Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_06-cv-05058/USCOURTS-arwd-5_06-cv-05058-1/pdf.json

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

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FAYETTEVILLE DIVISION

DAWN GARDNER PLAINTIFF

VS. CIVIL NO. 06-5058

LINDA S. MCMAHON, COMMISSIONER

SOCIAL SECURITY ADMINISTRATION DEFENDANT

MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

Plaintiff, Dawn Gardner, 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 claims for disability insurance benefits (“DIB”) and supplemental

security income (“SSI”) under the provisions of Titles II and XVI of the Social Security Act (the

“Act”). 

Procedural Background:

The application for DIB and SSI now before this court were filed on May 12, 2003, alleging

an onset date of May 1, 2002, due to hip pain. (Tr. 53-55, 65, 232-234). An administrative hearing

was held on May 4, 2004, after which, the ALJ submitted written interrogatories to a vocational

expert (“VE”). (Tr. 110). A supplemental hearing was then held on November 11, 2005. (Tr. 276-

293). Plaintiff was present and represented by counsel. 

At the time of the first administrative hearing, plaintiff was twenty-six years old and

possessed a tenth grade education. (Tr. 15, 215, 220). The ALJ could not determine whether

plaintiff’s past work (as an arcade attendant, front counter helper, assembly worker, and car hop)

equated to past relevant work (“PRW”) experience. (Tr. 15, 104, 106). As such, he proceeded as

though she had no PRW. 

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On November 17, 2005, the Administrative Law Judge (“ALJ”) issued a written decision

finding that plaintiff’s right sacroiliac (“SI”) joint pain and spina bifida occulta were severe

impairments. (Tr. 11-12). However, he concluded that these impairments 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, he determined that plaintiff retained the residual

functional capacity (“RFC”) to lift ten pounds occasionally, less than ten pounds frequently, stand

and walk for two hours during an eight-hour workday, and sit for six hours. Further, he concluded

that plaintiff could occasionally balance but could not climb,stoop, crouch, kneel, or crawl and must

avoid all exposure to heights and moving machinery. (Tr. 12). With the assistance of a vocational

expert (“VE”), the ALJ determined that plaintiff could still perform work as a charge account clerk,

call out operator, microfilm document preparer, lens inserter, final assembler, compact assembler,

fishing-reel assembler, cashier II, cafeteria cashier, ticket seller, gas island cashier, parking lot

cashier, auto carwash cashier, and toll collector. (Tr. 16). 

On March 6, 2006, the Appeals Council declined to review this decision. (Tr. 2-4).

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

and recommendation. Both parties have filed appeal briefs, and the case is now ready for decision.

(Doc. # 9, 10). 

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

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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 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 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

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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), 416.920. 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. 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 in the ALJ’s RFC determination. 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.

In the present case, the pertinent medical evidence reveals as follows. On June 22, 2002,

plaintiff was treated by Dr. James Slezak for acute appendicitis. (Tr. 133-152). A laparoscopic

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appendectomy was performed and revealed a ruptured corpus luteum cyst. Records indicate that

plaintiff’s postoperative convalescence was uncomplicated. She was released home on June 24,

2002. (Tr. 133).

On April 9, 2003, plaintiff was seen in the emergency room for complaints of pain in her

right buttock that radiated into her hip. (Tr. 212). An x-ray of her hip was normal. (Tr. 215).

Accordingly, she was prescribed Naprosyn for the pain. (Tr. 212). 

On April 16, 2003, plaintiff saw Dr. H.G. Weems. (Tr. 216). She complained of hip and

groin pain. An examination revealed mild tenderness with palpation in the region of the right

buttock but Dr. Weems was unable to determine a specific tender point. He noted a full range of

motion in the hip without pain, as well as intact motor strength. Dr. Weems diagnosed plaintiff with

long-term right hip pain which was “fairly vague in nature.” Although he was unsure of the exact

cause of plaintiff’s pain, he concluded that plaintiff was a candidate for an MRI. However, plaintiff

reportedly did not have the money for the MRI and indicated she needed to speak to her husband

before proceeding. (Tr. 216).

On August 29, 2003, a non-examining, consultative physician completed an RFC assessment.

(Tr. 129). After reviewing plaintiff’s medical records, the doctor concluded that plaintiff’s physical

impairment was non-severe. This determination was affirmed by a second consultative physician

on October 21, 2003. (Tr. 129).

In December 2003, plaintiff was treated in the emergency room for an ear infection. (Tr. 154,

159). Records indicate that she was prescribed antibiotics and pain medication. (Tr. 154, 159).

On August 3, 2004, plaintiff underwent a consultative physical exam with Dr. Robert

Thompson. (Tr. 225). Plaintiff complained of groin pain and pain in the sacroiliac joint area. She

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Spina bifida occulta is a form of spina bifida. See Mark R. Foster, M.D. , Spina Bifida,

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at www.emedicinehealth. However, it oftentimes goes undetected because the skin covers the

spinal deformity and associated abnormalities of the spinal cord and roots. Id.

Marie-Strumpell or ankylosing spondylitis is a type of progressive arthritis that leads to 2

chronic inflammation of the spine and SI joints. See Andrew A. Dahl, M. D., Ankylosing

Spodylitis, Opthalmologic Perspective, at www.emedicinehealth.com.

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reported taking occasional pain medication. Plaintiff also indicated that Ibuprofen occasionally

helped reduce her pain. A physical examination revealed a normal range of motion in the hips and

knees with pain referred to the right and left SI joints on lateral bending. Extension and lateral

flexion of the lumbar spine were also limited. (Tr. 227). Further, x-rays revealed spina bifida

occulta and a possible slight anomalous appearance of the right SI joint. (Tr. 225). Therefore, Dr. 1

Thompson diagnosed plaintiff with sacroiliitis of uncertain etiology. As plaintiff’s x-rays did not

reveal sclerotic changes, he stated that he could not diagnose her with Marie-Strumpell disease .

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However, Dr. Thompson did recommend that plaintiff undergo either a bone scan or an MRI of both

hips to try to determine the cause of her pain. (Tr. 225).

On November 19, 2004, Dr. Thompson completed a physical RFC assessment. He

determined plaintiff could frequently lift up to ten pounds, rarely lift more than ten pounds, sit four

hours in an eight hour day, stand for two hours during an eight hour day, and occasionally balance.

(Tr. 230). However, he noted plaintiff could not climb, stoop, crouch, kneel or crawl. Dr. Thompson

also indicated plaintiff would need to avoid all exposure to heights and moving machinery. (Tr.

230).

After reviewing this evidence, the ALJ concluded that plaintiff could lift ten pounds

occasionally, less than ten pounds frequently, stand and walk for two hours during an eight-hour

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workday, sit for six hours, occasionally balance, and never climb, stoop, crouch, kneel, or crawl. (Tr.

12). He also determined that plaintiff must avoid all exposure to heights and moving machinery.

In so doing, the ALJ acknowledged that his findings regarding plaintiff’s ability to sit varied from

the rating provided byDr. Thompson. He went on to state that Dr. Thompson’s finding that plaintiff

could sit no more than two hours during an eight-hour workday was not supported by any objective

medical findings or tests. However, we note that the ALJ adopted Dr. Thompson’s findings with

regard to plaintiff’s ability to lift and carry, stand and walk, balance, climb, stoop, crouch, kneel,

crawl, and be exposed to heights and moving machinery. We are hard pressed to see how Dr.

Thompson’s finding with regard to plaintiff’s ability to sit is not supported by objective medical

evidence while his other findings are. Clearly, Dr. Thompson used the same x-ray results and

findings from his physical examination to draw his conclusions concerning all of the limitations he

assessed in his RFC assessment.

Aside from Dr. Thompson’s assessment, there is also no additional medical evidence in the

record to indicate plaintiff’s limitations. While the record does contain one RFC assessment

completed by a non-examining, consultative physician, this doctor concluded that plaintiff’s

impairment was non-severe. As such, this assessment is of no use to the ALJ. This leave the ALJ

with only the RFC of Dr. Thompson. Because there is no evidence in the record to show that

plaintiff is able to sit for more than two hours during an eight-hour workday, we believe that remand

is necessary to allow the ALJ to revisit plaintiff’s RFC. Id.

Further, we note Dr. Thompson recommended that plaintiff undergo further evaluation to

consist of either a bone scan or an MRI. There is, however, no evidence in the record to indicate

that plaintiff was ever sent for either of these procedures. In fact, there is no evidence whatsoever

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to show that the ALJ ordered any additional evaluations of plaintiff. The ALJ does have a duty to

fully develop the record regarding a claimant’s impairments. See Stormo v. Barnhart, 377 F.3d 801,

806 (8th Cir. 2004). That duty includes seeking clarification from treating physicians if a crucial

issue is undeveloped or underdeveloped. Id. The ALJ is also required to recontact medical sources

and may order consultative evaluations when the available evidence does not provide an adequate

basis for determining the merits of the disability claim. See 20 C.F.R. §§ 416.912(e), 416.919a(b).

Given the fact that Dr. Thompson recommended that plaintiff undergo further evaluation to pinpoint

the cause of her pain, we believe that remand is necessary to allow the ALJ to further develop the

record in this regard.

These is also evidence to suggest that plaintiff might not have sought more consistent

medical treatment due to a financial inability to do so. “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 [s]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 711, 714 (8th Cir. 1984). 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 also directed to consider plaintiff’s financial situation

and what effect, if any, it has had on her ability to obtain medical treatment.

Conclusion:

Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore recommend that the denial of benefits to the plaintiff be reversed and this matter be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

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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 day 7th of February 2007.

/s/ J. Marschewski

HON. JAMES R. MARSCHEWSKI

UNITED STATES MAGISTRATE JUDGE

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