Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-2_04-cv-02244/USCOURTS-arwd-2_04-cv-02244-0/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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PV is an acquired disorder of the bone marrow that causes the overproduction of all 1

three blood cell lines: white blood cells, red blood cells, and platelets. See Emmanuel C. Besa,

Polycythemia vera, at www.emedicine.com. The disease usually develops slowly, and most

patients do not experience any problems related to the disease after being diagnosed. Id. 

However, the abnormal bone marrow cells may begin to grow uncontrollably in some patients

leading to acute myelogenous leukemia. Patients with polycythemia vera also have an

increased tendency to form blood clots that can result in strokes or heart attacks. Id. Some

patients may also experience abnormal bleeding because their platelets are abnormal. 

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FORT SMITH DIVISION

RUSSELL SWEARINGIN PLAINTIFF

VS. CIVIL NO. 04-2244

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Russell Swearingin (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 disability

insurance benefits (“DIB”), and supplemental security income benefits (“SSI”), under Titles II and

XVI of the Act.

Background:

The applications for DIB and SSI now before this court were filed on August 28, 2002,

alleging an onset date of August 6, 2002, due to chronic back pain status post lumbar fusion, the

residuals of carpal tunnel surgery on the right hand, polycythemia vera (“PV”), a somatoform

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disorder, hypertension, irritable bowel syndrome, panic disorder, depression, and anxiety. (Tr. 14,

16, 160-163, 418-422). An initial administrative hearing was held on May 22, 2003, resulting in an

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unfavorable decision. (Tr. 30-68). Plaintiff then appealed the decision to the Appeals Council, and

the Council vacated that ALJ’s decision and remanded the case for further proceedings. (Tr. 146-

148). A second hearing was held on April 5, 2004. (Tr. 69-103). Plaintiff was present and

represented by counsel.

At the time of the second administrative hearing on April 5, 2004, plaintiff was forty-four

years old and possessed the equivalent of a high school education. (Tr. 15). The record reveals that

he had past relevant work (“PRW”), as a sales representative, porter at an automobile dealership,

store manager, retail sales person, and delivery driver. (Tr. 15, 118-125, 296). 

On June 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. 108-120, 460-472). After discrediting

plaintiff’s subjective allegations, the ALJ concluded that he maintained the residual functional

capacity (“RFC”), to perform a wide range of light work, limited by an ability to perform occasional

overhead work; occasional stooping, crouching, kneeling, and crawling; and, frequent fingering with

his right hand. Further, the ALJ determined that plaintiff should not work near ropes, ladders, or

scaffolds, and was limited to only incidental contact with the general public and co-workers. (Tr.

24). With the assistance of a vocational expert (“VE”), he determined that plaintiff could not

perform his PRW. (Tr. 24). However, the VE testified that plaintiff could make a vocational

adjustment to perform work as an assembler and machine tender. (Tr. 25). 

On October 15, 2004, the Appeals Council declined to review this decision. (Tr. 5-8).

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

of the parties. Although both parties were afforded the opportunity to file appeal briefs, plaintiff has

chosen not to do so. (Doc. # 10). The case is now ready for decision.

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).

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

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“physical or mental impairment” as “an impairment that results from anatomical, physiological, or

psychological abnormalities which are demonstrable bymedically acceptable 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 failure to properly consider the RFC

assessments prepared by Drs. Patricia Walz, Allen Beachy, and Robert Thompson. Rather than to

analyze the opinions of these treating/examining doctors, the ALJ chose to dismiss their opinions,

simply stating that they were not “entirely supported by the medical evidence of record.” (Tr. 21).

See Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 730 (8th Cir. 2003) (holding that a treating

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physician's opinion is generally entitled to substantial weight). He did not, however, explain how

their opinions were in conflict with the medical evidence. See 20 C.F.R § 404.1527(d)(2); SSR 96-

2p; Prosch v. Apfel, 201 F.3d at 1010, 1012-13 (8th Cir. 2000) (holding that the ALJ must “always

give good reasons” for the particular weight given to a treating physician’s evaluation). Further, he

opted to adopt the RFC assessment of a non-treating, non-examining physician, over those of

examining and/or treating physicians. See Jenkins v. Apfel, 196 F.3d 922, 925 (8th Cir. 1999). 

(holding that the opinion of a consulting physician who examined the plaintiff once or not at all does

not generally constitute substantial evidence). 

The RFC assessments prepared by the aforementioned doctors reveals the following pertinent

information. On March 18, 2003, plaintiff was evaluated by Dr. Patricia J. Walz. (Tr. 379-385).

Plaintiff reported that he had not worked for eight months. (Tr. 380). He told Dr. Walz that he had

been treated by Dr. Beachy for anxiety and depression, but that he had tried eight different types of

medication, none of which worked. Following a general mental status examination, it was

determined that plaintiff’s I. Q. fell within the low average range. (Tr. 382). On the Beck Anxiety

Inventory, he earned a score of forty-five, which fell within in the severely anxious range. Further,

his MMPI-2 appeared to have some elements of exaggeration of symptoms, though not severe. Dr.

Walz indicated that this could probably be interpreted to correlate with a diagnosis of somatoform

disorder and/or depression. Although she concluded that plaintiff was abusing alcohol and possibly

prescription drugs to manage his pain and psychiatric illness, she did not believe that his addiction

problem was the primary issue. Instead, she was of the opinion that he was self-medicating, and

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lacked the intellectual and personality resources to deal with his chronic pain. In addition, Dr. Walz

determined that plaintiff’s level of anxiety was severe enough to impair his ability to interact

appropriately with peers and supervisors, as well as his ability to attend work regularly. (Tr. 383).

She also found that he had a poor ability to perform activities within a schedule, maintain regular

attendance and be punctual; complete a normal workday or workweek; and, accept instructions and

respond appropriately to criticism from supervisors. (Tr. 384-385). Further, Dr. Walz concluded

that plaintiff had only a fair ability to understand, remember and carry out detailed instructions;

maintain attention and concentration for extended periods; sustain an ordinary routine without special

supervision; work with or near others without being distracted by them; make simple work-related

decisions; perform at a consistent pace; interact appropriately with the general public; get along with

co-workers and peers; maintain socially appropriate behavior; respond appropriately to changes in

the work setting; be aware of normal hazards and take appropriate precautions; travel in unfamiliar

places or use public transportation; and, set realistic goals or make plans independently of others.

(Tr. 384-385). 

On May 20, 2003, Dr. Beachy, plaintiff’s treating physician, completed an attending

physician’s statement, indicating that plaintiff was suffering from degenerative disc disease, due to

failed back syndrome status post-laminectomy; polycythemia; hypertension; major depression with

features of anxiety; and, chronic alcoholism. (Tr. 388). His treatment was said to include possible

lumbar epidural steroid injections, periodic phlebotomies, antidepressant/anxiolytic medications, and

antihypertensive medication. Dr. Beachy characterized plaintiff’s condition as moderate, meaning

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that some physical activity could be tolerated, but the condition would cause a marked handicap in

the performance ofthe activity. Emotional factors were also said to contribute to his symptoms, with

his symptoms being severe enough to interfere with his ability to concentrate and tolerate work

stress. Dr. Beachy indicated that plaintiff would require unscheduled breaks during an eight-hour

workday, and would likely miss more than four days of work per month, due to his impairments. (Tr.

389). He was of the opinion that plaintiff was disabled from work activity. (Tr. 389). 

On February 9, 2004, Dr. Walz completed a second psychiatric evaluation of plaintiff. (Tr.

407-411). This time, she administered the WAIS IIintelligence exam, which revealed that plaintiff’s

I. Q. was actually within the borderline range intellectual functioning. (Tr. 410). Based on this, she

concluded that he could probably manage a simple budget. Interpersonally, Dr. Walz found that

plaintiff demonstrated a somatic focus with underlying depression, accompanied by possible

psychotic symptoms. As such, she was of the opinion that he qualified for a diagnosis of somatoform

pain disorder. Dr. Walz stated that this diagnosis would affect plaintiff’s ability to work, in terms

of his ability to attend regularly, interact appropriately with peers, and concentrate. Further, she

indicated that his prognosis was poor without intervention, and guarded to poor with treatment, based

on his I. Q., somatization, and limited coping skills. (Tr. 410). She then diagnosed him with

somatoform pain disorder, alcohol abuse in remission for three months, intermittent benzodiazepine

abuse, and borderline intellectual functioning. (Tr. 411). Based on these diagnoses, Dr. Walz

determined that plaintiff had a poor ability to deal with the public; understand, remember, and carry

out complex job instructions; and, demonstrate reliability. (Tr. 412-413). Further, she concluded

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that his ability to follow work rules; relate to co-workers; use judgment; interact with supervisors;

deal with work stresses; function independently; maintain concentration; understand, remember, and

carry out detailed job instructions; understand, remember, and carry out simple job instructions;

maintain personal appearance; behave in an emotionally stable manner; and, relate predictably in

social situations was only fair. (Tr. 412-413).

On February 10, 2004, Dr. Robert Thompson, an orthopaedist, evaluated plaintiff. (Tr. 414).

Plaintiff indicated that he had worked as a mechanic until 2001, at which point his back pain

intensified and, when combined with the onset of two unsuccessful inguinal hernia repairs, resulted

in weakness of the abdominal musculature and severe pain. On examination, Dr. Thompson noted

some decreased sensation in the left hand in the ulnar distribution compared to the right, slight

decreased sensation over the lateral aspect of the left calf, and slight weakness of dorsiflexion to the

left ankle compared to the right. Plaintiff was also noted to have a guarded gait, with limited flexion,

extension, and lateral flexion of the lumbar spine. (Tr. 416). Based on these findings, Dr. Thompson

concluded that plaintiff could frequently lift up to ten pounds, rarely lift eleven to twenty pounds,

and never lift more than twenty pounds. (Tr. 417). He indicated that plaintiff could sit for three

hours during an eight-hour workday, and stand one to two hours per day. In addition, it was Dr.

Thompson’s opinion that plaintiff could never climb, balance, stoop, crouch, kneel, or crawl, and

should avoid all exposure to heights and moving machinery. (Tr. 417).

In spite of this evidence, however, the ALJ concluded that plaintiff could lift ten pounds

frequently and twenty pounds occasionally; stand and walk for six hours during an eight-hour

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workday; occasionally stoop, crouch, kneel, and crawl; occasionally perform overhead work;

frequently finger with his right hand; never work around ropes, scaffolds, and ladders; and, perform

work involving only incidental contact with the general public and co-workers. (Tr. 22). Therefore,

based on the medical evidence of record, the undersigned concludes that remand is necessary to

allow the ALJ to properly consider the opinions of these physicians. Recognizing that Dr. Beachy’s

opinion does not contain specifics regarding plaintiff’s limitations, on remand, the ALJ is directed

to address interrogatories to him, asking him 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). 

Further, on remand, should the ALJ again choose to disregard the opinions of these

physicians, he is directed to provide “good reasons” for his decision. See 20 C.F.R § 404.1527(d)(2);

SSR 96-2p; Prosch, 201 F.3d at 1012-13 (8th Cir. 2000). In other words, he is to provide a detailed

explanation of his reasons for dismissing this evidence, including a description of how this evidence

is contradicted by the record as a whole. 

We also note that the ALJ failed to include the fact that plaintiff suffers from borderline

intellectual functioning in his hypothetical questions to the vocational expert. The United States

Court of Appeals for the Eighth Circuit has “previously concluded that borderline intellectual

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functioning . . . is a significant nonexertional impairment that must be considered by a vocational

expert.” Lucy v. Chater, 113 F.3d 905, 908 (8th Cir. 1997); Foreman v. Callahan, 122 F.3d 24, 26

(8th Cir. 1997). Accordingly, on remand, the ALJ is directed to recall the vocational expert, and to

pose a hypothetical question to the expert that includes the specific mental limitations imposed by

plaintiff’s borderline intellectual functioning. 

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 November 2005.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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