Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-3_04-cv-03047/USCOURTS-arwd-3_04-cv-03047-0/pdf.json

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

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HARRISON DIVISION

LINDA F. BURCH PLAINTIFF

VS. CIVIL NO. 04-3047

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Linda Burch (“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 her applications for 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 December 19, 2001,

alleging an onset date of February 5, 2001, due to degenerative disc disease, fatigue, hypertensive

vascular disease, and essential hypertension. (Tr. 11). An administrative hearing was held on

October 7, 2003. (Tr. 312-326). Believing that additional evidence was necessary, the

Administrative Law Judge (“ALJ”) ordered a mental status examination. (Tr. 329). A supplemental

hearing was then held on May 28, 2003, at which time testimony was elicited from a vocational

expert. (Tr. 327-341). Plaintiff was present and represented by counsel. 

On August 25, 2003, the ALJ, issued a written opinion finding that, although severe,

plaintiff’s impairments did not meet or equal the criteria of any of the impairments listed in

Appendix 1, Subpart P, Regulations No. 4. (Tr. 20). At this time, plaintiff was thirty-nine years old

and possessed a high school education. (Tr. 11). The record reflects that she had past relevant work

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(“PRW”) experience as a traveling salesperson, hotel desk clerk, factory worker, nurse’s aide, and

retail salesclerk. (Tr. 11). 

After discrediting plaintiff’s subjective allegations, the ALJ concluded that she maintained

the residual functional capacity ( “RFC”), to perform light work. (Tr. 21). With the assistance of

a vocational expert, the ALJthen found that plaintiff could still perform work existing in significant

numbers in the national economy. (Tr. 21). 

On May 14, 2004, the Appeals Council declined to review this decision. (Tr. 2-4).

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

of the parties. Both parties were afforded an opportunity to file appeal briefs, however, the plaintiff

chose not to do so. (Doc. # 8). 

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

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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, 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).

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Discussion:

Of particular concern to the undersigned is the ALJ’s failure to discuss and consider the RFC

assessment completed by Dr. Rolland Bailey, plaintiff’s treating physician. 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). In general, a treating physician’s opinion is entitled to substantial

weight. Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 730 (8th Cir. 2003). An ALJ may

discount a treating physician’s opinion if other medical assessments are supported by superior

medical evidence, or if the physician has offered inconsistent opinions that are inconsistent or not

fully supported by medical evidence Anderson v. Barnhart, 344 F.3d 809, 813 (8th Cir. 2003);

Holmstrom v. Massanari, 270 F.3d 715, 720 (8th Cir. 2001). However, whether the ALJ grants a

treating physician’s opinion substantial or little weight, the regulations provide that he must “always

give good reasons” for the particular weight given to a treating physician’s evaluation. 20 C.F.R §

404.1527(d)(2); see also SSR 96-2p; See Prosch v. Apfel, 201 F.3d 1010, 1012-13 (8th Cir. 2000).

In the present case, the ALJ failed to even mention the assessment completed by Dr. Bailey.

On June 11, 2003, Dr. Bailey stated that he had been treating plaintiff every one to three months for

degenerative disc disease, osteoarthritis, anxiety psychosis, major depression, and hypertension. (Tr.

288). He indicated that plaintiff’s symptoms included chronic neck and back pain, as well as

recurrent headaches, both made worse by activity. For this condition, Dr. Bailey had prescribed

analgesics and muscle relaxants, both of which could sedate and impair her cognition. He was of

the opinion that plaintiff’s prognosis was fair, and could be expected to last at least twelve months.

With regard to her anxiety and depression, Dr. Bailey stated that these diagnoses did not

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contribute to the severity of her physical condition but, rather were caused by her physical

impairments. (Tr. 288-289). As such, he determined that her impairments were severe enough to

cause frequent interference with her ability to pay attention and concentrate, rendering her incapable

of even a low stress job. (Tr. 289). Dr. Bailey then indicated that plaintiff could walk less than one

block without rest or severe pain. Further, he reported that plaintiff could sit, stand, and walk a total

of less than two hours per eight-hour workday. (Tr. 290). Dr. Bailey also noted that she would

require periods of walking around every ten minutes for approximately five minutes, require a job

that permitted shifting positions at will, and need to take frequent unscheduled breaks of five to ten

minutes each. In addition, he stated that plaintiff should rarely lift ten pounds or less and climb

stairs, and never lift more than ten pounds, twist, stoop, crouch, or climb ladders. (Tr. 291). Dr.

Bailey was also of the opinion that she could only use her arms for reaching overhead approximately

five percent of the time. As such, he concluded that plaintiff’s impairment would be likely to cause

her to miss more than four days of work per month. (Tr. 292).

As the ALJ failed to even mention Dr. Bailey’s opinion, we believe that remand is necessary

to allow for further consideration of the evidence. On remand, the ALJ is directed to discuss Dr.

Bailey’s evaluation, and provide “good reasons” for the particular weight given to it. Collins, 335

F.3d at 730; Prosch, 201 F.3d at 1012-13. 

We also note that the ALJ failed to properly consider plaintiff’s mental impairment. When

determining whether a claimant can engage in substantial employment, an ALJ must consider the

combination of the claimant’s mental and physical impairments. See Cunningham v. Apfel, 222 F.3d

496, 501 (8th Cir. 2000). In fact, according to the regulations, when considering a mental

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A PRT is a standard document which generally must be completed when a claimant 1

alleges a mental impairment,” Mapes v. Chater, 82 F.3d 259, 262 n. 8 (8th Cir. 1996),

indicating that the ALJ fully considered the assertion that plaintiff has a mental impairment. 

See Russell v. Sullivan, 950 F.2d 542, 544-45 (8th Cir. 1991) (procedure for mental

impairments).

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impairment, a special procedure must be followed at each level of administrative review. 20 C.F.R.

§ 404.1520a(a). The regulations require that the steps of the procedure are to be documented at each

level by completion of a standard document, the “Psychiatric Technique Review Form” (“PRT”).1

See id. § 404.1520a(d). This form must be attached to or incorporated into the ALJ’s decision. Id.

§ 404.1520a(d)(2), (e)(2). However, in the present case, although the ALJ acknowledged the

presence of evidence regarding plaintiff’s mental condition, he failed to complete or have a mental

health expert complete a PRT. In addition, he did not make specific findings regarding the affect,

if any, plaintiff’s mental impairment had on her RFC. 

The relevant mental health evidence reveals the following. On December 9, 2002, plaintiff

underwent a psychological assessment with Dr. Stephen Harris. (Tr. 274-276). Plaintiff reported

suffering from chronic pain in her lower back, rating it as a six on a scale of ten with medication, and

a ten without medication. (Tr. 274). She indicated that she gets unhappy, becomes very frustrated,

and will cry. Plaintiff also stated that she experienced difficulties with her teenage daughter who

wanted things that she could not have, due to a lack of finances. 

Testing revealed that plaintiff was experiencing severe levels of depression and anxiety,

evidenced by feelings of dejection, a loss of interest in most activities, emotional turmoil, poor

impulse control, and tendencies toward passive aggressive behavior. (Tr. 275). However, Dr. Harris

then concluded that plaintiff’s depression and anxiety focused on her physical ailments. (Tr. 276).

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Academic testing yielded results in the average range of intellect. (Tr. 276). 

Dr. Harris also completed a medical source statement of plaintiff’s mental ability to do workrelated activities, indicating that plaintiff had moderate limitations regarding her ability to make

judgments on simple work-related decisions, interact appropriately with the public, interact

appropriately with supervisors, interact appropriately with co-workers, and respond appropriately

to changes in a routine work setting. (Tr. 277-278). He also noted moderate to marked limitations

in her ability to respond appropriately to work pressures in a usual work setting. (Tr. 278).

Given the fact that plaintiff was noted to have both moderate and marked limitations in

several areas of functioning, we believe that the ALJ should have completed a PRT and made

specific findings as to how plaintiff’s mental limitations affected her ability to perform work-related

activities. Instead, he made no mention of her mental or non-exertional limitations in his RFC

determination, finding that she could perform a full range of light work. His failure to do so

constitutes error. See Cunningham, 222 F.3d at 501. 

The ALJ also failed to develop the evidence as to side effects of plaintiff’s medications. 

Records indicate that plaintiff was taking Hydromorphone, Paxil, Neurontin, Fosamax, and Zanaflex

on a daily basis. (Tr. 294). Although the ALJ did not believe plaintiff’s testimony concerning her

limitations, we note that the combination of Hydromorphone and an anti-depressant can result in

sedation, and Skelaxin can cause drowsiness, lack of muscular coordination, and weakness.

PHYSICIANS’ DESK REFERENCE (59th ed. 2005), available at www.gettingwell.com. Moreover,

Hydromorphone is a controlled substance with abuse liability similar to morphine. Id. Clearly, this

information should have been considered bythe ALJ when determining plaintiff’s ability to perform

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substantial gainful activity. See Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984). Therefore,

on remand, the ALJ is directed to do so. 

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 13th day of September 2005.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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