Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-6_04-cv-06095/USCOURTS-arwd-6_04-cv-06095-0/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

HOT SPRINGS DIVISION

CHARLES W. KING PLAINTIFF

v. Civil No. 04-6095

JO ANNE B. BARNHART, 

Commissioner, Social 

Security Administration DEFENDANT

MEMORANDUM OPINION

Factual and Procedural Background:

The plaintiff in this case has appealed the final decision of the Commissioner of the

Social Security Administration (hereinafter "Commissioner"), denying his claim 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. Both

parties have filed appeal briefs (Doc. #9 & 10). In this judicial review, the court must

determine whether there is substantial evidence in the administrative record to support the

Commissioner's decision. 42 U.S.C. § 405(g).

The history of the administrative proceedings is contained in the respective appeal briefs

and will not be recounted here except as necessary. 

The plaintiff asserts disability due to: status post bilateral total hip replacements;

arthritis; hypertension; and degenerative joint disease of the knees. The issue before this Court

is whether the Commissioner's decision is supported by substantial record evidence. 

Specifically, the plaintiff asserts that the ALJ erred in proffering a deficient hypothetical

question to the vocation expert (hereinafter “VE”); and, in discrediting his subjective

allegations and nonexertional limitations (Doc. #9, p. 1-2). 

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 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. § 404.1520(b). If the claimant is, benefits are denied; if not, the

evaluation goes to the next step.

Step 2 involves a determination, based solely on the medical evidence, of whether the

claimant has a severe impairment or combination of impairments. Id., § 404.1520(c); see 20

C.F.R. § 404.1526. If not, benefits are denied; if so, the evaluation proceeds to the next step.

Step 3 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., § 404.1520(d). If so, benefits are awarded; if not, the evaluation continues.

Step 4 involves a determination of whether the claimant has sufficient residual

functional capacity, despite the impairment(s), to perform past work. Id., § 404.1520(e). If so,

benefits are denied; if not, the evaluation continues.

Step 5 involves a determination of whether the claimant is able to perform other

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

experience. Id., § 404.1520(f). If so, benefits are denied; if not, benefits are awarded. 

The plaintiff’s current applications were protectively filed on June 21, 2002, alleging an

onset date for disability of November 11, 2001. An administrative hearing was held on

January 14, 2004 (T. 29-44), after which the ALJ issued his written decision, dated April 17,

2004, containing the following relevant findings: 

3. The medical evidence establishes that the claimant has avascular

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necrosis of the right hip status-post bilateral hip replacement and

hypertension, which are severe impairments.

4. The claimant does not have an impairment or combination of

impairments listed in or medically equal to one listed in 20

C.F.R., Part 404, Subpart P, Regulations No. 4. The factors

necessary to meet or equal the requirements of any Listing,

including 1.04 or 4.03, are not present. 

5. For reasons set out more fully in the rationale of the decision, the

claimant’s testimony as it relates to his ability to perform work is

generally credible, but even accepting his testimony as true, it is

inconsistent with disability (SSR 96-7p, 20 C.F.R. 404.1529 and

Polaski v. Heckler, 751 F.2d 943, 948 (8th Cir.1984). 

6. The claimant has a residual functional capacity for a wide range

of sedentary work which requires him to lift up to ten pounds

and occasionally lift or carry articles like docket files, ledgers and

small tools, with only occasional climbing, stooping, kneeling,

crouching or crawling. 

7. The claimant is unable to perform his past relevant work. The

testimony of the vocational expert was a key factor in making this

finding. 

10 Considering the claimant’s age, education, relevant work

experience and residual functional capacity, there are jobs which

the claimant could perform, existing in significant numbers in the

national economy. Examples of such jobs listed by the vocational

expert are printed circuit board assembler, press operator and

final assembler

11. The claimant is not disabled, as defined in the Social Security

Act, at any time since November 11, 2001. (20 CFR § 404.1566). 

 

(T. 20-21).

Applicable Law:

This court's review is limited to whether the decision of the Commissioner to deny

disability benefits to the plaintiff is supported by substantial evidence on the record as a whole. 

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Lorenzen v. Chater, 71 F.3d 316, 318 (8th Cir.1995). Substantial evidence is less than a

preponderance, but enough so that a reasonable mind might accept it as adequate to support a

conclusion. Pickney v. Chater, 96 F.3d 294, 296 (8th Cir.1996). The undersigned must

consider both evidence that supports and evidence that detracts from the Commissioner's

decision, but the denial of benefits shall not be overturned even if there is enough evidence in

the record to support a contrary decision. Johnson v. Chater, 87 F.3d 1015, 1017 (8th

Cir.1996) (citing Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir.1993). The decision should not

be reversed "merely because substantial evidence would have supported an opposite

conclusion." Harris v. Shalala, 45 F.3d 1190, 1193 (8th Cir.1995) (citation omitted). 

Moreover, the court's review is not simply "a rubber stamp for the [Commissioner's]

decision and involves more than a search for evidence supporting the [Commissioner's]

findings." Tome v. Schweiker, 724 F.2d 711, 713 (8th Cir.1984). Indeed, "[t]o determine

whether existing evidence is substantial, '[the court] must consider evidence that detracts from

the [Commissioner's] decision as well as evidence that supports it.' " Warburton v. Apfel, 188

F.3d 1047, 1050 (8th Cir.1999) (quoting Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir.1993)).

In addition, the court's review of the decision must include a determination as to whether the

proper legal standards were applied. See Nettles v. Schweiker, 714 F.2d 833, 835-36 (8th

Cir.1983). Thus, this court’s review is both limited and deferential to the agency. See

Ostronski v. Chater, 94 F.3d 413, 416 (8th Cir.1996). 

The plaintiff bears the burden of proving that he is unable to engage in substantial

gainful activity due to a medically determinable physical or mental impairment which is

expected to last for at least 12 months or result in death. 42 U.S.C. § 423(d)(1)(A). See also,

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Ingram v. Chater, 107 F.3d 598, 601 (8th Cir.1997); Nettles v. Schweiker, 714 F.2d 833, 836

(8th Cir.1983). Further, the plaintiff has the burden of showing that he is not able to perform

his past relevant work. Barrett v. Shalala, 38 F.3d 1019, 1024 (8th Cir.1994). Thus, the

plaintiff has a responsibility to present the strongest case possible. See Thompson v. Sullivan,

928 F.2d 255, 260 (8th Cir.1991).

Because the ALJ determined that this plaintiff was unable to return to his past relevant

work, the burden of persuasion shifted to the Commissioner to show that plaintiff was able to

engage in work in the national economy. Sanders v. Sullivan, 983 F.2d 822, 823 (8th

Cir.1992). In the present case, the ALJ utilized the testimony of a vocational expert

(hereinafter “VE”), to reach his decision that plaintiff was not disabled. When, as here, the ALJ

finds the plaintiff's nonexertional impairments significantly diminish his or her residual

functional capacity to perform the full range of activities listed in the Guidelines, the

Commissioner must produce expert vocational testimony or other similar evidence to establish

that there are jobs available in the national economy for a person with the plaintiff's

characteristics. Thompson, 850 F.2d at 349; see also Harris v. Shalala 45 F.3d 1190, 1194 -

1194 (8th Cir.1995).

Nonexertional limitations are limitations other than on strength but which nonetheless

reduce an individual's ability to work. Examples are mental, sensory or skin impairments, as

well as impairments which result in postural and manipulative limitations or environmental

restrictions. See 20 C.F.R. Subpart P, Appendix 2, § 200.00(e) (1986). Pain is a nonexertional

impairment. See Beckley v. Apfel 152 F.3d 1056, 1059 (8th Cir.1998); Cline, 939 F.2d 560,

565 (8th Cir.1991).

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When making determinations regarding the credibility of a plaintiff's subjective

allegations of pain, Polaski v. Heckler, 739 F.2d 1320 (8th Cir.1984), requires the

administrative factfinder to examine such matters as: (1) the claimant's daily activities; (2) the

duration, frequency and intensity of the pain; (3) dosage, effectiveness, and side effects of

medication; (4) precipitating and aggravating factors; and, (5) functional restrictions. Polaski,

739 F.2d at 1322. When rejecting a plaintiff's complaints of pain, however, the ALJ must make

an express credibility determination detailing his reasons for discrediting the testimony. Ricketts

v. Secretary of H.H.S., 902 F.2d 661, 664 (8th Cir.1990).

Further, the ALJ may discredit subjective complaints which are inconsistent with the

record as a whole. Ownbey v. Shalala, 5 F.3d 342, 344 (8th Cir.1993). The law on this issue is

clear. Under Polaski v. Heckler, 739 F.2d 1320, 1321-22 (8th Cir.1984), "an ALJ must look at

five factors when determining the credibility of a claimant's subjective allegations of pain: (1)

the claimant's daily activities; (2) the duration, frequency and intensity of the pain; (3)

aggravating and precipitating factors; (4) dosage, effectiveness and side effects of medication;

and (5) functional restrictions." Harris v. Shalala, 45 F.3d 1190, 1193 (8th Cir.1995); see also

Baker v. Sec. of HHS, 955 F.2d 552, 555 (8th Cir.1992). The absence of an objective medical

basis which supports the subjective complaints of pain is just one factor to be considered in

evaluating the credibility of a plaintiff's subjective complaints of pain. Polaski v Heckler, 751

F.2d 943, 948 (8th Cir.1984); see also, Chamberlain v. Shalala, 47 F.3d 1489, 1494 (8th

Cir.1995). The ALJ must "discuss" these factors in the hearing decision. Herbert v. Heckler,

783 F.2d 128, 131 (8th Cir.1986)(citing Polaski v. Heckler, 751 F.2d 943, 948-950 (8th

Cir.1984)). Consideration must also be given to all the evidence presented related to the

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claimant’s prior work history, and the observations of non-medical third parties, as well as

treating and examining physicians related to the above matters. 20 C.F.R. § 416.929; Social

Security Ruling 96-7p; Polaski v. Heckler, 751 F.2d 943 (8th Cir.1984)(subsequent history

omitted).

"While the claimant has the burden of proving that the disability results from a

medically determinable physical or mental impairment, direct evidence of the cause and effect

relationship between the impairment and the degree of claimant's subjective complaints need

not be produced." Polaski v. Heckler, 739 F.2d at 1322. 

To determine whether the ALJ properly applied the factors listed in Polaski, we must

determine whether the ALJ took into account all the relevant evidence, and whether that

evidence contradicted the claimant's own testimony so that the ALJ could discount the

testimony for lack of credibility. Benskin v. Bowen, 830 F.2d 878, 882 (8th Cir.1987). The

ALJ's credibility assessment must be based on substantial evidence. Rautio v. Bowen, 862 F.2d

176, 179 (8th Cir.1988). 

Implicit in the ALJ’s task of making a credibility determination is the requirement that

he "discuss" the Polaski factors. Herbert v. Heckler, 783 F.2d at 130 (the Polaski cases and the

Social Security Disability Reform Act of 1984 require that the Commissioner set forth the

inconsistencies in the objective medical evidence presented and discuss the factors set forth in

the Polaski settlement when making "credibility" determinations concerning claimant’s

subjective complaints of pain).

In summary, the ALJ must discuss and point out the inconsistencies in the record, in

order to make a credibility determination. Cline v. Sullivan, 939 F.2d 560, 565 (8th Cir.1991)

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("it is not enough that inconsistencies may be said to exist, the ALJ must set forth the

inconsistencies in the evidence presented and discuss the factors set forth in Polaski when

making credibility determinations"); Herbert v. Heckler, 783 F.2d at 131 (even though

evidence with respect to Polaski factors is in the record, those factors must be discussed in the

decision). 

Residual functional capacity is what a plaintiff can do despite his limitations, and it

must be determined on the basis of all relevant evidence, including medical records, physician's

opinions, and the plaintiff’s description of his limitations. Dunahoo v. Apfel, 241 F.3d 1033,

1039 (8th Cir.2001); see also, Anderson v. Shalala, 51 F.3d 777, 779 (8th Cir.1995); 20 C.F.R.

§§416.945(a). 

Further, the prevailing rule, in the United States Court of Appeals for the Eighth Circuit

and elsewhere, is that "the report of a consulting physician who examined the claimant once

does not constitute 'substantial evidence' upon the record as a whole, especially when

contradicted by the evaluation of the claimant's treating physician." Turpin v. Bowen, 813 F.2d

165, 170 (8th Cir.1987). However, neither is the opinion of the treating physician "conclusive

in determining disability status, [since it] must be supported by medically acceptable clinical or

diagnostic data." Matthews v. Bowen, 879 F.2d 422, 424 (8th Cir.1989). Moreover, the

deference accorded a treating physician is premised upon, as exists here, a presumed familiarity

with the plaintiff's condition. See, e.g., Peterson v. Shalala 843 F.Supp. 538, 541

(D.Neb.,1993) citing Havas v. Bowen, 804 F.2d 783, 785 (2d Cir.1986). 

The fact that a physician is not trained in the statutes and regulations of the Social

Security Act does not preclude the physician from evaluating the plaintiff. The physician's

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 This approach is consistent with Social Security Regulations that grant controlling 1

weight to a treating physician's opinion if it is "well-supported by medically acceptable clinical

and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence"

in the case. See 20 C.F.R. § 416.927(d)(2) (1993) (effective Aug. 1, 1991); Nelson v. Sullivan,

966 F.2d 363, 367-68 (8th Cir.1992) (recognizing that "the new regulation merely codifies this

circuit's law regarding the opinions of treating physicians").

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findings and conclusions constitute substantial evidence which must be carefully weighed by

the ALJ and the Commissioner. Unless there is medical evidence that contradicts or refutes the

physician's medical conclusion, the Commissioner is bound to treat the treating physician's

diagnosis and conclusion as substantial evidence. Morse v. Shalala 16 F.3d 865, 872 -873 (8th 1

Cir.1994), citing Bastien v. Califano, 572 F.2d 908, 912 (2d Cir.1978); see also Whitney v.

Schweiker, 695 F.2d 784, 789 (7th Cir.1982) ("If the ALJ concludes that a treating physician's

evidence is credible, therefore, he should give it controlling weight in the absence of evidence

to the contrary because of the treating physician's greater familiarity with the plaintiff's

conditions and circumstances."

We note, however, that although a treating physician's opinion is entitled to great

weight, it does not automatically control or obviate the need to evaluate the record as whole. 

Hogan v. Apfel 239 F.3d 958, 961 (8th Cir.2001). The ALJ may discount or disregard such an

opinion if other medical assessments are supported by superior, or more thorough medical

evidence, or if the treating physician has offered inconsistent opinions. Id; Rogers v.

Chater,118 F.3d 600, 602 (8th Cir.1997). 

Discussion:

At the outset, the plaintiff contends that the ALJ erred in that he failed to “present a

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hypothetical that included all of plaintiff’s disabilities.” (Doc. #9, p. 1). The plaintiff, stating

further, contends that the ALJ ignored the treating surgeon’s opinion of September 26, 2002:

He is stiff in his back. He is stiff in his hips. He is stiff in his knees. Certainly

with a picture of bilateral hip arthritis, aseptic necrosis. He also has some

significant arthritis in the lower back and this has the picture of an inflammatory

type of arthritis perhaps even an ankylosing spondylitis or rheumatoid. 

Although the x-rays were more of an aseptic necrosis.

Try him on some anti-inflammatories today to see if we can decrease this

morning stiffness. Placed him on Vioxx 25 daily. He still has weakness in both

hip abductors as you would expect and this man is obviously totally disabled for

any employment and really on a permanent basis.

(T. 241). Dr. Ralph Cash, an orthopedic surgeon, began treating the plaintiff on November 13,

2001. He performed the right total hip replacement surgery on February 1, 2002 (T. 221-224),

and the left total hip replacement surgery on May 9, 2002 (T. 225-227). Nonetheless, the ALJ

fails to mention Dr. Cash’s findings and opinions, much less articulate as to why the same were

discounted. This is error. 

 The ALJ should determine a plaintiff’s RFC “based on all the relevant evidence,

including the medical records, observations of treating physicians and others, and an

individual's own description of his limitations.” McKinney v. Apfel, 228 F.3d 860, 863 (8th

Cir.2000). He may not simply draw his own inferences about plaintiff's functional ability from

medical reports. Shontos v. Barnhart, 328 F.3d 418, 427 (8th Cir.2003). The ALJ must at least

minimally articulate reasons for crediting or rejecting evidence of disability. Strongson v.

Barnhart 361 F.3d 1066, 1070 (8th Cir.2004);Ingram v. Chater, 107 F.3d at 601. 

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Conclusion:

Accordingly, the undersigned concludes that the decision of the ALJ, denying benefits

to the plaintiff, is not supported by substantial evidence of record and should be reversed and

this matter remanded to the Commissioner for proper consideration of the treating physician’s

opinion. Upon remand, the parties are also directed to obtain a residual functional capacity

assessment from the treating surgeon. 

ENTERED this 24 day of August, 2005. th

/s/ Bobby E. Shepherd 

HONORABLE BOBBY E. SHEPHERD 

 UNITED STATES MAGISTRATE JUDGE

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