Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-6_04-cv-06130/USCOURTS-arwd-6_04-cv-06130-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (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

HOT SPRINGS DIVISION

CHRISTINA D. WILKERSON PLAINTIFF

v. Civil No. 04-6130

JO ANNE B. BARNHART,

Commissioner, Social

Security Administration DEFENDANT

MEMORANDUM OPINION

Christina D. Wilkerson (hereinafter "Plaintiff"), appeals from the decision of the

Commissioner of the Social Security Administration (hereinafter “Commissioner”), denying her

applications for a period of disability and disability insurance benefits (hereinafter "DIB"),

pursuant to §§ 216(i) and 223 of Title II of the Social Security Act (hereinafter "the Act"), 42

U.S.C. §§ 416(i) and 423, and for supplemental security income (hereinafter "SSI") benefits

pursuant to § 1602 of Title XVI, 42 U.S.C. § 1381a. 

Plaintiff, whose date of birth is September 12, 1978, was 24 years of age at the time of

the, September 11, 2003, administrative hearing (T. 286, 281-314). Plaintiff had the equivalent

of a high school education, as well as attending one semester of classes at a community college

(T. 287, 92). She last worked as a jewelry salesperson (T. 288, 290, 95). Plaintiff protectively

filed her applications for benefits on September 16, 2002, alleging that she became disabled on 

February 5, 2002 (T. 284, 272, 68). 

Plaintiff alleges an inability to work due to the following alleged disabling impairments: 

depression; epilepsy; grand mal seizures; petit mal seizures; fatigue; memory loss; loss of

concentration; heat sensitivity; confusion following seizures; headaches; carpal tunnel

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1Plaintiff alleges that she has been exposed to both HIV and Hepatitis C via her

husband, who tested positive for both of these diseases. Plaintiff alleges that she has had both

negative and positive tests for HIV since her exposure. However, the only HIV test results of

record yield a negative result (T. 182, 188).

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syndrome; numbness; history of falls; and, exposure to HIV and Hepatitis C1. 

 The Social Security Administration denied plaintiff’s application initially and upon

reconsideration. Plaintiff then requested and received a hearing before an Administrative Law

Judge (hereinafter “ALJ”), which hearing was held on September 11, 2003 (T. 281-314). The

ALJ rendered a decision adverse to Plaintiff on February 13, 2004 (T. 15-30).

The Plaintiff then petitioned the Appeals Council for review on February 19, 2004 (T.

10). The Appeals Council denied Plaintiff’s request for review on July 30, 2004 (T. 7-9), thus

making the ALJ’s decision the final decision of the Commissioner. Plaintiff now seeks judicial

review of that unfavorable decision (Doc. #1, 5). This matter is before the undersigned by

consent of the parties (Doc. #7).

Applicable Law:

Our role on review is to determine whether the Commissioner’s findings are supported

by substantial evidence in the record as a whole. See Prosch v. Apfel, 201 F.3d 1010, 1012 (8th

Cir. 2000). Substantial evidence is less than a preponderance but is enough that a reasonable

mind would find it adequate to support the Commissioner’s decision. Id. In determining

whether existing evidence is substantial, we consider evidence that detracts from the

Commissioner's decision as well as evidence that supports it. See Craig v. Apfel, 212 F.3d 433,

436 (8th Cir.2000). As long as substantial evidence in the record supports the Commissioner's

decision, we may not reverse it because substantial evidence exists in the record that would

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have supported a contrary outcome, see id., or because we would have decided the case

differently. See Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir.1993).

The Commissioner has established, by regulation, a five-step sequential evaluation for

determining whether an individual is disabled.

The first step involves a determination of whether the claimant is involved in substantial

gainful activity. 20 C.F.R. § 416.920(b). If the claimant is so involved, benefits are denied; if

not, the evaluation goes to the next step.

Step two involves a determination, based solely on the medical evidence, of whether

claimant has a severe impairment or combination of impairments. Id., § 416.920(c); see 20

C.F.R. § 416.926. If not, benefits are denied; if so, the evaluation proceeds to the next step.

The third step involves a determination, again based solely on the medical evidence, of

whether the severe impairment(s) meets or equals a listed impairment which is presumed to be

disabling. Id., § 416.920(d). If so, benefits are awarded; if not, the evaluation continues.

Step four involves a determination of whether the claimant has sufficient residual

functional capacity, despite the impairment(s), to perform past work. Id., § 416.920(e). If so,

benefits are denied; if not, the evaluation continues.

The fifth step involves a determination of whether the claimant is able to perform other

substantial and gainful work within the economy, given the claimant’s age, education and work

experience. Id., § 404.920(f). If so, benefits are denied; if not, benefits are awarded.

In addition, whenever adult claimants allege mental impairment, the application of a

special technique must be followed at each level of the administrative review process. See 20

C.F.R. § 416.920a(a).

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2Plaintiff’s seizure disorder was found to be her only severe impairment (T. 17-18).

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The Commissioner is then charged with rating the degree of functional limitation, and

applying the technique to evaluate mental impairments. See 20 C.F.R. § 416.920a(d). 

Application of the technique must be documented by the Commissioner at the ALJ hearing and

Appeals Council levels. See 20 C.F.R. § 416.920a(e). Such documentation, as referred to

within the regulations, shall be referred to herein as the PRT factors.

Discussion:

The ALJ evaluated the plaintiff’s claim according to the five-step sequential evaluation

analysis prescribed by the social security regulations. See 20 C.F.R. §§ 404.1520(a)-(f); see

also Bowen v. Yuckert, 482 U.S. 137, 140-42 (1987) (describing five-step analysis). At the first

step, the ALJ found the Plaintiff had not engaged in substantial gainful activity since Plaintiff’s

alleged onset date (T. 17). At the second step, the ALJ determined that the Plaintiff had a

severe, medically determinable impairment2 (T. 17-18). However, at step three, the ALJ found

that Plaintiff’s severe impairment did not meet or medically equal a listed impairment (T. 18). 

At the fourth step of the sequential analysis, the ALJ determined that Plaintiff maintained the

residual functional capacity to perform a wide range of work at all exertional levels (T. 19), so

long as said work did not involve driving a vehicle, working in a hazardous environment or

working at unprotected heights (T. 19, 29). Relying on the testimony of the vocational expert

(hereinafter "VE"), the ALJ determined that Plaintiff could perform her past relevant work as a 

jewelry store clerk, a collections clerk, and a cashier, as those jobs meet the criteria of Plaintiff’s

residual functional capacity (T. 28, 30). Thus, the ALJ ended the sequential analysis at step

four (T. 28-30).

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3

 See Doc. #5, pp. 12-23.

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On appeal, Plaintiff advances several arguments3 in support of her theory that the

Commissioner’s decision should be reversed. Indeed, Plaintiff’s arguments that the ALJ erred

in 1) failing to render a decision supported by substantial evidence, 2) failing to properly

consider and develop the medical evidence, and 3) failing to properly analyze Plaintiff’s alleged 

mental impairments all have merit (Doc. #5, pp.12-16).

The relevant criteria for evaluation of mental impairments is set forth in 20 C.F.R. Pt.

404, Subpt. P, App. 1, Listings 12.00 and 20 C.F.R. § 416.920a. With respect to Plaintiff’s

diagnosis of depression, the criteria used for the listed impairments is found at 20 C.F.R. Pt.

404, Subpt. P, App. 1, Listings 12.04. 

Listing 12.00 provides in relevant part:

C. Assessment of severity. We measure severity according to the functional

limitations imposed by your medically determinable mental impairment(s). We

assess functional limitations using the four criteria in paragraph B of the

listings: Activities of daily living; social functioning; concentration,

persistence, or pace; and episodes of decompensation. Where we use

"marked" as a standard for measuring the degree of limitation, it means more

than moderate but less than extreme. A marked limitation may arise when

several activities or functions are impaired, or even when only one is impaired,

as long as the degree of limitation is such as to interfere seriously with your

ability to function independently, appropriately, effectively, and on a sustained

basis. See §§ 404.1520a and 416.920a.

(emphasis added).

After the ALJ determines the extent of the four criteria above, the ALJ must then

document those findings as provided below:

(a) General. The steps outlined in §§ 416.920 and 416.924 apply to the

evaluation of physical and mental impairments. In addition, when we evaluate

the severity of mental impairments for adults (persons age 18 and over) and in

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persons under age 18 when Part A of the Listing of Impairments is used, we

must follow a special technique at each level in the administrative review

process. We describe this special technique in paragraphs (b) through (e) of this

section. Using this technique helps us:

(1) Identify the need for additional evidence to determine impairment severity;

(2) Consider and evaluate functional consequences of the mental disorder(s)

relevant to your ability to work; and

(3) Organize and present our findings in a clear, concise, and consistent manner.

(b) Use of the technique.

(1) Under the special technique, we must first evaluate your pertinent symptoms,

signs, and laboratory findings to determine whether you have a medically

determinable mental impairment(s). See § 416.908 for more information about

what is needed to show a medically determinable impairment. If we determine

that you have a medically determinable mental impairment(s), we must specify

the symptoms, signs, and laboratory findings that substantiate the presence of the

impairment(s) and document our findings in accordance with paragraph (e) of

this section.

(2) We must then rate the degree of functional limitation resulting from the

impairment(s) in accordance with paragraph (c) of this section and record our

findings as set out in paragraph (e) of this section.

(c) Rating the degree of functional limitation.

(1) Assessment of functional limitations is a complex and highly individualized

process that requires us to consider multiple issues and all relevant evidence to

obtain a longitudinal picture of your overall degree of functional limitation. We

will consider all relevant and available clinical signs and laboratory findings, the

effects of your symptoms, and how your functioning may be affected by factors

including, but not limited to, chronic mental disorders, structured settings,

medication, and other treatment.

(2) We will rate the degree of your functional limitation based on the extent to

which your impairment(s) interferes with your ability to function independently,

appropriately, effectively, and on a sustained basis. Thus, we will consider such

factors as the quality and level of your overall functional performance, any

episodic limitations, the amount of supervision or assistance you require, and the

settings in which you are able to function. See 12.00C through 12.00H of the

Listing of Impairments in appendix 1 to subpart P of part 404 of this chapter for

more information about the factors we consider when we rate the degree of your

functional limitation.

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(3) We have identified four broad functional areas in which we will rate the

degree of your functional limitation: Activities of daily living; social

functioning; concentration, persistence, or pace; and episodes of

decompensation. See 12.00C of the Listing of Impairments.

(4) When we rate the degree of limitation in the first three functional areas

(activities of daily living; social functioning; and concentration, persistence, or

pace), we will use the following five-point scale: None, mild, moderate, marked,

and extreme. When we rate the degree of limitation in the fourth functional area

(episodes of decompensation), we will use the following four-point scale: None,

one or two, three, four or more. The last point on each scale represents a degree

of limitation that is incompatible with the ability to do any gainful activity.

(d) Use of the technique to evaluate mental impairments. After we rate the

degree of functional limitation resulting from your impairment(s), we will

determine the severity of your mental impairment(s).

(1) If we rate the degree of your limitation in the first three functional areas as

"none" or "mild" and "none" in the fourth area, we will generally conclude that

your impairment(s) is not severe, unless the evidence otherwise indicates that

there is more than a minimal limitation in your ability to do basic work activities

(see § 416.921).

(2) If your mental impairment(s) is severe, we must then determine if it

meets or is equivalent in severity to a listed mental disorder. We do this by

comparing the medical findings about your impairment(s) and the rating of

the degree of functional limitation to the criteria of the appropriate listed

mental disorder. We will record the presence or absence of the criteria and the

rating of the degree of functional limitation on a standard document at the initial

and reconsideration levels of the administrative review process, or in the

decision at the administrative law judge hearing and Appeals Council levels (in

cases in which the Appeals Council issues a decision). See paragraph (e) of this

section.

(3) If we find that you have a severe mental impairment(s) that neither

meets nor is equivalent in severity to any listing, we will then assess your

residual functional capacity.

(e) Documenting application of the technique. At the initial and

reconsideration levels of the administrative review process, we will complete a

standard document to record how we applied the technique. At the

administrative law judge hearing and Appeals Council levels (in cases in

which the Appeals Council issues a decision), we will document application

of the technique in the decision.

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(1) At the initial and reconsideration levels, except in cases in which a disability

hearing officer makes the reconsideration determination, our medical or

psychological consultant has overall responsibility for assessing medical

severity. The disability examiner, a member of the adjudicative team (see §

416.1015), may assist in preparing the standard document. However, our medical

or psychological consultant must review and sign the document to attest that it is

complete and that he or she is responsible for its content, including the findings

of fact and any discussion of supporting evidence. When a disability hearing

officer makes a reconsideration determination, the determination must document

application of the technique, incorporating the disability hearing officer's

pertinent findings and conclusions based on this technique.

(2) At the administrative law judge hearing and Appeals Council levels, the

written decision issued by the administrative law judge or Appeals Council

must incorporate the pertinent findings and conclusions based on the

technique. The decision must show the significant history, including

examination and laboratory findings, and the functional limitations that were

considered in reaching a conclusion about the severity of the mental

impairment(s). The decision must include a specific finding as to the degree of

limitation in each of the functional areas described in paragraph (c) of this

section.

(3) If the administrative law judge requires the services of a medical expert to

assist in applying the technique but such services are unavailable, the

administrative law judge may return the case to the State agency or the

appropriate Federal component, using the rules in § 416.1441, for completion of

the standard document. If, after reviewing the case file and completing the

standard document, the State agency or Federal component concludes that a

determination favorable to you is warranted, it will process the case using the

rules found in § 416.1441(d) or (e). If, after reviewing the case file and

completing the standard document, the State agency or Federal component

concludes that a determination favorable to you is not warranted, it will send the

completed standard document and the case to the administrative law judge for

further proceedings and a decision. 

20 CFR § 416.920a (emphasis added).

Here, the ALJ failed to comply with the requirements as set forth above. The ALJ failed

to include proper analysis of the Plaintiff’s mental impairment which is required to be addressed

in the PRT analysis within his decision (T. 15-30). Although the ALJ address the four

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categories of analysis required in the PRT, the ALJ failed to fully consider the medical evidence

with respect to Plaintiff’s depression. The ALJ failed to mention the antidepressant medications

prescribed to Plaintiff by her physician. Plaintiff was administered Effexor, but had to

discontinue the use of Effexor due to the side effects that she experienced (T. 105, 133, 180,

181). The ALJ also failed to mention that Plaintiff not only reported her symptoms of

depression to the Commissioner, but also reported those symptoms to her treating physician, Dr.

Jeff C. Bearden, of the Amity Community Health Center, a satellite clinic of Cabun Rural

Health Services, Inc., which is located in Amity, Arkansas (T. 240). While Dr. Bearden found it

necessary to have Plaintiff sign a contract, wherein she essentially promised that she would not

harm herself, the ALJ did not include that information within his decision. Rather, the ALJ

quickly listed the PRT findings and summarily determined that Plaintiff’s depression was not a

"severe" impairment. 

A "severe" impairment is one that has "more than a minimal effect on the claimant’s

ability to work." Hudson v. Bowen, 870 F.2d 1392, 1396 (8th Cir. 1989). Plaintiff’s depression

has necessitated medication and was of such serious nature that Dr. Bearden felt it necessary to

extract a promise of no self harm from the Plaintiff. Depression to that degree would certainly

rise to the level of "more than minimal effect". Therefore, the undersigned finds that the ALJ

erred in finding Plaintiff’s depression was not a severe impairment.

Upon remand, the undersigned also suggests that the ALJ obtain consultative

evaluations with respect to Plaintiff’s seizure disorder and depression. The ALJ’s decision

clearly states that he finds Dr. Bearden’s credibility to be sorely lacking. However, the ALJ’s

finding that Dr. Bearden’s opinion was an accommodation to the Plaintiff is based on findings

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which are not supported by the record. For example, the ALJ notes that Plaintiff’s seizures

were not by Dr. Bearden. He also repeatedly points to the lack of tongue lacerations,

incontinence or other symptoms typically found in the medical records of a seizure patient. 

However, the record evidences an emergency room visit where the medical providers document

abrasions to Plaintiff’s tongue, which are consistent with a grand mal seizure (T. 216). 

However, the ALJ states that no such evidence exists. Clearly, the ALJ was mistaken. 

The ALJ also found Plaintiff’s allegations of a lack of financial means to be without

merit due to the treatment and tests Plaintiff was able to undergo. However, Plaintiff was

alleging an inability to purchase medication, not seek medical treatment. Plaintiff is a medicaid

recipient (T. 177). The record reflects that Plaintiff had Medicaid coverage for her medical

treatment. However, there is no evidence that Plaintiff received any financial assistance in

paying for prescription medication. Plaintiff consistently discussed her inability to afford

prescription medications with Dr. Bearden (T. 178, 172, 292). Plaintiff’s husband is

unemployed (T. 309, 42,. 103). Plaintiff does not receive food stamps or "welfare" (T. 289). 

Plaintiff’s mother assists Plaintiff and her family with what she can. However, there is no

payment source for Plaintiff’s prescription medications and Dr. Bearden provides Plaintiff with

samples as often as possible. Additionally, the Amity Community Health Center/Cabun Clinic,

as well as UAMS, are medical resources utilized by unemployed and uninsured patients. The

ALJ fails to consider any of these relevant issues. 

The undersigned acknowledges that the ALJ’s decision may be the same after proper

analysis. Nonetheless, proper analysis must occur. Groeper v. Sullivan, 932 F.2d 1234, 1239

(8th Cir. 1991). 

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In light of the undersigned’s decision to remand, all other issues raised by Plaintiff are

rendered moot and are not addressed herein.

Conclusion:

Accordingly, we conclude that the decision of the ALJ herein, denying benefits to the

Plaintiff, is not supported by substantial evidence of record, and should be reversed. This

matter should be remanded to the Commissioner for reconsideration consistent with this

opinion. 

ENTERED this 25th day of October, 2005.

/s/Bobby E. Shepherd 

 Honorable Bobby E. Shepherd 

 United States Magistrate Judge 

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