Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-3_05-cv-03003/USCOURTS-arwd-3_05-cv-03003-0/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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At the administrative hearing held on December 2, 2003, plaintiff amended his alleged onset date to June 28, 2002. 1

 (Tr. 409).

The vestibular organs of the inner ear provide the brain with information about changes in head movement. If the 2

 vestibular system is not functioning properly, dizziness, vertigo, imbalance, spatial disorientation, and other symptoms

 can result. 

http://www.vestibular.org/vestibular-disorders/causes-of-dizziness/dizziness-caused-by-vestibular-disorders.php

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HARRISON DIVISION

JAMES HARVEY GASH PLAINTIFF

v. CIVIL NO. 05-3003

JO ANNE B. BARNHART, Commissioner

Social Security Administration DEFENDANT

MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION

Plaintiff James Harvey Gash 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

(Commissioner) denying his claims for period of disability and disability insurance benefits

(DIB) and supplemental security income (SSI) benefits under the provisions of Titles II and XVI

of the Social Security Act (Act). 

Procedural Background:

The applications for DIB and SSI presently before this court were filed on October 7,

2002, alleging an inability to work since September 5, 2001, due to pain in his back, head and 1

neck; a disorder of the back; headaches; a vestibular disorder; and a cognitive deficit. (Tr. 60- 2

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62). An administrative hearing was held on December 2, 2003. (Tr. 392-446). Plaintiff was

present and represented by counsel. 

By written decision dated February 26, 2004, the ALJ found that plaintiff has an

impairment or combination of impairments that are severe. (Tr. 22). However, after reviewing

all of the evidence presented, he determined that plaintiff’s impairments do not meet or equal the

level of severity of any impairment listed in the Listing of Impairments found in Appendix I,

Subpart P, Regulation No. 4. (Tr. 22). The ALJ found plaintiff retained the residual functional

capacity (RFC) to perform a significant range of sedentary work. More specifically, the ALJ

found plaintiff is restricted from exposure to hazards and from driving an automobile or

dangerous moving machinery; that he is able to frequently finger bilaterally; and is able to

perform work that requires simple one-two steps. (Tr. 22). With the help of vocational expert

testimony, the ALJ found plaintiff can perform assembly work. (Tr. 23).

Plaintiff appealed the decision of the ALJ to the Appeals Council. Plaintiff’s request for

review of the hearing decision was denied on November 26, 2004. (Tr. 3-5). When the Appeals

Council declined review, the ALJ’s decision became the final action of the Commissioner.

Plaintiff now seeks judicial review of that decision. (Doc. #1). Both parties have submitted

appeal briefs and this case is before the undersigned for report and recommendation. (Doc. #

5,6).

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

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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 maynot 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 prevents him 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 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

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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, 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 residual functional capacity. See McCoy v. Schwieker, 683 F.2d 1138,

1141-42 (8th Cir. 1982); 20 C .F.R. §§ 404.1520, 416.920.

Discussion:

In the present case, the undersigned is particularly trouble by 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). This includes medical records,

observations of treating physicians and others, and the claimant’s own descriptions of his or her

limitations. 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,

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353 F.3d 642, 646 (8th Cir. 2003). “Under this step, the ALJ isrequired to set forth specifically

a claimant’s limitations and to determine how those limitations affect her RFC.” Id.

The medical evidence establishes plaintiff, who worked as a logger and sawmill worker,

sustained head injuries as a result of two on the job injuries in September of 2001, and June of

2002, respectively. (Tr. 138, 142-144, 148-150, 185, 190-194, 347-354). Plaintiff has continued

to complain of dizziness, balance problems and back and neck pain since the accident in 2002.

(Tr. 163-165, 181-182, 185-186, 168-171, 206, 216, 269,272-274,276-279, 292-293). The ALJ

determined plaintiff obtained the RFC to perform a wide range of sedentary work but was

restricted to performing one and two step tasks and could not work around moving machinery.

We are particularly concerned with the ALJ’s determination with regard to plaintiff’s

alleged cognitive deficit. (Tr. 19). A review of the record indicates that Dr. Bruce L. Safman

recommended plaintiff undergo neuropsychological testing to determine if plaintiff had a

cognitive impairment on numerous occasions. (Tr. 276-277, 280). On April 28, 2003, Dr.

Safman indicated plaintiff was able to clearly remember past medications since his injury, but

he could not recall the medication he was taking at bedtime. (Tr. 275). On June 16, 2003, Dr.

Safman stated it was “critical” that he obtain the results from plaintiff’s psychological testing so

that he could declare plaintiff at maximum medical improvement or order additional intervention

if necessary. (Tr. 272). The ALJ noted that Dr. Safman had recommended neuropsychological

testing but justified not obtaining these test results or sending plaintiff for a consultative

evaluation by noting Dr. Safman reported that despite plaintiff’s memory deficit there were

certain things plaintiff was able to recall very clearly, such as past medication. (Tr. 19). While

Dr. Safman did indicate plaintiff was able recall some of his past medications on April 28, 2003,

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he also noted plaintiff could not recall the medication he was taking at bedtime. Furthermore,

on June 16, 2003, Dr. Safman indicated it was critical to have the results from plaintiff’s

neuropsychological testing. (Tr. 272). On April 7, 2003, Dr. Safman indicated that to treat

plaintiff effectively it was critical to know whether or not plaintiff had a cognitive impairment.

If plaintiff’s treating physician was unable to establish plaintiff’s cognitive ability without these

test results, we are troubled by the ALJ’s determination of plaintiff’s cognitive abilities

especially since there is no medical evidence in the record indicating what exactly plaintiff is

capable of performing. 

We are also troubled with the ALJ’s physical RFC determination. On September 3, 2003,

Dr. Justice, plaintiff’s treating physician, completed a Physical Residual Functional Capacity

Questionnaire, opining that due to chronic dizziness, lower back pain, post traumatic headaches

and neck pain, plaintiff could perform less than sedentary work. (Tr. 283-286). The ALJ did not

discuss in detail his reasoning for discounting Dr. Justice’s opinion, rather he simply stated that

the assessment was not supported by the overall medical evidence of record but certain aspects

of the assessment were consistent with his RFC determination. We note, whether the ALJ

grants a treating physician's opinion substantial or little weight, the regulations provide that the

ALJ must “always give good reasons” for the particular weight given to a treating physician's

evaluation. 20 C.F.R § 404.1527(d)(2); see also SSR 96-2p; See Prosch v. Apfel, 201 F.3d at

1010, 1012-13 (8th Cir. 2000). Further, in making his RFC determination, the ALJ also failed

to address the limitations recommended in the RFC assessment dated January 10, 2003,

completed by a non-examining consultant, indicating plaintiff could not turn quickly or arise

quickly, could not walk over rough or uneven ground, could not walk in poor illumination or

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We note there is a RFC assessment completed by a non-examining consultant dated November 4, 2002, indicating 3

 plaintiff can perform medium work. (Tr. 195-202). However, this assessment was completed prior to much of

 plaintiff’s treatment for his alleged impairments.

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over slippery services, could not change positions frequently and could occasionally slowly reach

overhead with the left arm. (Tr. 219-226). After reviewing the entire evidence of record, we do 3

not find substantial evidence to support the ALJ’s RFC determination. 

Based on the above discussion, we believe remand is warranted so that the ALJ can more

fully and fairly develop the record. On remand, the ALJ is directed to address interrogatories to

the physicians who have evaluated and/or treated plaintiff–including, Dr. Safman --asking the

physicians to review plaintiff's medical records; to complete a 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). The ALJ may also order a consultative exam, in which, the consultative examiner should

be asked to review the medical evidence of record, perform a physical examination and

appropriate testing needed to properly diagnosis plaintiff's condition and level of pain, and

complete a medical assessment of plaintiff's ability to perform work related activities. See 20

C.F.R. §§ 404.1517, 416.915.

With regard to plaintiff’s cognitive abilities, the ALJ is directed to obtain the test results

from plaintiff’s neuropsychological testing. If these test results cannot be obtained, we strongly

suggest the ALJ send plaintiff for a consultative neuropsychological evaluation. This consultative

examiner should be asked to review the medical evidence of record, perform examinations and

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appropriate testing needed to properly diagnosis plaintiff's condition(s), and complete a medical

assessment of plaintiff's mental abilities to perform work related activities. See 20 C.F.R. §§

404.1517, 416.917.

With this evidence, the ALJ should then re-evaluate plaintiff's RFC and specifically list

in a hypothetical to a vocational expert any limitations that are indicated in the RFC assessments

and supported by the evidence.

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 14 day of February 2006. th

/s/ Beverly Stites Jones 

HON. BEVERLY STITES JONES

UNITED STATES MAGISTRATE JUDGE 

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