Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_05-cv-05067/USCOURTS-arwd-5_05-cv-05067-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FAYETTEVILLE DIVISION

GEORGE A. NELSON PLAINTIFF

v. Civil No. 05-5067

JO ANNE B. BARNHART, Commissioner

Social Security Administration DEFENDANT

MEMORANDUM OPINION

Plaintiff George A. Nelson brings this action under 42 U.S.C. § 405(g), seeking judicial

review of a decision of the Commissioner of Social Security Administration (Commissioner)

denying his claims for a period of disability and disability insurance benefits (DIB) pursuant to

§§ 216(i) and 223 of Title II of the Social Security Act (hereinafter "the Act"), 42 U.S.C. §§

416(i) and 423. In this judicial review, the court must determine whether there is substantial

evidence in the administrative record to support the Commissioner's decision. See 42 U.S.C. §

405(g).

Procedural and Factual Background

The plaintiff filed his application for DIB on June 17, 2003, alleging an onset date of

June 1, 2002. (Tr. 42-53.) Plaintiff is eligible for DIB through December 31, 2006. (Tr. 67.)

The application was initially denied (Tr. 22-23; 26-29) and that denial was upheld upon

reconsideration (Tr. 24-25; 32-33). Plaintiff then made a request for a hearing by an

Administrative Law Judge (ALJ). (Tr. 34-35.) 

On June 3, 2004, a hearing was held by the ALJ. The plaintiff was represented by

counsel at this hearing. (Tr. 231.) The ALJ issued an unfavorable ruling on November 12, 2004,

deciding that the plaintiff was not disabled within the meaning of the Act. (Tr. 9-20.) The

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plaintiff then requested a review of the hearing by the Appeals Council (Tr. 7-8), which denied

that request on March 7, 2005 (Tr. 3-5); thus, the ALJ's decision became the final action of the

Commissioner. The plaintiff filed his complaint with this court on April 18, 2005, seeking

judicial review of that decision. (Doc. 1.) Both parties have filed appeal briefs with the court.

(Docs. 7, 8.) This case is before the undersigned pursuant to the consent of the parties. (Doc.

4.) 

At the time of the hearing, plaintiff was 35 years of age. He had received his GED after

he completed only tenth grade in high school, where he did take some special education classes

for math skills. (Tr. 42, 61, 73, 84, 234-35.) His past relevant work included work in

repossessions forrent-to-own stores and with computer repair. (Tr. 56, 234.) He also spent three

years in military service, from which he was honorably discharged. (Tr. 235.) Plaintiff is

presently on military disability due to a 60% disability resulting from injuries and pain to his

back and knee, and his frequent migraine headaches. (Tr. 235-236.) 

In his application for DIB, plaintiff alleged that his was disabled due to back and left knee

injuries, limited back mobility, anxiety, paranoia, and depression. (Tr. 55.) He also mentioned

in his Disability Report Adult (DRA) that he was treated my doctors for migraine headaches,

high blood pressure, and allergies. (Tr. 57.) Plaintiff reported in this DAR that he was taking

medications for depression, anxiety, migraines, and pain. (Tr. 60.) The medical records support

that plaintiff received treatment for his back injury (Tr. 55, 57, 71-73, 98, 102, 106, 124, 129,

130, 136, 144, 145, 148, 149, 150-151), anxiety (Tr. 55, 57, 74, 84, 95, 96, 99, 190), paranoia

(55, 74, 84, 99, 105), depression (Tr. 55, 57, 74, 84, 100, 105, 109, 126, 127, 135, 138, 142, 154,

172, 173, 190), and migraines (Tr. 57, 71, 83, 84, 98, 102, 106, 121, 124, 127, 129, 132, 134,

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137, 140, 141, 143, 184, 209, 214, 215). Additionally, plaintiff was treated for allergies (Tr.

57,84, 100, 172), chronic obstructive pulmonary disease (COPD) (Tr. 210, 212-213, 217, 220),

and Alpha-1 Antitrypsin Deficiency (Tr. 84, 209, 210, 212-213, 220). Plaintiff reported some

difficulties with alcohol and marijuana use (Tr. 95, 96,, 98, 103, 105, 126, 127, 138, 142, 153,

173, 190, 218). 

Plaintiff testified that he suffered from migraine headaches on at least a weekly basis and

that the headaches usually last an hour to two, but that he has had some that lasted twelve to

fourteen hours. (Tr. 236-237.) He has been seeing Dr. Michael Morris, a neurologist, for several

months prior to the hearing, and Dr. Morris has provided plaintiff with numerous medications

for the migraines, however none of the medications have helped plaintiff's condition. (Tr. 237.)

Plaintiff also testified that he suffers from a dull, throbbing lower back pain that radiates

down his left leg. According to plaintiff, a doctor at the Veteran's Administration hospital told

him not to lift more than ten pounds and not to stand for long periods of time. His prior

employment as a computer repairman required him to stoop and crawl under desks to run cables,

and the pain in his back prohibits him from performing these tasks. Plaintiff stated that at no

time is his back pain-free, however he does get some relief through medication. He has been

taking oxycodone and acetaminophen for approximately three years. (Tr. 238-241.) The back

pain combined with fluid collecting on his chest has resulted in difficulties sleeping. Plaintiff

stated that he is tired and aches when he wakes in the mornings. (Tr. 241.) 

Concerning his lung condition, plaintiff testified that he was diagnosed with Alpha-1-

Antitrypsin Deficiency, which he understands affects his liver and respiratory system. He states

that this condition causes him shortness of breath, even when he is not performing strenuous

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physical activity. Also, plaintiff suffers from flu-like symptoms regarding his respiratory system,

for which he daily takes Allegra, Dayquil, and Tylenol Sinus. (242-244.) Dr. Templeton, a

pulmonologist, is treating plaintiff for this condition. 

After the hearing, the ALJ issued a decision on November 12, 2004, finding that (1)

plaintiff met the nondisability requirements for a period of disability and DIB, (2) plaintiff had

not engaged in substantial gainful activity since the alleged onset date, (3) plaintiff suffered from

chronic back pain, mood disorders, and a history of substance abuse disorder which were

considered "severe" under the regulations, (4) none of plaintiff's medically determinable

impairments met any of the listed impairments in Appendix 1, Subpart P, Regulation No. 4, (5)

plaintiff's claims concerning his limitations were not totally credible, (6) plaintiff retained the

residual functional capacity (RFC) to lift and/or carry 25 pounds frequently and 50 pounds

occasionally; to sit for a total of 6 hours and stand and/or walk for a total of 6 hours each in an

8-hour workday; and to perform work where interpersonal contact is only incidental to the work

performed, complexity of the task is learned and performed by rote with few variables, little

judgment is required, and supervision is simple, direct, and concrete, (7) plaintiff was unable to

perform any past relevant work, (8) plaintiff had the RFC to perform "a significant range of

medium work," (9) although plaintiff could not perform the full range of medium work, using

the Medical-Vocational Guidelines "as a framework for decision-making" there were significant

jobs in the national economy he could perform such as janitor/cleaner, food prep worker, and

hand packer, and (10) plaintiff was not under a disability as defined by the Act at any time

through the date of the decision. (Tr. 19-20.) Notably, the ALJ determined that plaintiff's

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A "good" ability is defined as follows: "Ability to function in this area is limited but 1

satisfactory."

A "fair" ability is defined as follows: "Ability to function in this area is seriously 2

limited, but not precluded."

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migraine headaches were not a severe impairment as the plaintiff had failed to show that the

migraines limited his ability to perform work-related activities. (Tr. 16-17.) 

The ALJ noted in the opinion that plaintiff was diagnosed as an alpha antitrypsin carrier

and that Dr. Templeton had assessed plaintiff "with cough (related to either chronic bronchitis

or bronchiectasis), heterozygous for alpha antitrypsin deficiency (with a level that had not been

reduced to the dangerous zone and no significant obstructive lung disease on his pulmonary

function test), and epigastric pain and diarrhea (related to possible cystic fibrosis)." (Tr. 15.)

The ALJ made no specific finding as to whether the alpha antitrypsin deficiency and related

symptoms constituted a "severe" impairment under the regulations. 

The plaintiff submitted to the Appeals Council an undated letter purporting to be from

his treating physician, Dr. Templeton, which was filed as Appeals Council Exhibit 1. According

to this letter, plaintiff should "avoid exposure to dust, mold, smoke, or any industrial chemicals

or household cleaners such as bleach or ammonia" and "should not pursue any employment that

might expose him to such environments." (Tr. 220.) The plaintiff also submitted to the Appeals

Council a Medical Assessment of Ability to Do Work-Related Activities (Mental) completed by

Lawrence R. Thompson, a licensed social worker, and progress notes from Thompson who is

employed by Wellspring Healthcare Associates. According to the assessment, plaintiff has a

"good" ability to follow work rules and maintain personal appearance; a "fair" ability to relate 1 2

to co-workers, deal with the public, use judgment, interact with supervisors, function

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A "poor/none" ability is defined as follows: "No useful ability to function in this

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area." 

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independently, maintain attention/concentration, understand and carry out detailed or simple but

not complex job instructions, and demonstrate reliability; and "poor" or no ability to deal with 3

work stresses, understand and carry out complex job instructions, behave in an emotionally

stable manner, and relate predictably in social situations. Thompson's determinations were based

on plaintiff's chronic depression, anxiety, learning disabilities, short-term memory deficit, and

difficulty controlling anger in social settings. (Tr. 221-228.) 

On appeal, the plaintiff argues that the ALJ erred in determining that the plaintiff was not

disabled under the meaning of the Act where the ALJ (1) erred in failing to consider all of the

impairments in combination, (2) erred in the analysis and credibility findings in regard to

subjective complaints of pain and depression, (3) erred in applying the Grid to direct a finding

of not disabled when the plaintiff suffered from non-exertional limitations of chronic pain and

depression, (4) erred in finding an RFC permitting performance of a significant range of medium

work, and (5) erred in failing to fully and fairly develop the record. (Doc. 7.) 

In response, the defendant argues that (1) the ALJ properly considered the combined

effects of plaintiff's impairments, (2) the record was fully and fairly developed, (3) the ALJ

properly analyzed plaintiff's subjective complaints and discounted them for legally sufficient

reasons, (4) substantial evidence supports the ALJ's RFC determination, and (5) proper VE

testimony provides substantial evidence to support the ALJ's determination that there are jobs

existing in significant numbers in the economy which plaintiff could perform. (Doc. 8.) 

Applicable Law

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This court's role is to determine whether the Commissioner's findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir.

2002). Substantial evidence is less than a preponderance but it is enough that a reasonable mind

would find it adequate to support the Commissioner's decision. The ALJ's decision must be

affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d

964, 966 (8th Cir. 2003). As long as there is substantial evidence in the record that supports the

Commissioner's decision, the court maynot reverse it simply because substantial evidence exists

in the record that would have supported a contrary outcome, or because the court would have

decided the case differently. Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other

words, if after reviewing the record it is possible to draw two inconsistent positions from the

evidence and one of those positions represents the findings of the ALJ, the decision of the ALJ

must be affirmed. Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).

It is well-established that a claimant for Social Security disability benefits has the burden

of proving her disability by establishing a physical or mental disability that has lasted at least one

year and that prevents her from engaging in any substantial gainful activity. Pearsall v.

Massanari, 274 F.3d 1211, 1217 (8th Cir.2001); see also 42 U.S.C. § § 423(d)(1)(A),

1382c(a)(3)(A). The Act defines “physical or mental impairment” as “an impairment that results

from anatomical, physiological, or psychological abnormalities which are demonstrable by

medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § § 423(d)(3),

1382(3)(c). A plaintiff must show that her disability, not simply her impairment, has lasted for

at least twelve consecutive months.

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The Commissioner's regulations require her to apply a five-step sequential evaluation

process to each claim for disability benefits: (1) whether the claimant has engaged in substantial

gainful activity since filing his claim; (2) whether the claimant has a severe physical and/or

mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal

an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past

relevant work; and, (5) whether the claimant is able to perform other work in the national

economy given his age, education, and experience. See 20 C.F.R. §§ 404.1520, 416.920. Only

if the final stage is reached does the fact finder consider the plaintiff's age, education, and work

experience in light of his residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138,

1141-42 (8th Cir. 1982); 20 C.F.R. §§ 404.1520, 416.920.

Discussion

It is clear from the ALJ's decision that the ALJ did consider plaintiff's complaints both

individually and in combination. The ALJ noted that plaintiff's chronic back pain, mood

disorders, and history of substance abuse disorder were not severe enough "to meet or medically

equal, either singularly or in combination to one of the impairments listed in Appendix 1,

Subpart P, Regulations No. 4." (Tr. 14.) "When determining whether a claimant can engage in

substantial employment, an ALJ must consider the combination of the claimant's mental and

physical impairments and determine the claimant's RFC." See Baldwin v. Barnhart, 349 F.3d

549, 556 (8th Cir. 2003). The ALJ in this case established plaintiff's RFC after "a careful review

of the objective medical evidence of the record as a whole." (Tr. 17.) 

"The ALJ must make express credibility determinations and set for the inconsistencies

in the record which cause him to reject the plaintiff's complaints." See Masterson v. Barnhart,

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363 F.3d 731, 738 (8th Cir. 2004). The ALJ clearly considered plaintiff's subjective complaints

of pain and discredited those complaints by relying upon the medical evidence in the record.

Specifically, the ALJ noted that plaintiff complained about the sharp pain in his lower back,

migraines, difficulty sleeping, depression, and memory loss. The ALJ stated, "it is reasonable

to assume that Mr. Nelson does experience some limitations due to chronic back pain, mood

disorders and history ofsubstance abuse disorder; however, the degree to which his impairments

are functionally limiting is an issue which is very much open to question." (Tr. 16.) The ALJ

then proceeded to point out the medical evidences which contradict plaintiff's subjective

complaints, such as (1) the medical reports from Dr. Bokhari which noted that back pain was

caused by lifting heavy weights and from Dr. Becaycay which stated that the back pain was

caused by a motor vehicle accident, however the accident was in the remote past, the injury did

not require surgical intervention, and the back pain was mild and stable, (2) the medical reports

from Dr. Bokhari, Dr. Hull, and Dr. Luelf which indicated that plaintiff's depression was wellcontrolled with medications including Lexapro, Clorazepate, and Citalopram, and (3) the medical

reports from Dr. Hull, Dr. Bokhari, Dr. Bucaycay, and Dr. Morse which point out that the

plaintiff's headaches were caused by computer work or other temporary conditions such as the

death of his brother, the dependence of others on plaintiff, weather changes, and allergies;

improved significantly after he quit working with computers; and were well-controlled by

Fiorinal or other medications such as Topamax. Therefore, the ALJ did set forth specific reasons

for questioning plaintiff's credibility and determining that plaintiff's subjective complaints were

not supported by the record. See Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984)

(subjective complaints may be discredited if there are inconsistencies in evidence as whole);see

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 "Medium work. Medium work involves lifting no more than 50 pounds at a time

4

with frequent lifting or carrying of objects weighing up to 25 pounds." 20 C.F.R.

§ 404.1567(c). 

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also, Benskin v. Bowen, 830 F.2d 878, 882 (8th Cir. 1987) (credibility of claimant's subjective

testimony is primarily for ALJ to decide, not courts). 

The ALJ relied upon the opinions of a VE in determining that other jobs exist in the

national economy that the plaintiff can perform. The VE, through interrogatory responses,

opined that while plaintiff could not perform his past relevant work, he could perform work as

a janitor/cleaner, a food prep worker, and a hand packer. (Tr. 87.) This opinion was issued in

response to a hypothetical question which recognized both plaintiff's physical and emotional

limitations. (Tr. 89.) The VE opined that there were no jobs in the national economy when the

hypothetical indicated that the person had "no useful ability to follow work rules, deal with the

public, use judgment, deal with work stresses, function independently, maintain attention and

concentration, understand, remember, and carry out simple instructions, and demonstrate

reliability." (Tr. 89.) The evidence submitted to the Appeals Council shows that plaintiff's

mental and emotional limitations are not comparable to that provided in the second hypothetical

question. The plaintiff is incorrect in his claim that the ALJ considered only the Grid in

determining whether plaintiff could perform other jobs in the economy. (Tr. 18.) 

The ALJ did not err in finding that plaintiff had the ability to perform a significant range

of medium work. As discussed above, the ALJ found that the objective medical evidence did 4

not support plaintiff's subjective complaints of pain. The ALJ noted that the plaintiff's conditions

were controlled by medication and that his back injury was mild and stable. In determining a

claimant's residual functional capacity, the ALJ has a duty to establish, by competent medical

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evidence, the physical and mental activity that a claimant can perform in a work setting, after

giving appropriate consideration to all of his impairments. See Ostronski v. Chater, 94 F.3d 413,

418 (8th Cir. 1996). The RFC which indicated that plaintiff could perform medium work is

consistent with the medical evidence that the ALJ found credible. Thus, substantial evidence

supports the ALJ's findings as the plaintiff's RFC. See McGeorge v. Barnhart, 321 F.3d 766, 768

(8th Cir. 2003). 

The plaintiff also contends that the ALJ failed to fully and fairly develop the record,

especially as to the plaintiff's migraines and "newly discovered Alpha-1 Antitrypsin Deficiency."

The record contains numerous references to the plaintiff's migraine condition, and the ALJ

thoroughly evaluated these references. recognizing that the treating physicians' opinions that the

headaches were caused by the plaintiff's work with computers and based on plaintiff's own report

that his migraines were well-controlled by Fiorinal, which he used periodically. (Tr. 16.)

Concerning the Alpha-1 Antitrypsin Deficiency, the treating physician, Dr. Templeton, noted that

plaintiff's level had not been reduced to the "danger zone," and that plaintiff did not have

significant obstructive lung disease, only a restrictive defect. Further, the additional letter

submitted to the Appeals Council that purports to be from Dr. Templeton, although it contains

a different signature and is not on letterhead as was the previous letter, merely restates that

reported complaints from the plaintiff and then states that plaintiff should avoid employment

situations which expose him to dust, mold, smoke, industrial chemicals and household cleaners.

(Tr. 2170-220.) It is well settled that the ALJ has a duty to develop the record fully and fairly.

See Snead v. Barnhart, 360 F.3d 834, 836-37 (8th Cir. 2004). "This duty includes the

responsibility of ensuring that the record includes evidence from a treating physician, or at least

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an examining physician, addressing the particular impairments at issue." See Strongson v.

Barnhart, 361 F.3d 1066, 1071-72 (8th Cir. 2004). Here, the record does contain a thorough

statement from Dr. Templeton, plaintiff's treating physician for purposes of the Alpha-1

Antitrypsin Deficiency, and the ALJ did review, discuss, and evaluate Dr. Templeton's opinions,

and the ALJ did not find the Alpha-1 Antitrypsin Deficiency a severe impairment, nor does the

record support an opposite finding. (Tr. 15.) 

Finally, although not addressed by the ALJ, it appears that during the relevant time

period, plaintiff may have been attending some form of school. According to a notation made

on August 7, 2003, plaintiff contacted Dr. Hull's office requesting "a note for his school stating

that his family has been seen in the Dr.'s office repeatedly this year. He's had to miss school due

to illness with himself, his son, and his wife when she was having bad HA's. If pt. doesn't get

a note, they will flunk him." (Tr. 172.) Plaintiff did receive a note from Dr. Hull on August 7,

2003 stating that he had been seen in the office on numerous occasions over the past year (Tr.

184). Plaintiff had previously received a note from Dr. Hull on March 7, 2003, excusing him

"from school 3-5-03 thru 3-7-03 due to illness." (Tr. 186.) Attendance at school would discredit

plaintiff's claims that he is disabled. See Baker v. Apfel, 159 F.3d 1140, 1145 (8th Cir. 1998)

(where ALJ relied in part on claimant's ability to attend four hours of classes daily in finding him

capable of performing full range of light work, substantial evidence supported ALJ's conclusion).

Conclusion:

Accordingly, having carefully reviewed the record, the undersigned finds substantial

evidence supporting the ALJ's decision denying the plaintiff benefits, and thus the decision

should be affirmed and plaintiff’s complaint should be dismissed with prejudice.

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DATED this 8th day of May 2006.

/s/ Beverly Stites Jones

_________________________________________

HON. BEVERLY STITES JONES 

UNITED STATES MAGISTRATE JUDGE

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