Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-4_04-cv-04077/USCOURTS-arwd-4_04-cv-04077-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 42:405g Review of HHS Decision (RSI)

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Plaintiff originally alleged December 31, 1998, as his date of onset. (Tr. 35). 1

However, at the hearing, he amended this date to July 30, 2001, the date of his heart attack. (Tr.

35).

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

TEXARKANA DIVISION

ANDREW L. WIMLEY PLAINTIFF

VS. CIVIL NO. 04-4077

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Andrew Wimley (hereinafter “plaintiff”), brings this action pursuant to § 205(g) of the Social

Security Act (“the Act”), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the

Commissioner of the Social Security Administration denying his applications for a period of disability

and disability insurance benefits (“DIB”), under Title II, and supplemental security income benefits

(“SSI”), under Title XVI of the Act.

Background:

The applications for DIB and SSI now before this court were filed on September 31, 2001,

alleging an amended onset date of July 30, 2001, due to chronic pancreatitis, the residuals of heart 1

bypass surgery, and Bells Palsy. (Tr. 83-85, 130, 407-408). An administrative hearing was held on

February 21, 2003. (Tr. 33-58). Plaintiff was present and represented by counsel. 

At the time of the administrative hearing on February 21, 2003, plaintiff was thirty-eight years

old and possessed a high school education. (Tr. 37). The record reflects that he has relevant previous

work experience as a moving company laborer/driver, fast food worker, construction worker, cook,

and department manager. (Tr. 23, 38-40, 121-128). 

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On September 25, 2003, the Administrative Law Judge (hereinafter “ALJ”), issued a written

opinion finding that plaintiff’s pancreatitis, status post coronary artery bypass surgery, and chronic

sinusitis constituted severe impairments. (Tr. 24). However, he concluded that plaintiff did not have

an impairment or a combination of impairments listed in, or medically equal to one listed in Appendix

I, Subpart P, Regulations No. 4. After discrediting plaintiff’s testimony, the ALJ determined that

plaintiff maintained the residual functional capacity (“RFC”), to lift, carry, push, and pull ten pounds

occasionally and frequently; sit for a total of six hours during an eight-hour workday, with two hours

uninterrupted; stand and walk for four hours during an eight-hour workday, with one hour

uninterrupted; frequently balance; and, occasionally stoop, crouch, kneel, and crawl. He also stated

that plaintiff “must be able to alternately stand and sit,” and could never climb. As such, the ALJ

found that plaintiff could not return to his past relevant work (“PRW”). However, with the assistance

of a vocational expert, he concluded that plaintiff could perform a significant number of jobs in the

national economy. (Tr. 25).

The Appeals Council declined to review this decision on May 11, 2004. (Tr. 7-11).

Subsequently, plaintiff filed this action. (Doc. # 1). This case is before the undersigned by consent

of the parties. The plaintiff and Commissioner have filed appeal briefs, and the case is now ready for

decision. (Doc. # 9, 10). 

Applicable Law:

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

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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 may not 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 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.

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 her 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 her age, education,

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and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003). Only if the final stage is reached does the

fact finder consider the plaintiff’s age, education, and work experience in light of his or her residual

functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42 (8th Cir.1982); 20 C .F.R. §

§ 404.1520, 416.920 (2003).

Discussion:

Of particular concern to the undersigned is the ALJ’s conclusion that plaintiff suffers from a

non-severe mental impairment. “A majority of the Supreme Court has adopted what has been referred

to as a ‘de minimis standard’ with regard to the severity standard.” Hudson v. Bowen, 870 F.2d 1392,

1395 (8th Cir. 1989); Funderburg v. Bowen, 666 F.Supp. 1291 (W.D. Ark. 1987). Accordingly, only

those slight abnormalities that do not significantly limit any “basic work activity” can be considered

non-severe. Bowen v. Yuckert, 482 U.S. 137, 158 (1987).

In the present case, the evidence reveals that plaintiff’s treating psychologist, Dr. Michael

McAllister, diagnosed him with dysthymic disorder and a mood disorder. (Tr. 345). In addition, Dr.

Sanjeev Singhal, a psychiatrist, diagnosed plaintiff with major depressive disorder, rule out depression

secondary to his general medical condition, and a history of alcohol dependence in partial remission.

(Tr. 337). Plaintiff complained of a fluctuating appetite without significant weight loss, poor sleep,

lack of motivation, feeling lonely, lack of desire to do anything, and an inability to report to work. Dr.

Singhal indicated that plaintiff became tearful at times, especially when discussing his physical

problems. Accordingly, Dr. Singhal prescribed Paxil and Trazodone. (Tr. 337). Progress notes from

both treating doctors indicate that he continued to have problems with depression and anxiety through

March 2003. (Tr. 233, 334-335, 368-369, 376, 377, 385, 387). 

On March 13, 2002, Dr. Dan Donahue, a consulting, non-examining, psychologist completed

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a psychiatric review technique form. (Tr. 293-306). After reviewing plaintiff’s medical records, he

concluded that plaintiff was suffering from an affective disorder, namely a depressive syndrome. (Tr.

293, 296). As a result, he found that plaintiff experienced moderate limitations regarding his activities

of daily living; social functioning; and, ability to maintain concentration, persistence, and pace. (Tr.

303). However, no episodes of decompensation were noted. (Tr. 303). Dr. Donahue then completed

a mental RFC assessment, indicating that plaintiff had moderate limitations regarding his ability to

understand, remember, and carry out detailed instructions, maintain attention and concentration for

extended periods, complete a normal workday, and interact appropriately with the general public. (Tr.

325-326).

On March 10, 2003, Dr. McAllister, completed a psychiatric documentation form indicating

that plaintiff suffered from an affective disorder, namely a depressive syndrome. (Tr. 359, 361). He

then opined that plaintiff had moderate limitations regarding his ability to perform activities of daily

living and maintain social functioning, often experienced deficiencies of concentration, and continually

experienced episodes of deterioration. (Tr. 365). See Collins ex rel. Williams v. Barnhart, 335 F.3d

726, 730 (8th Cir. 2003) (holding that a treating physician's opinion is generally entitled to substantial

weight).

We find it significant to note that both the non-examining, consulting physician and plaintiff’s

own treating psychologist concluded that plaintiff’s mental impairment resulted in moderate limitations

in several vital areas of mental functioning. As such, we cannot say that substantial evidence supports

the ALJ’s conclusion that plaintiff suffered from a non-severe mental impairment. Accordingly,

remand is necessary to allow the ALJ to reconsider the evidence concerning plaintiff’s mental

impairment. On remand, the ALJ should also request that Dr. Singhal complete a mental RFC and

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The undersigned notes that plaintiff submitted these additional medical records on 2

October 14, 2003, and October 30, 2003, approximately one month after the ALJ rendered his

final decision on September 25, 2003, and ten months after the administrative hearing was held

on February 21, 2003. (Tr. 10). 

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psychiatric review technique form. 

We also note that the record contains additional medical records presented to and considered

by the Appeals Council. (Tr. 10-11). Because this evidence was not submitted until after the ALJ had

rendered his decision, he did not have the opportunity to review it. “[I]f a claimant files additional

medical evidence with a request for review prior to the date of the [Commissioner’s] final decision,

the Appeals Council must consider the additional evidence if the additional evidence is (a) new, (b)

material, and (c) relates to the period on or before the date of the ALJ’s decision.” Williams v.

Sullivan, 905 F.2d 214, 215-216 (8th Cir. 1990). When, as here, “‘the Appeals Council has considered

[the] new and material evidence and declined review, we must decide whether the ALJ’s decision is

supported by substantial evidence in the whole record, including the new evidence.’” Gartman v.

Apfel, 220 F.3d 918, 922 (8th Cir. 2000) (quoting Kitts v. Apfel, 204 F.3d 785, 786 (8th Cir. 2000)).

In the present case, plaintiff presented additional medical records to the Appeals Council,

covering the period from March 2003, until October 2003. On March 19, 2003, plaintiff was admitted 2

to the hospital due to unstable angina, coronary artery disease, hypercholesterolemia, and tobacco

abuse. (Tr. 417). Plaintiff reported chest pain, describing it as a pressure-like sensation in his midchest that radiated to his left shoulder and upper extremity, with some associated shortness of breath.

He stated that the pain occurred at rest, as well as with exertion. Further, plaintiff indicated that he had

been experiencing similar intermittent pains over the previous one and one-half to two years. The pain

was relieved with sublingual Nitroglycerine and eventual Nitropaste. However, plaintiff continued to

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report some mild nausea and a headache caused by the nitroglycerin. (Tr. 417). Although an EKG

revealed sinus bradycardia at fifty-two and mild nonspecific ST and T wave changes, there was no

evidence of ischemia or injury. (Tr. 418). As such, plaintiff was diagnosed with unstable angina and

coronary artery disease. Because a chest x-ray revealed a heart size in the upper limits of normal, the

doctor ordered a cardiac catheterization and percutaneous coronary intervention. (Tr. 418, 425). The

echocardiogram revealed a left ventricular ejection fraction rate of fifty to fifty-five percent, with

normal internal dimensions. (Tr. 427). His left atrial, right atrial, and right ventricular size, functions,

and dimensions were structurally normal. Further, his aortic root and mitral and tricuspid valves were

also normal. No prolapse, vegetation, pericardial effusion, or intraventricular thrombi were noted. (Tr.

427-428). However, there was some trace tricuspid regurgitation. (Tr. 427). An angiography revealed

severe multivessel native coronary artery disease with patent saphenous vein graft to the obtuse

marginal branch of the left circumflex and left internal mammary artery to the left anterior descending

artery (“LAD”), occluded saphenous vein grafts to the right coronary artery and first diagonal branch

of the LAD, preserved left ventricular systolic function, and trace mitral regurgitation. (Tr. 430). As

there appeared to be no further revascularization indicated, the doctor suggested aggressive medical

therapy and strict risk factor modification. Therefore, he opted to place plaintiff on Imdur and

Lopressor. On March 22, 2003, plaintiff was released from the hospital. (Tr. 418). 

On April 16, 2003, plaintiff complained of a knot in his right leg. (Tr. 466). He stated that he

was having less chest pain than before, although he continued to report occasional chest pain and

shortness of breath with exertion. His main complaint was the pain in his right leg. After a physical

examination detected a hematoma, plaintiff was discharged home with directions to continue his

current medications, take the nitroglycerin as needed, and return to the emergency room if his pain

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necessitated three nitroglycerin tablets or more. (Tr. 467). 

On April 22, 2003, plaintiff was reportedly doing fairly well at home, although he did complain

of pain in his groin related to his recent cardiac catheterization. (Tr. 433). Plaintiff also complained

of bilateral aching in his thighs and calves with walking. He indicated that the pain usually began after

walking one-half block to one block. With rest, the pain reportedly resolved. However, he reported

no lower extremity swelling, significant chest pain, or shortness of breath. Dr. Scott Black ordered an

arterial doppler of the right groin and ankle-brachial index studies of the lower extremities. (Tr. 434).

As plaintiff indicated that he had been previously unable to obtain an arterial doppler due to his

financial situation, Dr. Black arranged for him to have these procedures performed at a different

facility. After increasing plaintiff’s Imdur dosage and giving him samples of Nexium to take in place

of the Protonix, Dr. Black directed plaintiff to return to the clinic in three months. (Tr. 434).

On September 9, 2003, plaintiff presented at the hospital with substernal chest pain that

radiated into his left arm. He indicated that the pain was not associated with or affected by activity,

although it was relieved with sublingual Nitroglycerine. (Tr. 441). Plaintiff also reported experiencing

nausea, vomiting, musculoskeletal cramps, fatigue, dry mouth, polyuria, and weight loss over the past

two months. Although plaintiff failed the exercise treadmill stress test, cardiolite images showed no

focal ischemia. Nevertheless, a cardiolite myocardial perfusion scan revealed scarring from his

previous myocardial infarction, and depressed left ventricular systolic function with an ejection fraction

rate of thirty-seven percent. (Tr. 454-455). An echocardiogram also revealed mildly depressed left

ventricular systolic function with an estimated ejection fraction rate between thirty-five and forty

percent, mild thickening of the mitral and tricuspid valves, mild calcification of the mitral leaflets,

thickened aortic root leaflets, mitral regurgitation, tricuspid regurgitation, and systemic atrial

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hypertension. (Tr. 457). At the time of admission, his glucose was 380, and his cardiac enzymes and

EKG were both normal. Therefore, plaintiff was diagnosed with recurrent chest pain, newly diagnosed

adult onset diabetes, severe native coronary artery disease, hypercholesterolemia, and tobacco abuse.

Plaintiff’s hospital stay was unremarkable, except for complaints of left-sided maxillary pain secondary

to a possible left upper incisor abscess, for which he was prescribed Clindamycin. Once stable,

plaintiff was discharged home on September 11, 2003. (Tr. 441). Dr. Joseph Radawi stated that

plaintiff could perform activities as tolerated, placed him on an 1800 calorie diabetic diet, and

prescribed Prevachol, Protonix, and Toprol XL. He then directed plaintiff to follow-up with Dr. Black,

and to go to Dr. Black’s office for free samples of his medications. (Tr. 442). 

On September 13, 2003, plaintiff presented at the emergency room stating that he could not get

his blood sugar level down to normal. (Tr. 437). He stated that his blood sugar was 448 at his home.

At the hospital, his glucose level was noted to be 353. Plaintiff was given four units of insulin, and

later released in stable condition. (Tr. 437). 

On October 8, 2003, plaintiff had a follow-up concerning his diabetes, hypertension, coronary

artery disease, and increased lipid level. (Tr. 464). His home glucose levels reportedly ranged from

the 170's to 400. As such, his insulin dosage was adjusted, and he was placed on a sliding scale

regimen. (Tr. 465). In addition, plaintiff was scheduled for diabetes education. (Tr. 464). 

After reviewing this evidence, it is clear that the information contained in these medical records

is both material and relative to plaintiff’s condition as it existed at the time of the ALJ’s decision, and

that the evidence was considered by the Appeals Council. (Tr. 10). Therefore, based upon our

consideration of the evidence, we are of the opinion that there is a reasonable likelihood that this

additional evidence would have changed the ALJ’s opinion. Accordingly, on remand, the ALJ should

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consider this evidence in conjunction with the other medical evidence contained in the file, before

making a final decision. 

Conclusion:

 Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore, the denial of benefits to the plaintiff, should be reversed and this matter should be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

405(g). 

ENTERED this 22nd day of August 2005.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

 UNITED STATES MAGISTRATE JUDGE 

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