he was hopeful that a psychiatry referral would
“assist with his disability claim.” Exh. 3F, p.
5. The claimant was reminded that the purpose of such a
referral would be primarily for treatment of his symptoms,
that he had reported seeing a psychiatrist in the past, and
had reported that he knew that medications would not help.
Exh. 3F, p. 5. Despite this, he indicated he wanted another
referral to a psychiatrist, whose purpose would only be to
diagnose and manage his symptoms though the use of
medications. Exh. 3F, p. 5. In addition, the claimant took
the MMPI twice, but his results were invalid due to a pattern
of atypical and rarely given responses with resulting
“grossly over-elevated” clinical scale profiles,
and suggesting “possible exaggeration.” Exh. 2F,
p. 13. Therefore, while the claimant's treatment history
supports some degree of limitation, it is not inconsistent
with a disabling degree of limitation.
considered Mr. Springer's mental status exam findings of
depression and anxiety and found they are not as persistent
or limiting as Mr. Springer's allegations might suggest.
AR18-19. The ALJ found:
The claimant's mental status exams have revealed
depressed and severely anxious mood; flat and labile affect;
agitated psychomotor activity; and difficulty expressing
himself. Exh. 2F, p. 3.; Exh. 3F, pp. 6, 8, 24, 29; Exh. 6F,
p. 7. Formal mental status exam revealed an inability to
recall more than three out of five objects on delayed recall,
nor an ability to repeat a three-digit sequence in reverse.
Exh. 2F, p. 5. These findings are consistent with some degree
of limitation in the ability to sustain concentration or
interact with others.
However, the claimant's mental status exams have often
revealed no abnormalities, and generally reflect appropriate
dress, hygiene, and grooming; cooperative demeanor; normal
thought processes, content, and associations; appropriate
affect and speech. Exh. 1F, p. 1; Exh. 3F, p. 25; Exh 7F, p.
4; Exh. 8F, p. 3. Formal mental status exams finding[s ] have
revealed an intact ability to perform serial seven
calculations and an overall score of 27/30 on the Montreal
Cognitive Assessment (MOCA), which is in the average range.
Exh. 2F, p. 5.
These mental status exam findings suggest that the
claimant's depression and anxiety are not as persistent
or limiting as the claimant's allegations might suggest.
The findings of normal speech, behavior, and appearance
suggest that the claimant is able to get along appropriately
with others on an occasional basis. In terms of his ability
to sustain concentration, his depression and anxiety would
preclude his ability to perform complex or detailed tasks.
However, the relative normalcy of [his] mental status exams,
including his overall MOCA score and ability to perform
serial seven calculations, demonstrate that he is able to
perform simple routine tasks, and make simple work-related
considered that Mr. Springer's daily activities were
inconsistent with the presence of disabling limitations.
AR19. For example, Mr. Springer was able to pay bills, count
change, use a checkbook, go shopping alone, drive, and
followed spoken instructions fairly well. AR19, 259, 267,
269. The ALJ also noted that Mr. Springer's daily
activities were fairly limited. AR19.
considered the opinions of the State agency psychological
consultant, Robin Carter-Visscher, Ph.D., who had found there
was insufficient evidence in the record to determine if Mr.
Springer had a medically determinable severe impairment, and
found the opinion was not consistent with the current record
and gave it little weight. AR20.
considered the opinions of the State agency psychological
consultant, Alison Musso, Ph.D., and gave her opinion partial
weight because the opinion used imprecise and vocationally
useless terminology in assessing Mr. Springer's ability
to perform the mental aspects of work. AR21. The ALJ referred
to Dr. Musso's opinion that Mr. Springer could perform
“low stress, low social work.” AR21.
considered the opinions of Thomas Price, Ph.D., and stated he
gave his opinion little weight. AR20. The ALJ gave Dr.
Price's opinion little weight because the opinion was
rendered after a single examination of Mr. Springer, the
opinion only addressed Mr. Springer's ability to perform
one of his past jobs, the opinion did not suggest he would be
unable to perform other types of work and the opinion that a
claimant cannot work is an issue reserved for the
considered the opinions of the State agency medical
consultants, and gave them partial weight because the ALJ
found that Mr. Springer's ongoing exam abnormalities
regarding his right upper extremity supported a greater
degree of limitation on the use of that arm than envisioned
by the medical consultants. AR21.
considered the opinion of treating physician Jeffrey Meyer,
M.D., who the ALJ indicated had opined that Mr. Springer
should work at home, and gave the opinion little weight.
AR19. The ALJ found that Dr. Meyer's opinion was
inconsistent with Mr. Springer's mental status exam
findings and treatment history, Mr. Springer's current
job at the time of the opinion rendered significant
interaction with the public, and the opinion did not address
whether Mr. Springer could perform other types of work. AR19.
considered the opinion of treating physician Jonathan
Bannwarth, M.D., who the ALJ indicated had completed housing
disability paperwork indicating Mr. Springer was unable to
work. AR20. The ALJ gave Dr. Bannwarth's opinion little
weight because the opinion was not explained in any detail,
did not include function-by-function limitations, was not
consistent with mental status exams, treatment history, or
activities of daily living, and the issue of disability is
reserved to the Commissioner. AR20.
considered the opinion of treating physician Bradley Kamstra,
M.D., who the ALJ indicated completed a disability parking
permit indicating Mr. Springer was disabled and would be
unable to work until further notice. AR21. The ALJ gave Dr.
Kamstra's opinions little weight because they were not
explained in any detail, did not include function-by-function
limitations, was not consistent with mental status exams,
treatment history, or activities of daily living, and the
issue of disability is reserved to the Commissioner. AR21.
on the RFC determined by the ALJ, the ALJ found that Mr.
Springer was not capable of performing his past relevant
5, the ALJ found Mr. Springer capable of adjusting to other
work that existed in significant numbers such as a copy
machine operator, DOT# 207.685-014; mail clerk, DOT#
209.687-026; and clerical checker, DOT# 222.687-010, relying
on testimony from the vocational expert regarding the number
of jobs available for each occupation nationally and denied
the claim. AR22-23.
Springer timely requested review by the Appeals Council and
submitted additional evidence related to his cerebral palsy,
an article or excerpts from a website, as well as a personal
statement. AR33-75, 310-313. The Appeals Council denied Mr.
Springer's request for review, making the ALJ's
decision the final decision of the Commissioner. AR1-7. When
denying Mr. Springer's request for review, the Appeals
Council considered the personal statement Mr. Springer
Plaintiff's Age, Education and Work Experience
Springer was born in April of 1975 and completed the 12th
grade in 1993. AR222.
found that Mr. Springer had past relevant work as a telephone
customer clerk and a statistical report clerk. AR21.
Relevant Medical Evidence (chronological sequence)
Springer saw Dr. Meyer at Sanford Family Medicine on October
5, 2015, to follow up on depressive symptoms including
depressed mood, anhedonia, anxiety, diminished interest in
activities, diminished concentration, fatigue, feelings of
worthlessness, feelings of inappropriate guilt, hopelessness,
and insomnia. AR382. Mr. Springer had been seen approximately
one year earlier with symptoms gradually getting worse.
AR382. Mr. Springer reported that he liked his work, but
would like to work from home, as he was having trouble
keeping up and was worried he might lose his job or be forced
into the office to work. AR382. He reported that the social
anxiety at the office was more than he could stand. AR382.
Mr. Springer was alert, oriented to time, person and place,
and his thought content, speech, affect, mood and dress were
normal. AR382. Zoloft and Ambien were prescribed, counseling
recommended, and he was put off work for three weeks. AR382.
Springer saw Dr. Meyer at Sanford Family Medicine on November
16, 2015, to follow up on his anxiety, depression, and
insomnia and reported he continued to struggle with anxiety
and was not sleeping well. AR376. He reported he would like
to continue to work from home because he felt the office
environment was too stressful. AR376. Dr. Meyer noted Mr.
Springer's anxiety was improving. AR376. Dr. Meyer stated
he was willing to recommend that he work from home. AR377.
November 18, 2015, Mr. Springer contacted Dr. Meyer's
office complaining of sweats, which he felt were due to his
medications, but Dr. Meyer stated he had discussed this with
Mr. Springer before and felt that the sweats were due to his
anxiety, not his medications. AR376.
Springer saw Dr. Meyer at Sanford Family Medicine on November
25, 2015, for his anxiety and Mr. Springer reported he was
really struggling. AR375. He was having chest pain, sweats,
and sleeping problems. AR375. Mr. Springer felt he would be
able to return to work on December 8 if things worked out.
AR375. Mr. Springer also reported some neuropathy in his
right fourth and fifth fingers, which Dr. Meyer noted was the
extremity that Mr. Springer had his disability from cerebral
palsy, and Mr. Springer was wondering about getting botox
shots for spasticity. AR375.
revealed that Mr. Springer was “extremely anxious as
usual, ” and it was difficult to hold a conversation
with him because of his interruptions. AR375. Examination of
his right arm revealed chronic spasticity from cerebral palsy
and some numbness in the ulnar nerve distribution. AR375.
Seroquel was added to his medications to help with mood and
sleep. AR375. Mr. Springer had been seeing a counselor, and
Dr. Meyer recommended continued counseling. AR375. Dr. Meyer
stated he would be happy to fill out paperwork to put him
back to work on December 8 if possible. AR375.
Springer was seen on December 1, 2015, at Midwest Ear, Nose
and Throat for evaluation of possible sleep apnea. AR318. Mr.
Springer reported excessive daytime sleepiness with decreased
concentration and frequent memory problems. AR318. Objective
findings show Mr. Springer was in no apparent acute or
chronic distress; had normal ability to communicate; had
normal and appropriate mood and affect; and had normal gait.
AR319-20. Following examination, the assessments were
deviated nasal septum, hypertrophy of nasal turbines, and
hypersomnia, and a polysomnogram was recommended. AR320.
Springer saw Dr. Meyer at Sanford Family Medicine on December
10, 2015, for anxiety and insomnia and continued to report
being exhausted during the day and sleeping poorly at night.
AR374. He continued to be unable to work. AR374. Dr. Meyer
noted that it was very unusual for someone to miss work due
to sleep apnea, but noted Mr. Springer was an extremely
anxious individual, and Dr. Meyer felt he would have great
difficulty working and excused him from working until the end
of the year. AR374.
Springer underwent a sleep study on December 22, 2015, at the
Sleep Center of the Midwest which revealed moderate
obstructive sleep apnea, and severe treatment emergent
central apnea, which was resistant to CPAP and BIPAP therapy.
AR321. A titration study with ASV therapy was presented as an
Springer saw Dr. Meyer on January 4, 2016, to discuss his
sleep study. AR366. Dr. Meyer noted he would start an
echocardiogram, urine drug test, and an MRI of the brain for
workup of Mr. Springer's central apnea. AR367. In an
addendum dated January 15, 2016, Dr. Meyer noted Mr.
Springer's MRI showed his cerebral palsy but nothing
acute; his echocardiogram had normal ejection fraction; and
his urine drug screen was negative. AR367. Dr. Meyer noted
Mr. Springer was anticipated to return to work by February 1.
Springer had the follow-up full night, titration sleep study
on January 18, 2016, at the Sleep Center. AR327. ASV
pressures were gradually increased, and the majority of
respiratory events and snoring were controlled. AR327. The
impression was complex sleep apnea with past CPAP failure,
snoring controlled with positive pressure therapy, and
follow-up was recommended for ASV therapy. AR327.
Springer saw Dr. Meyer at Sanford Family Medicine on January
29, 2016, for anxiety and sleep issues. AR363. Dr. Meyer
noted that based on sleep studies, a brain MRI and an
echocardiogram, he had been diagnosed with central sleep
apnea and determined to be a candidate for an ASV, a
specialized CPAP for his type of sleep apnea. AR363. Mr.
Springer was waiting for insurance approval to obtain the
machine and remained exhausted, and his chronic anxiety had
been much worse due to this problem. AR363. Dr. Meyer
continued to keep him off work while waiting for the ASV
February 3, 2016, Mr. Springer contacted Dr. Meyer's
office stating his short-term disability company was not
finding any abnormal findings on his recent exams to explain
why he was still not working. AR363. Dr. Meyer stated there
would never be abnormal physical exam findings for his
condition, but they could get a psych assessment for his
Springer saw Dr. Meyer on February 24, 2016, on follow-up for
his anxiety, depression and sleep apnea. AR359. Dr. Meyer
noted Mr. Springer started CPAP and hoped it worked and
helped his sleep and anxiety. AR359. Dr. Meyer had also
doubled Mr. Springer's medication dose for his mood and
for his hypertension since his last visit. AR359.
Springer was seen on March 4, 2016, at Sanford Family
Medicine by Nicole Vlegersdyk, LPC-MH, for an initial
assessment of his mental health symptoms. AR355-56. Ms.
Vlegersdyk noted Mr. Springer was seeking short-term
disability and was hopeful that the psychiatry referral would
assist with his disability. AR356. Ms. Vlegersdyk explained
to Mr. Springer that a psychiatry referral was to help with
symptoms presented/diagnosis and that short-term disability
was secondary. AR356. Ms. Vlegersdyk noted Mr. Springer saw a
psychiatrist one time at Falls Community Health and went to
two therapy sessions in November, 2015, and he reported,
“they just wouldn't throw medication at the problem
and I know that wouldn't help.” AR356. Ms.
Vlegersdyk documented that Mr. Springer still wanted to go
through with the referral for a psychiatric evaluation.
AR356. Examination revealed Mr. Springer was agitated,
anxious, had excessive worry, and he reported panic attacks
and memory problems. AR357. He was given a psychiatric
March 15, 2016, Mr. Springer contacted his primary care
clinic regarding a psychiatric exam, scheduled with Dr.
Price, that Mr. Springer's disability company had
requested. AR355. Dr. Meyer referred Mr. Springer to Thomas
Price, Ph.D., for additional information on Mr.
Springer's short-term disability through his employer,
related to Mr. Springer's anxiety, depression, and
March 23, 2016, Dr. Price conducted a psychological
evaluation at Dr. Meyer's referral. AR335. Dr.
Price's psychological evaluation consisted of records
review, behavioral observations, sleep-related screening,
functional impairment ratings, Barkley Deficits in Executive
Functioning Scale, mental status exam, Montreal Cognitive
Assessment, vocational history review, Occupational Stress
Inventory and personality testing (administered twice).
AR335-350. Dr. Price noted that Mr. Springer reported he has
cerebral palsy on his right side, but his left side is
normal, and his cerebral palsy has not affected his cognitive
functioning. AR343. Mr. Springer denied going to the
emergency department for mental health problems and reported
never receiving inpatient or residential mental health care,
other than very limited counseling at the Sanford Clinic.
Price observed that Mr. Springer was alert throughout the
evaluation, but did appear a bit sleepy at several points.
AR336. Examination revealed very flat affect, depressed mood,
emotionally labile, easily agitated and tense at times.
AR336. Mr. Springer became more easily distracted as the
evaluation proceeded. AR336. Mr. Springer was given the
Montreal Cognitive Assessment (MOCA) which indicated he had
mild attention and memory-related difficulties. AR342. Mr.
Springer was given the Occupational Stress Inventory, which
revealed significant problems in the workplace. AR346. Mr.
Springer was twice given the Minnesota Multiphasic
Personality Inventory - Revised (MMPI-2), which showed
excessive number of atypical and rarely given responses to
the inventory. AR347. Based on the MMPI-2 results, Dr. Price
noted Mr. Springer's clinical scale profile could be
grossly over-elevated because of the severity of his
psychopathology, an extreme plea for help or deliberate
malingering. AR347. Dr. Price concluded that Mr.
Springer's overstatements and possible exaggeration were
too extreme for further interpretation and his MMPI-2 profile
were not considered. AR347.
Springer also completed the Million Clinic Multiaxial
Inventory - Third Edition (MCMI-III), designed to assess both
clinical syndromes as well as personality patterns. AR347.
Mr. Springer's MCMI-III response tendency scores
indicated that he magnified the level of experienced illness
or characterlogical inclination to be self-pitying, and his
Clinical Syndromes scale may be somewhat exaggerated, but
standard scale modifications were utilized to account for his
response style. AR347. The MCMI-III indicated Mr. Springer
was experiencing major depression. AR347.
the tests, Dr. Price diagnosed Mr. Springer with major
depressive disorder, recurrent, severe, without psychotic
features; generalized anxiety disorder; panic disorder with
agoraphobia; personality disorder with avoidant and
depressive personality traits; and complex sleep apnea.
AR349. Dr. Price concluded that Mr. Springer met the
definition of disability given by his employer because his
mental illness prevented him from performing one or more of
the essential duties of his occupation. AR349. Dr. Price
noted that Mr. Springer's mental disorder had adversely
impacted his ability to function in occupational and social
settings, and that he was experiencing lethargy, significant
fatigue, daytime sleepiness, impatience, irritability, low
tolerance for frustration, poor motivation, problems focusing
his attention, difficulties with vigilance, problems
processing information, problems remembering, lack of
self-discipline, agitation and anxiety towards others, and
challenges to remain in social settings or interact with
Price also stated Mr. Springer was inclined to perceive
others' comments or reactions in a negative way; he
predicts that he will not be treated well and has a tendency
to react abruptly and in an irrational manner; he is easily
annoyed; his mood shifts quickly; and when away from home he
becomes tense and panicky. AR350. Dr. Price concluded that
Mr. Springer's worry, panicking, low mood, moodiness, and
social apprehension prevent him from performing his current
March 28, 2016, Mr. Springer went to Eugenio B. Matos, M.D.,
a neurologist with Sanford Health, regarding his sleep apnea.
AR354. Dr. Matos noted Mr. Springer had a history of cerebral
palsy with right spastic hemiparesis, which had been stable.
AR354. Dr. Matos conducted a physical examination and noted
Mr. Springer was in no distress; was alert and oriented; and
had normal speech and normal memory. AR354. Mr.
Springer's cranial nerves were normal, and he had no
facial asymmetry or weakness. AR354. Due to cerebral palsy,
Mr. Springer had right spastic hemiparesis, overall 5-5
exempt for right foot dorsiflexion, which is 4-/5, stable as
per Mr. Springer, and he had no involuntary movements. AR354.
Mr. Springer's sensory was normal bilaterally; his
finger-nose-finger was normal; and his gait was right
hemiparetic but stable. AR354. Dr. Matos' impression was
central sleep apnea with complex sleep apnea seen after
treatment of obstructive sleep apnea, spastic cerebral palsy,
and arterial hypertension. AR354. Dr. Matos' plan was to
obtain report of CPAP and ordered laboratory testing. AR354.
MRI obtained on January 6, 2016, showed a loss of white
matter in the left frontoparietal region with ex vacuo
dilatation of the left lateral ventricle, suggestive of
chronic changes possibly due to an old ischemic insult in
that region. AR354, 393, 408. “The MRI of the brain
otherwise appear[ed] unremarkable. An acute process [was] not
identified.” AR393. Mr. Springer was complaining of
daytime sleepiness and a polysomnogram obtained on December
22, 2015, had found moderate obstructive sleep apnea. AR354.
A second polysomnogram on January 18, 2016, showed
“complex sleep apnea with failure of CPAP (in the past)
with snoring controlled by positive pressure of
therapy.” AR354. Mr. Springer was currently using a
CPAP or ASV therapy, but was still feeling tired and sleepy
during the day despite being compliant with the CPAP
Springer's significant tiredness and sleepiness was
causing him to be off work. AR354. Dr. Matos examined Mr.
Springer and noted he was in no distress; was alert,
oriented; had normal speech and normal memory; his weight was
stable at 233 pounds, with a BMI of 37.63; his cranial nerves
II through XII and visual fields were normal; and he had no
facial asymmetry or weakness. AR354. A motor exam showed
right spastic hemiparesis, overall 5/5 except for right foot
dorsiflexion, which is 4-/5, stable as per Mr. Springer due
to cerebral palsy. AR354. Mr. Springer had no involuntary
movements; had normal sensory bilaterally; and his gait was
right hemiparetic but stable. AR354. Dr. Matos'
impression was central sleep apnea with complex sleep apnea
seen after obstructive sleep apnea and during polysomnogram,
and spastic cerebral palsy, and Dr. Matos stated Mr. Springer
might need cognitive behavioral therapy for insomnia.
9, 2017, Mr. Springer was seen by Jonathan Bannwarth, M.D., a
physician at Falls Community Health, to establish care since
losing his insurance and to request that a work function form
be filled out. AR432. Examination revealed atrophy on the
right upper and lower extremities secondary to cerebral
palsy, with reduced strength on the entire right side
compared to the left side, and depressed mood. AR433.
9, 2017, Dr. Bannwarth completed a “Work Ability
Form” for the county's rental assistance program.
AR426. In the form, Dr. Bannwarth stated Mr. Springer
suffered from panic disorder, anxiety disorder, depressive
disorder, complex sleep apnea, and avoidant and dependent
personality traits. AR426. Dr. Bannwarth stated Mr. Springer
was not able to work because his mental illness adversely
impacted his ability to function in a job setting. AR426. Dr.
Bannwarth also stated Mr. Springer was unable to attend
training programs and/or search for employment. AR426.
November 6, 2017, Mr. Springer saw Dr. Kamstra of Falls
Community Health, who noted Mr. Springer was applying for
disability due to cerebral palsy that was diagnosed when he
was two years old. AR431. Dr. Kamstra noted Mr. Springer was
there asking for forms to be filled out. AR431. Dr. Kamstra
noted Mr. Springer had a history of cerebral palsy, and his
biggest deficit is most of his right arm. AR431. Dr. Kamstra
stated, “I think the physical disability in addition to
his psychological issues certainly have been compounded, and
I do not foresee any changes that are going to happen,
especially with the cerebral palsy. I think he will start
getting more weakness and maybe some spasticity.”
AR431. Examination noted that Mr. Springer's arm
“is kind of held at his side. He has boutonierre [sic]
type deformity of his hand and certainly a weakness and
immobility of that area. It is not completely flaccid. He can
move it some, but he doesn't have the strength as
compared to his left arm.” AR431. Dr. Kamstra also
noted Mr. Springer's mental issues will be an ongoing.
AR431. Dr. Kamstra wrote a “To whom it may
concern” note, stating that Mr. Springer was unable to
work until further notice, and authorized Mr. Springer for a
companion animal due to his mental health symptoms. AR436-37.
State Agency Assessments
21, 2016, Gregory Erickson, M.D., State agency physician
consultant at the initial level, stated that Mr. Springer had
severe cerebral palsy and could occasionally lift 25 pounds
and frequently lift 20 pounds, and that Mr. Springer had no
manipulative limitations. AR120-21. Dr. Erickson did state
that Mr. Springer was limited to occasional pushing or
pulling with the right upper and lower extremities due to his
history of cerebral palsy with right spastic hemiparesis.
AR120. Dr. Erickson also stated that due to cerebral palsy
and spastic right hemiparesis, Mr. Springer had postural
limitations and was limited to frequent balancing, kneeling,
crouching, and crawling; to occasional climbing of ramps,
stairs, ladders, ropes and scaffolds; and to avoid even
moderate exposure to hazards, such as machinery and heights.
AR120-21. Dr. Erickson noted that no ADL's were available
for review when he issued his opinion, and that he gave heavy
weight to the neurology exam from March 28, 2016, when he
completed his opinion of Mr. Springer's physical residual
functional capacity (PRFC). AR121. Dr. Erickson also found
that Mr. Springer's sleep apnea and high blood pressure
were considered non-severe impairments with medical
Stevens, M.D., State agency physician consultant at the
reconsideration level, issued identical PRFC findings on
September 27, 2016. AR133, 135-37. Dr. Stevens also stated
that Mr. Springer had a history of cerebral palsy
“although he is only noted to have a tremor at a couple
of exams, otherwise is [sic] remains
state agency psychological consultant concluded:
Mental - [Mr. Springer] alleges significant social anxiety
and depression. He does appear to have some limitations due
to his mental allegations, but he is still able to go out
alone, maintain romantic relationships, and grocery shop. He
appears to have some difficulty taking instructions from
supervisors. He is noted in evaluations to exaggerate
symptoms, and the possibility of deliberate malingering was
even mentioned. [W]hile he complains of increased anxiety in
his appeal form, he does not seek mental health treatment. He
is independent in his daily activities, and has no periods of
inpatient hospitalizations. He is only noted to seek
treatment when requesting letters or statements from
providers in order to remain on short-term disability,
otherwise he states he is uninterested in medications or
therapy. He was noted to be capable of performing in his work
at home[.] [I]t was when he was told to come into 5 days of
training at the office that he stopped working…. [Mr.
Springer] appears capable of low social unskilled work.
23, 2016, Robin Carter-Visscher, Ph.D., State agency
psychological consultant at the initial level, stated that
Mr. Springer had severe medically determinable impairments
due to cerebral palsy and anxiety disorder. AR117. Dr.
Carter-Visscher also seemed to indicate that she looked at
whether the evidence supported the existence of an impairment
due to an affective disorder and personality disorder, but
indicated there was insufficient evidence in the file to
evaluate the “B” and “C” criteria.
September 28, 2016, Alison Musso, Ph.D., State agency
psychological consultant at the reconsideration level, found
that Mr. Springer had mild restrictions in ADLs, moderate
difficulties in maintaining social functioning, and moderate
difficulties in maintaining concentration, persistence or
pace (the “B” criteria), and also found the
evidence did not establish the presence of the
“C” criteria. AR133. Dr. Musso stated Mr.
Springer was capable of “low social, low stress
environment” unskilled work AR132, 139.
Testimony at the ALJ Hearing
Mr. Springer's Testimony
Springer testified he lived alone in an
“income-based” apartment, and received SNAP
benefits. AR81-82. Mr. Springer testified that he drives
AR82. Mr. Springer testified that he is 5'6” tall
and weighs 235 pounds. AR82. Mr. Springer testified that he
was lefthanded as long as he could remember because he had
cerebral palsy on the right side. AR82.
Springer testified that he has some college education,
majoring in computer science, but it did not work out because
he was working a full-time job. AR82. Mr. Springer testified
that he last worked at Esurance in January or February, 2016,
but went on short-term disability. AR83-84. Mr. Springer also
testified that he tried to go back to work at Esurance a
couple of times, but it did not work so he went back on
short-term disability. AR83-84. He testified that both the
Esurance job and his prior jobs at Wells Fargo and Cigna were
incoming calls, customer service desk jobs that did not
require much lifting. AR85-86.
Springer testified that he tried to get call center jobs with
more talking due to his disability from his cerebral palsy.
AR86. He explained the first he tried was at Pizza Hut, but
he did not have the needed hand dexterity to perform that
type of work. AR86. Mr. Springer testified that he had recent
additional symptoms from his ...