Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_04-cv-05242/USCOURTS-arwd-5_04-cv-05242-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
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

REX. E. BOWMAN PLAINTIFF

VS. CIVIL NO. 04-5242

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Rex Bowman (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 application for supplemental

security income benefits (“SSI”), under Title XVI of the Act.

Background:

The application for SSI now before this court was filed on August 27, 2002, alleging an onset

date of August 1, 2002, due to back injuries. (Tr. 56-58, 60). An administrative hearing was held

on September 24, 2003. (Tr. 190-213). Plaintiff was present and represented by counsel.

At the time ofthe administrative hearing on September 24, 2003, plaintiff was forty-six years

old and possessed a seventh grade education. (Tr. 195-196). The record reveals that he had past

relevant work (“PRW”) as a bricklayer. (Tr. 196). 

On March 24, 2004, the Administrative Law Judge (“ALJ”), found that plaintiff had severe

impairments, but that those impairments did not meet or equal the criteria of any of the impairments

listed in Appendix 1, Subpart P, Regulations No. 4. (Tr. 22-23). After discrediting plaintiff’s

subjective allegations, the ALJ concluded that he maintained the residual functional capacity

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(“RFC”), to perform light work. (Tr. 23). Utilizing the Medical-Vocational Guidelines (“Grids”),

he then determined that plaintiff could perform work that exists in significant numbers in the national

economy. (Tr. 23). 

On May 18, 2004, the Appeals Council declined to review this decision. (Tr. 8-10).

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. # 7, 9). 

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 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).

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

proving his disability by establishing a physical or mental disability that has lasted at least one year

and that prevent him 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 bymedicallyacceptable clinical and laboratory

diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A plaintiff must show that his

disability, not simply his 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 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(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 RFC determination. RFC is the most

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a person can do despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). A disability claimant

has the burden of establishing his or her RFC. See Masterson v. Barnhart, 363 F.3d 731, 737 (8th

Cir.2004). “The ALJ determines a claimant’s RFC based on all relevant evidence in the record,

including medical records, observations of treating physicians and others, and the claimant’s own

descriptions of his or her limitations.” Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004);

Guilliams v. Barnhart, 393 F.3d 798, 801 (8th Cir. 2005). Limitations resulting from symptoms such

as pain are also factored into the assessment. 20 C.F.R. § 404.1545(a)(3). The United States Court

of Appeals for the Eighth Circuit has held that a “claimant’s residual functional capacity is a medical

question.” Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001). Therefore, an ALJ’s determination

concerning a claimant’s RFC must be supported by medical evidence that addresses the claimant’s

ability to function in the workplace.” Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). “Under

this step, the ALJ is required to set forth specifically a claimant’s limitations and to determine how

those limitations affect her RFC.” Id.

In the present case, the ALJ determined that plaintiff could perform a full range of light work.

However, in so doing, he failed to properly consider the medical evidence concerning plaintiff’s back

condition and Hepatitis C. In fact, he made no mention of plaintiff’s Hepatitis C diagnosis. Our

review of the medical evidence reveals the following. 

On June 5, 2002, plaintiff complained of pain radiating from his lower back to his neck. (Tr.

95). Records indicate that he was experiencing sharp pain that had worsened. Plaintiff reported that

he had originally injured his back in the 1970's. However, the previous Friday, while working as a

bricklayer, he repeatedly lifted a cement block above his head, resulting in back pain. He stated that

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he had been seeing a chiropractor, but had obtained no relief. Plaintiff also indicated that he had

been taking his wife’s Ultram. On examination, Dr. Robert Wilson noted tenderness, even to light

touch, throughout the thoracic and lumbar areas. However, plaintiff had a normal range of motion,

a normal sensory and motor exam, negative straight-leg raise test, and no weakness. (Tr. 95). As

such, Dr. Wilson diagnosed him with thoracic and lumbar sprain. He prescribed Naprosyn and

Flexeril, and limited plaintiff to lifting no more than ten pounds with no repetitive bending, twisting,

or overhead work. (Tr. 96).

On September 9, 2002, plaintiff reported that his back pain had not improved. (Tr. 92). He

also stated that he did not have a complete range of motion in his back, and that sitting and standing

for extended periods of time increased his pain. Records indicate that plaintiff wastaking Naprosyn

and Flexeril. Dr. William Kendrick advised plaintiff to rest the involved muscles for two to seven

days, until the pain resolved. He also recommended that he apply heat (or cold) and massage to help

relieve his discomfort. Then, Dr. Kendrick prescribed Flexeril and Lorcet Plus Tabs, and gave

plaintiff an injection of Depo Medrol. (Tr. 92). 

On December 30, 2002, plaintiff underwent a general physical examination. (Tr. 97-103).

Plaintiff complained of back pain radiating down his left leg, mild numbness, an inability to sit more

than fifteen minutes, and an inability to stand more than five minutes. (Tr. 97). He rated his pain

as an eight on a ten scale. On examination, plaintiff had a decreased range of motion in his lumbar

spine and shoulders, with a normal range of motion in all other areas. (Tr. 100). The doctor also

noted that x-rays of his lumbar spine revealed a decreased lordotic curve and mild sclerosis. (Tr.

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102). Therefore, he diagnosed plaintiff with mild osteoarthritis, back pain strain, chronic bronchitis,

and hypertension. (Tr. 103). The doctor indicated that plaintiff could walk, handle, finger, see, hear

and speak. However, he stated that plaintiff would have the following limitations: moderate

limitations regarding his ability to stand, mild limitations with regard to sitting, and moderate to

severe limitations affecting his ability to lift and carry. 

On January 28, 2003, plaintiff presented to the emergency room (“ER”), with lower back

pain, indicating that he had injured his back in June 2002. (Tr. 120). Further, he stated that he had

reinjured his back that day. (Tr. 121). Plaintiff also reported that he was out of his pain medication.

(Tr. 121). Following an examination, plaintiff was diagnosed with back pain, given an injection of

Toradol, and prescriptions for Vicodin and Flexeril. (Tr. 120). The doctor also directed him to apply

moist heat to the affected area. (Tr. 120, 123). 

On January 29, 2003, plaintiff was treated in the ER for complaints of continued back pain.

(Tr. 115). He stated that he had not had filled his prescriptions from the previous night, and now

wanted a shot. On examination, sacroiliac joint and lower paraspinal tenderness was noted. After

diagnosing him with lower back pain, the doctor gave plaintiff Demerol and Phenergan injections,

and told him to rest and apply ice three times per day. (Tr. 115, 118). He was also advised not to

lift over five pounds or perform repetitive movements for three days. (Tr. 118). 

On August 30, 2003, plaintiff presented at the ER with complains of chronic lower back and

neck pain. (Tr. 111). He requested an injection of Demerol. (Tr. 111-112). Plaintiff was noted to

have difficulty ambulating. (Tr. 112). He was released with prescriptions for Ultram and Flexeril.

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(Tr. 111). 

On September 28, 2003, plaintiff presented at the ER with complaints of chronic lower back

pain. (Tr. 148). An examination revealed that his spine was not tender. Records indicate that

plaintiff was moving around the room “easily.” After receiving prescriptions for Ultram and Flexeril,

plaintiff was discharged. (Tr. 148).

On October 1, 2003, plaintiff sought treatment from Dr. William Burt for chronic back pain.

(Tr. 135). Records indicate that he had not seen Dr. Burt in over a year. Plaintiff reported pain from

his neck to his right hip, a headache, and irritability. An examination revealed an elevated blood

pressure. Further, x-rays of his cervical and lumbar spine revealed straightening of the lordotic

curvature and mild degenerative changes. (Tr. 136). Dr. Burt diagnosed him with hypertension,

cervical myositis, lumbar pain, and anxiety. He then prescribed Hydrochlorothiazide and ordered

laboratory tests. (Tr. 136).

Records dated October 3, 2003, indicate that plaintiff’s laboratory results were normal, with

the exception of his liver function levels. (Tr. 133). Dr. Burt indicated that there had not been

enough blood drawn to run a Hepatitis panel. As such, he stated that he would order additional blood

work. Further, he gave plaintiff refills of Naprosyn and Flexeril, to treat his thoracic and lumbar

strain. (Tr. 133).

Progress notes dated October 22, 2003, reveal that plaintiff was having continued extreme

lower back pain. (Tr. 132). He had been taking Hydrochlorothiazide regularly, and his blood

pressure was “good.” Lab results revealed elevated liver function levels, but were otherwise normal.

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Although he had no history of Hepatitis, he did admit to drinking one six pack of beer per week. Due

to his laboratory results, Dr. Burt ordered additional blood work to retest his liver function levels

and to run a Hepatitis panel. (Tr. 132). 

On October 29, 2003, plaintiff was treated for general malaise, weight loss, and nervous

episodes. (Tr. 129). Records indicate that his Hepatitis C antibody was positive, and his liver

function levels remained elevated. Dr. Burt listed his active impairments as thoracic and lumbar

strain, Hepatitis C, and chronic pain syndrome. He then prescribed Nortriptyline and referred

plaintiff to a gastroenterologist to see if he was a candidate for Interferon therapy. (Tr. 130).

On November 13, 2003, plaintiff was evaluated by Dr. Alice Martinson, an orthopaedist. (Tr.

150). He complained of ongoing severe and constant lower back pain without radiation into his

lower extremities. Plaintiff stated that his pain sometimes radiated up his back, toward his armpits.

He indicated that his pain was made worse by bending, twisting, lifting objects weighing more than

fifteen to twenty pounds, and sitting for longer than fifteen minutes. His current medications were

noted to be Hydrochlorothiazide, Tramadol, Nortriptyline, and Flexeril. On examination, Dr.

Martinson indicated that plaintiff stood with a straight spine, could demonstrate full forward flexion

bringing his fingertips to the floor, had ten degrees of extension with palpable spasm, fifteen degrees

each of lateral bend and rotation without spasm, a negative sealed root test, and straight-leg raising

limited to fifty degrees bilaterally by hamstring tightness. (Tr. 151). He also had a full range of

motion in his cervical spine in all directions, but complained of discomfort at the range extremes.

X-rays of his lumbar spine showed loss of disc height at the L5-S1 with some traction-type spurs on

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the margins of the vertebral bodies at the L4-5 and L3-4. As such, Dr. Martinson concluded that

plaintiff was suffering from degenerative disc disease in the lumbar spine without evidence of

radiculopathy. Utilizing the AMA guidelines, she determined that plaintiff had a total body

impairment of five percent, based on the physical abnormalities in his lumbar spine. (Tr. 151). 

Dr. Martinson completed a medical assessment of ability to perform work-related activities.

(Tr. 153). She indicated that plaintiff could frequently lift up to ten pounds, occasionally lift eleven

to twenty pounds, and never lift more than twenty pounds. Dr. Martinson reported that plaintiff

could sit for eight hours per day and stand and/or walk for four hours per day. As for postural

activities, she found that plaintiff could never stoop or crouch. (Tr. 153). 

On December 10, 2003, plaintiff was referred to Dr. Terryl Ortego for further evaluation of

his Hepatitis C. (Tr. 176). He reported a history of fever, chills, sweats, a weight loss of six pounds,

headaches, chest pain, and heartburn. Dr. Ortego noted that his medical history was positive for

hypertension and chronic pain syndrome. Further, plaintiff admitted previously drinking a six-pack

of beer per week, stating that his father was an alcoholic. After a physical examination was

unremarkable, Dr. Ortego diagnosed him with elevated liver enzymes and a positive antibody test

for Hepatitis C. He then ordered a quantitative assay for Hepatitis C virus. (Tr. 176). 

On January 9, 2004, after a positive quantitative assay for Hepatitis C, plaintiff underwent

a liver biopsy. (Tr. 167). The pathology report revealed evidence of chronic Hepatitis, mildly active,

with a minimal increase in periportal fibrosis. (Tr. 164). No evidence of granulomatous

inflammation or malignancy was noted. (Tr. 164). 

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On January 16, 2004, plaintiff presented at the ER with complaints of back pain. (Tr. 157).

An examination revealed right lower paraspinal and sacroiliac joint tenderness. Results of an MRI

performed three days earlier showed degenerative joint disease at the L5-S1 level with loss of disc

space height, anterior osteophytes, and broad-based mild disc protrusion that narrowed the

neuroforamina. (Tr. 162). For this, plaintiff was given Tylox and Flexeril. (Tr. 157). He was

restricted to lifting nothing over five pounds or performing repetitive movements for at least three

days. (Tr. 159). 

In light of this evidence, we believe that remand is necessary to allow the ALJ to reconsider

the evidence concerning plaintiff’s back impairment. Specifically, he should reevaluate the evidence

indicating that plaintiff does have postural limitations, such as an inability to stoop, crouch, bend,

crawl, or climb, that would prevent him from performing a “full range” of light work. (Tr. 153). In

addition, as the ALJ failed to consider the evidence concerning plaintiff’s Hepatitis C diagnosis, on

remand, he should fully consider whether the combined effect of appellant's separate impairments

considered together constitute a severe impairment. 42 U.S.C.A. § 423 (requiring the Secretary to

consider the combined effect of all of an individual's impairments without regard to whether any such

impairment, if considered separately, would be of such severity to entitle that person to benefits),

Reeder v. Apfel, 214 F.3d 984, 988 (8th Cir. 2000) (holding that the ALJ is not free to ignore medical

evidence, rather must consider the whole record); Anderson v. Heckler, 805 F.2d 801, 805 (8th Cir.

1986) (holding that ALJ is required to consider the combined effect of plaintiff’s impairments). 

After reviewing the entire record, it also appears that none of plaintiff’s treating physicians

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have completed an RFC assessment for the time period in question. See Vaughn v. Heckler, 741 F.2d

177, 179 (8th Cir. 1984.) (If a treating physician has not issued an opinion which can be adequately

related to the disability standard, the ALJ is obligated to address a precise inquiry to the physician

so as to clarify the record). The ALJ, in concluding that plaintiff could perform the exertional and

non-exertional requirements of a full range of light work, relied on RFC assessments completed by

examining medical consultants, who examined plaintiff on only one occasion. (Tr. 97-103, 150-

153.) We note, that the opinion of a consulting physician who examined the plaintiff once or not at

all does not generally constitute substantial evidence. See Jenkins v. Apfel, 196 F.3d 922, 925 (8th

Cir. 1999). Therefore, based on the current evidence of record, we do not find substantial evidence

supporting the ALJ’s RFC determination. 

On remand, the ALJ is directed to address interrogatories to the physicians who have

evaluated and/or treated plaintiff, asking the physicians to review plaintiff’s medical records; to

complete a mental and physical RFC assessment regarding plaintiff’s capabilities during the time

period in question; and, to give the objective basis for their opinions, so that an informed decision

can be made regarding plaintiff’s ability to perform basic work activities on a sustained basis during

the relevant time period in question. Chitwood v. Bowen, 788 F.2d 1376, 1378 n.1 (8th Cir. 1986);

Dozier v. Heckler, 754 F.2d 274, 276 (8th Cir. 1985). 

The ALJ also failed to consider evidence indicating that plaintiff failed to seek more

treatment and fill prescription medications, due to financial hardship. (Tr. 202-204, 207). While it

is for the ALJ in the first instance to determine a plaintiff’s motivation for failing to follow a

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prescribed course of treatment, or to seek medical attention, such failure may be excused by a

claimant’s lack of funds. Tome v. Schweiker, 724 F.2d 711, 714 (8th Cir. 1984); Jackson v. Bowen,

866 F. 2d 274, 275 (8th Cir. 1989). “Although it is permissible in assessing the severity of pain for

an ALJ to consider a claimant’s medical treatment and medications, the ALJ must consider a

claimant’s allegation that he has not sought medical treatment or used medications because of a lack

of finances.” Dover v. Bowen, 784 F.2d 335, 337 (8th Cir. 1986) (citing Tome v. Schweiker, 724

F.2d at 714). Economic justifications for lack of treatment can be relevant to a disability

determination. Murphy v. Sullivan, 953 F.2d 383, 386 (8th Cir. 1992). Therefore, on remand, the

ALJ is directed to further develop the record concerning plaintiff’s financial ability to obtain

treatment and medication. 

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). 

DATED this 15th day of September 2005.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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