Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_06-cv-05213/USCOURTS-arwd-5_06-cv-05213-1/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 42:0405g Review of HHS Decision (RSI)

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Michael J. Astrue became the Commissioner of Social Security on February 12, 2007. Pursuant to Rule 1

25(d)(1) of the Federal Rules of Civil Procedure, Michael J. Astrue should, therefore, be substituted for Jo Anne B.

Barnhart as the defendant in this suit. No further action need be taken to continue this suit by reason of the last

sentence of section 205(g) of the Social Security Act, 42 U.S.C. § 405(g).

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FAYETTEVILLE DIVISION

CARLETTA M. MORRIS PLAINTIFF

VS. CIVIL NO. 06-5213

MICHAEL J. ASTRUE, COMMISSIONER 1

SOCIAL SECURITY ADMINISTRATION DEFENDANT

MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

Plaintiff, Carletta Morris, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial

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

“Commissioner”) denying her claim for supplemental security income (“SSI”) under the provisions

of Title XVI of the Social Security Act (the “Act”). 

Procedural Background:

The application for SSI now before this court was filed on January 15, 2004, alleging an

onset date of November 1, 1995, due to complex partial seizures, post traumatic stress disorder

(“PTSD”), restless leg syndrome, and dysthymic disorder. (Tr. 13, 51-53, 74-78, 89-94). An

administrative hearing was held on February 7, 2006. (Tr. 336-359). Plaintiff was present and

represented by counsel. 

At the time of the administrative hearing, plaintiff was forty-nine years old and possessed an

Associates Degree in business technology. (Tr. 342). The record indicates that she had past relevant

work experience as a substitute teacher, stocker, and billing clerk. (Tr. 16, 343-345). 

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On May 22, 2006, the Administrative Law Judge (“ALJ”) issued a written decision finding

that plaintiff’s impairments were severe. (Tr. 13). However, he concluded that they did not meet

or equal the criteria of any of the impairments listed in Appendix 1, Subpart P, Regulations No. 4.

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

residual functional capacity (“RFC”) to perform light work limited by her inability to be exposed to

heights and machinery. He also found that she could only perform work where the interpersonal

contact is routine, the complexity of the tasks is learned by experience, the use of judgment is within

limits, and the supervision required is little for routine tasks but detailed for non-routine tasks. (Tr.

14). With the assistance of a vocational expert, the ALJ determined that plaintiff could return to her

PRW as a billing clerk. He also concluded that plaintiff could perform her PRW as a stocker, with

the exception of the work performed in the pet department. (Tr. 16). 

On September 22, 2006, the Appeals Council declined to review this decision. (Tr. 3-5).

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

and recommendation. Both parties were afforded the opportunity to file appeal briefs, but plaintiff

has chosen not to do so. (Doc. # 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

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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 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 laboratorydiagnostic 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 him 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), 416.920. Only

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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. Schwieker, 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 assessment. RFC is the most 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.

The ALJ is required to consider a plaintiff’s non-exertional, as well as exertional limitations

when assessing the plaintiff’s RFC. Examples of non-exertional limitations include obesity, pain,

depression, intolerance to dust or fumes, and difficulty performing manipulative or posterior

functions such as reaching, handling, stooping, climbing, crouching, or crawling. 20 C.F.R. §

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Clinoril is a prescription drug used to treat inflammation and pain associated with 2

rheumatoid arthritis and other related impairments. See Clinoril, at www.medicinenet.com. 

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404.1569(c). The United States Court of Appeals for the Eighth Circuit has made the following

ruling concerning pain:

Pain may be a nonexertional factor to be considered in combination with exertional

limitations as well as a separate and independent ground for disability. . . . Where

pain is considered in combination with exertional limitations, however, it need only

be found significant enough to prevent the claimant from engaging in the full range

of jobs contemplated by the exertional category for which the claimant otherwise

qualifies. 

McCoy v. Schweiker, 683 F.2d 1138, 1148 (8th Cir. 1982) (en banc) (reversed on other grounds). 

The record in the current case indicates that plaintiff was treated for pain in her lower

extremities. On December 21, 2004, she complained of pain in both legs with constant aching and

periods of sharp pain from her hips down to her feet. (Tr. 216). Dr. Cheryl Hennigan noted

sensitivity in the legs and severe pain with deep tendon reflexes. Further, plaintiff’s posterior tibial

and distal pulses were faint and hard to find. Dr. Hennigan ordered bilateral lower leg arterial

dopplers and prescribed Keflex and Clinoril. (Tr. 216). An arterial ultrasound revealed low-grade 2

arterial inflow disease of both lower extremities with a greater degree of trifurcation disease on the

right. (Tr. 212). 

On September 15, 2005, plaintiff presented at Dr. Hennigan’s office for a follow-up

evaluation. (Tr. 245-246). She was diagnosed with bronchitis, mixed hyperlipidemia,

arteriosclerosis, peripheral vascular disease, and hypertension. Dr. Hennigan noted persistent

claudication (pain in the legs due to circulation problems) and prescribed Levaquin. (Tr. 244, 246).

 

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On November 7, 2005, plaintiff was treated by Dr. Hennigan for restless legs,

arteriosclerosis, agoraphobia with panic attacks, and mixed hyperlipidemia. (Tr. 240-241). Plaintiff

complained of pain in her legs while sitting, standing, and walking long distances. An examination

revealed no right dorsal pedal pulse or left post tibial pulse. Plaintiff was prescribed Levaquin,

Zocor, Requip, Darvon, and Trileptal and told to follow-up in a few weeks. (Tr. 241).

First, we note that this evidence was neither mentioned nor discussed by the ALJ in his

opinion. See 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). There is absolutely no discussion

of whether or not this impairment impacted plaintiff’s ability to perform work-related activities. As

the ALJ is required to consider all of the plaintiff’s impairments in combination, we believe that this

alone warrants remand of this matter for further consideration. See Cunningham v. Apfel, 222 F.3d

496, 501 (8th Cir. 2000) (holding that the ALJ is required to consider all impairments in

combination, regardless of whether or not any single impairment would be considered disabling).

However, we also note that the most recent RFC assessment contained in the file was prepared prior

to plaintiff obtaining this diagnosis. As such, an updated RFC is required. Therefore, on remand,

the ALJ is directed to address interrogatories to Dr. Hennigan, plaintiff’s treating physician, asking

her to review plaintiff’s medical records; complete a mental and physical RFC assessment regarding

plaintiff’s capabilities during the time period in question; and, give the objective basis for her

opinion, so that an informed decision can bemade 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). 

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Conclusion:

Based on the foregoing, we recommend reversing the decision of the ALJ and remanding this

case to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. § 405(g).

The parties have ten days from receipt of our report and recommendation in which to file

written objections pursuant to 28 U.S.C. § 636(b)(1). The failure to file timely objections may

result in waiver of the right to appeal questions of fact. The parties are reminded that

objections must be both timely and specific to trigger de novo review by the district court.

DATED this 23rd day of October2007.

/s/ J. Marschewski

HON. JAMES R. MARSCHEWSKI

UNITED STATES MAGISTRATE JUDGE

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