Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-06-03863/USCOURTS-ca8-06-03863-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 

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1

The HONORABLE CHARLES R. WOLLE, United States District Judge for

the Southern District of Iowa.

2

The same analysis determines disability under Title II and Title XVI. Russell

v. Sullivan, 950 F.2d 542, 543 n.2 (8th Cir. 1991). Title XVIII provides health care

benefits for persons under 65 entitled to Title II benefits for at least 24 months.

 United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 06-3863

___________

Robert C. House, *

*

Plaintiff - Appellant, *

* Appeal from the United States

v. * District Court for the

* Southern District of Iowa.

Michael J. Astrue, *

*

Defendant - Appellee. *

___________

Submitted: April 13, 2007

Filed: September 14, 2007

___________

Before LOKEN, Chief Judge, BYE and RILEY, Circuit Judges.

___________

LOKEN, Chief Judge.

Robert House appeals the district court's1

 order affirming the decision of the

Commissioner of Social Security to deny House's application for disability insurance

and supplemental security income benefits under Title II, Title XVI, and Title XVIII

of the Social Security Act. See 42 U.S.C. §§ 401 et seq., 1381 et seq., 1395c et seq.

2

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3

Lymphedema is an abnormal accumulation of lymph fluid in body tissue,

caused by disruption of the lymphatic system that normally drains the fluid away. Its

effects can range from minimal to incapacitating. The American Medical Association

Encyclopedia of Medicine 655 (Dr. Charles B. Clayman ed., 1989).

-2-

The parties agree that the critical issue on appeal is whether substantial evidence

supports the Administrative Law Judge’s (ALJ's) decision to give “little weight” to

a treating physician's opinions that House cannot tolerate even one hour of prolonged

sitting and must have the ability to elevate his legs at least parallel to the ground to

avoid worsening the chronic lymphedema condition in his lower left leg. After careful

review of the administrative record focused on this issue, we affirm.

House claims that he is disabled from a combination of impairments including

chronic lymphedema3

 in his lower left leg, recurrent deep vein thrombosis (clotting)

in his legs which has caused pulmonary embolisms, obesity, depression, and

borderline intellectual functioning. These conditions severely limit his ability to stand

and walk. After a hearing, the ALJ denied the claim. The Commissioner's Appeals

Council remanded, primarily for further consideration of the opinions of House's

treating physician, Dr. Bret McFarlin, as those opinions might be clarified and

supplemented on remand. The ALJ held two additional hearings and again denied the

claim, finding that House has severe impairments that leave him unable to perform his

past relevant work but is not disabled because he retains the residual functional

capacity to perform certain unskilled sedentary jobs such as parking lot cashier,

cafeteria cashier, hand packager, and office helper. 

The medical evidence in the record reflects that House was hospitalized for

three days in March 2001 when he experienced swelling and pain in his lower left leg

after working eleven hours the prior day at a construction job. He was bed-rested with

the leg elevated and treated with anti-coagulant medications until testing revealed no

deep vein thrombosis. Dr. McFarlin stated on a hospital discharge report that House

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was fitted for compression hose and told to exercise and change his diet; no work

restrictions were noted. 

On May 28, 2001, House was hospitalized with shortness of breath from a

pulmonary embolism. Dr. McFarlin stated in his discharge report that House was

released five days later with a prescription for Coumadin, an anti-coagulant, and a

work restriction of “[n]o prolonged standing greater than 1-2 hours.” On July 25, he

was again hospitalized, this time for six days, for a pulmonary embolism after he

stopped taking Coumadin. Dr. McFarlin’s discharge report noted that Coumadin was

again prescribed and that House was instructed “about his need to keep active.” No

work restrictions were noted. In September 2001 Dr. McFarlin saw House for a

regular monthly follow-up and noted that his lymphedema was chronic but stable. 

In a December 2001 Residual Functional Capacity Assessment, Dr. Lawrence

Staples noted that House's “left lower extremity lymphedema was stabilizing.” Dr.

Staples opined that House could lift twenty pounds occasionally and ten pounds

frequently, could stand or walk six hours and sit six hours in a work day, and was

therefore “capable of work activities.”

In a June 2002 disability letter, Dr. McFarlin described House's treatment since

March 2001 and opined that House had “severely limited range of motion and ability

to ambulate, stand for extended periods or time, or bear any significant weight on his

left lower extremity.” Dr. McFarlin noted that lymphedema “is a permanent,

irreversible state with no satisfying therapy” and therefore House “will be doomed to

a life of anticoagulation therapy and a limited physical activity.” In July, Dr.

McFarlin's notes from a periodic check-up stated:

Lymphedema, this appears to be a permanent, irreversible, disabling

condition for this individual, greatly limiting his ability to ambulate or

pursue meaningful levels of activity. Even two hours of mostly

sedentary but standing work will greatly increase his symptoms and

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diminish his ability to ambulate without assistance. I have encouraged

him to again pursue a disability application.

In November 2002, another physician in Dr. McFarlin's clinic noted that House

was “doing very well.” He had lost weight, there was less swelling in his left leg, and

he was walking and exercising more. In December, House sprained his ankle while

raking leaves. In January 2003, his physical therapist noted he was walking without

difficulty, except for the sprained ankle, and was on a home exercise program for

strength and cardiovascular fitness. In March 2003, House reported no changes in left

leg swelling and said he tries to keep his legs elevated as much as possible. In August

2003, he told a physician’s assistant that his left calf hurt if he danced or walked a lot.

On September 29, 2003, Dr. McFarlin wrote the Iowa Division of Vocational

Rehabilitation that House suffers from a “chronic and permanent disabling condition,”

explaining that recurrent deep vein thrombosis required “a lifelong course of

anticoagulation” and severe lower left leg lymphedema caused swelling and pain that

“will greatly limit Mr. House's ability to perform any meaningful act of employment

that might involve walking, standing, ambulating, or lifting to any significant degree.”

However, Dr. McFarlin added, it is “not unrealistic to think” that House could perform

“a sedentary occupation” without worsening his health problem.

House was hospitalized for pneumonia in January 2004. Dr. McFarlin's

discharge report stated that House could return to work. At a May 2004 six-month

check-up, House reported no pain in his legs, which he felt were staying the same size.

Dr. McFarlin described the lymphedema as stable.

In June 2004, Dr. McFarlin responded to a request from House’s attorney “to

clarify prior descriptions” of House’s condition. Dr. McFarlin wrote that his prior use

of the word “sedentary” did not mean the Social Security definition, but rather that

House “could not be expected to spend significant periods of time ambulating,

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standing upright, or sitting without aggravating the lymphedema” (emphasis added).

Dr. McFarlin then opined that House could not tolerate an eight-hour workday with

“any periods of lifting, standing, sitting, or walking for periods of time measured even

in multiple minutes, let alone hours.” A job involving prolonged periods of sitting

“would necessitate a special prosthetic chair with the ability to elevate legs.” 

At the November 2004 supplemental hearing, the vocational expert testified that

he had never seen a “special prosthetic chair” in the workplace. He opined that the

need to elevate one's legs to waist-level or higher “would preclude employment,” but

the need to raise House's legs onto a box underneath his feet “could be

accommodated.” After the hearing, House submitted a second letter from Dr.

McFarlin explaining that his reference to a special prosthetic chair was not intended

to prescribe a specific chair. “Ideally,” Dr. McFarlin opined, House’s left leg “would

be elevated as much as possible . . . at least parallel with the ground” in a chair whose

capacity equaled or exceeded House's substantial weight. In concluding, the letter

stated Dr. McFarlin's intent “to clarify and reiterate my strong belief that Mr. House

is a legitimate candidate for long term and permanent disability.”

The ALJ’s lengthy opinion described House’s extensive medical history and his

subjective complaints in detail. In determining residual functional capacity, the ALJ

gave significant weight to Dr. McFarlin’s opinion that House has “severe limitations

in his ability to stand or walk.” However, the ALJ gave little weight to Dr. McFarlin's

opinions that prolonged sitting, “measured in terms of minutes, not hours,” and the

inability to elevate his legs at least to waist level while working would exacerbate

House's leg problems. These opinions, the ALJ explained, were not supported by the

medical evidence and House’s own testimony, which indicate that House's lower leg

condition will not be exacerbated if he is employed at a sedentary job where “he is

allowed to get up and move around every 1⁄2 to one hour during the day.” The ALJ

then found that House’s severe leg impairments preclude him from performing his

past relevant work and many work-related tasks, but he retains the residual functional

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capacity to lift and carry up to twenty pounds occasionally and ten pounds frequently,

to sit for thirty to sixty minutes at a time for about six hours in an eight-hour work

day, and to stand or walk a total of about two hours in an eight-hour work day. The

ALJ credited the vocational expert's testimony that a person with these abilities can

perform certain sedentary jobs which exist in significant numbers in the national

economy, including parking lot cashier, cafeteria cashier, hand packager, and office

helper. Accordingly, House was not disabled.

A treating physician’s opinion is given controlling weight “if it is wellsupported by medically acceptable clinical and laboratory diagnostic techniques and

is not inconsistent with the other substantial evidence.” Reed v. Barnhart, 399 F.3d

917, 920 (8th Cir. 2005) (quotation omitted). However, while entitled to special

weight, it does not automatically control, particularly if “the treating physician

evidence is itself inconsistent.” Bentley v. Shalala, 52 F.3d 784, 786 (8th Cir. 1995);

see Wagner v. Astrue, No. 06-3580, slip op. at 10-11 (8th Cir. Aug. 24, 2007);

Guilliams v. Barnhart, 393 F.3d 798, 803 (8th Cir. 2005). Here, the inconsistencies

are profound. In treatment notes and hospital discharge reports, Dr. McFarlin noted

a work limitation on “prolonged standing greater than 1-2 hours” only once, after a

May 2001 pulmonary embolism, and he opined in September 2003 that House could

perform sedentary work. Dr. McFarlin consistently described the lymphedema

condition as stable and as being aggravated by standing or walking, not by sitting. His

July 2002 treatment notes, for example, reported that “[e]ven two hours of mostly

sedentary but standing work will greatly increase his symptoms and diminish his

ability to ambulate without assistance.” By contrast, when writing House's attorney

in June 2004 after the Appeals Council remand, and in November 2004 following the

supplemental hearing, Dr. McFarlin for the first time opined that prolonged sitting will

exacerbate the lower left leg lymphedema and only elevating House's leg above waist

level in a special chair will avoid exacerbating that condition. As Dr. McFarlin had

been urging House to seek disability benefits since before June 2002, the ALJ had

good reason to discount the new inconsistent opinions that House lacked the capacity

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to engage in sedentary occupations that require prolonged sitting. These opinions

were rather obviously based upon Dr. McFarlin's understanding of the relevant

disability criteria, not on medical evidence. A treating physician's opinion that a

claimant is disabled or cannot be gainfully employed gets no deference because it

invades the province of the Commissioner to make the ultimate disability

determination. See Krogmeier v. Barnhart, 294 F.3d 1019, 1023 (8th Cir. 2002).

In addition, other substantial evidence in the record supports the ALJ’s decision

to discount these opinions. A disability report House completed soon after he applied

for disability benefits in July 2001 stated that he had problems standing and walking

but made no mention of sitting. That same month, he was hospitalized for a second

pulmonary embolism after failing to take his prescribed medication; a doctor told him

he needed to keep active. In a November 2001 Social Security questionnaire, House

stated that he could stand or sit for two hours and walk half a mile. House testified

that, from 2001 through 2003, he worked four hours per day, twenty hours per week,

cooking lunch for four or five people at the rescue mission where he lived. As we

noted in Goff v. Barnhart, 421 F.3d 785, 790 (8th Cir. 2005), this is “substantial,

indeed compelling, evidence inconsistent with [Dr. McFarlin's] assessment.” House

also received assistance from the Iowa Division of Vocational Rehabilitation Services

beginning in August 2003; the agency's records report that he was actively looking for

work between February and June 2004. In September 2004, he told a psychologist

that he wanted to get back into the job market and could stand for a couple of hours

per day. At the hearing, House testified that he currently spends most of his days

sitting, standing, or walking. He testified that he can sit for up to thirty minutes at a

time and then has to stand up and walk around. His current job at the rescue mission

involves cleaning rooms, and he climbs stairs, with some difficulty, to his room on the

second floor.

After careful review, we conclude that substantial evidence supports the ALJ's

findings giving little weight to Dr. McFarlin's opinions regarding House’s inability to

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tolerate prolonged sitting and the need to elevate his legs to waist level during a work

day. The medical evidence reflects that elevating his lower left leg alleviates swelling

and that prolonged periods of elevation in the hospital were needed when House

suffered severe swelling after working eleven-hour days at construction or failing to

take his prescribed medication and to remain active. But the issue is whether his

chronic lymphedema could tolerate a sedentary job at which his legs would be

elevated with a box under his feet, he would be able to get up and walk around after

one-half hour to one hour of sitting, and he could elevate his legs to waist level during

breaks, lunch periods, in the evenings, and on weekends. The evidence on this issue

is mixed, and our task is to determine whether the Commissioner’s decision is

supported by substantial evidence on the administrative record as a whole, not to

substitute our fact-finding for the Commissioner's. When substantial evidence

supports the Commissioner’s findings and conclusion, we may not reverse because

substantial evidence would also support the opposite conclusion. See Moad v.

Massanari, 260 F.3d 887, 890 (8th Cir. 2001).

Accordingly, the judgment of the district court is affirmed. 

BYE, Circuit Judge, dissenting.

I respectfully dissent as I do not believe there is substantial evidence in the

record to support the administrative law judge's (ALJ's) rejection of the treating

physician's opinion regarding Robert House's need to elevate his legs as much as

possible during the day.

The ALJ gave two reasons for rejecting the treating physician's opinion

regarding House's need to elevate his legs. Specifically, the ALJ said:

There is nothing in the record to support Dr. McFarlin's assertion that the

claimant's left lower extremity lymphedema will be exacerbated if he

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cannot elevate both of his legs throughout the day. More importantly,

the medical evidence indicates that the claimant developed recurrent

deep vein thrombosis and pulmonary embolism in June 2001 because he

stopped taking Coumadin, not because he did not spend most of the day

with his legs elevated (Exhibit 6F). Since the June 2001 hospitalization,

the claimant has been taking Coumadin faithfully and he had not

developed further deep vein thrombosis or pulmonary embolism.

Finally, the claimant did not testify that he needed to elevate his legs

during the day. It is clear that the statements of opinion were

manufactured for the purpose of this adjudication, and are not well

supported by the clinical findings and/or laboratory studies (20 CFR

404.1527(d), 416.972(d)).

Administrative Record at 22.

Thus, the two reasons the ALJ gave for rejecting the treating physician's

opinion on House's need to elevate his legs were: (1) House was hospitalized because

he failed to take his Coumadin, not because he was not elevating his legs; and (2)

House did not testify he needed to elevate his legs. 

The ALJ's first reason simply does not support the conclusion House does not

need to elevate his legs. The only conclusion that follows from the fact House was

hospitalized for failure to take his Coumadin is House will require hospitalization if

he fails to take his Coumadin. The issue whether he should also elevate his legs is an

entirely separate matter.

The second reason given by the ALJ is not supported by substantial evidence

in the record. In fact, the record indicates just the opposite – House specifically

testified he needs to – and does – elevate his legs: 

Q. About how long can you sit?

A. Usually 20 minutes. If I try, I can sit 30 at the most.

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Q. And then after 20 minutes, what happens?

A. I have to get up and stand and walk around.

Q. If you're sitting down, do you need to have your legs elevated?

A. Yes.

Q. All the time or - -

A. Supposed to be, but I try to elevate them as much as possible.

Administrative Record at 524 (emphasis added).

House also testified he elevates his leg while driving:

Q. Do you have that pain all the time or does it come and go?

A. It's pretty much all the time. I got to keep moving my leg and

even when I drive I have to keep picking my leg up and moving

it.

Id. at 546.

When the ALJ asked House about his daily activities, such as cooking and

cleaning at the mission, the ALJ did not ask House whether he took breaks to elevate

his legs.

In sum, I do not believe there is substantial evidence in the record to support the

ALJ's rejection of the treating physician's opinion about House's need to elevate his

leg during a typical work day. The record indicates House may have to amputate his

leg if his lymphedema does not improve. The record also indicates a failure to elevate

his leg aggravates the lymphedema. Because the adverse consequences of House's

lymphedema could be severe, I believe this is an issue which should be looked at more

closely in a further hearing after additional information is developed on whether and

how often House needs to elevate his legs during a typical work day.

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For the reasons stated, I would reverse and remand for additional consultative

exams to be performed to address House's need to elevate his legs during the work

day.

______________________________

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