Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_04-cv-05211/USCOURTS-arwd-5_04-cv-05211-0/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

FAYETTEVILLE DIVISION

RONALD SWAYZE PLAINTIFF

v. CIVIL NO. 04-5211

JO ANNE B. BARNHART, Commissioner

Social Security Administration DEFENDANT

MEMORANDUM OPINION

Plaintiff Ronald Swayze 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 December 27,

2002, alleging an inability to work since December 31, 2000, due to a back disorder,

degenerative disc/joint disease, osteoarthritis of the right foot. (Tr. 53-55, 222-224). An

administrative hearing was held on November 20, 2003. (Tr. 280-319). Plaintiff was present

and represented by counsel. 

By written decision dated January 29, 2004, the ALJ found that plaintiff has an

impairment or combination of impairments that are severe. (Tr. 20). However, after reviewing

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

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

Subpart P, Regulation No. 4. (Tr. 20). The ALJ found plaintiff retained the residual functional

capacity (RFC) to perform a full range of medium work. (Tr. 19-20). The ALJ then found

plaintiff was able to perform his past relevant work as a janitor. (Tr. 20).

Plaintiff appealed the decision of the ALJ to the Appeals Council. After considering

additional medical evidence submitted by plaintiff, plaintiff's request for review of the hearing

decision was denied on June 18, 2004. (Tr. 4-9). 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 pursuant to the consent of the parties. (Doc. # 6,7).

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

Commissioner's decision, the court may not reverse it simplybecause 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

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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)©). 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

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.

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We note we consider this evidence, as it was submitted to the Appeals Council and the Appeals Council considered it 1

 before denying review. (Tr. 4-9) See Riley v. Shalala, 18 F.3d 619, 622 (8th Cir. 1994).

4

Discussion:

Of particular concern to the undersigned is the ALJ’s RFC assessment. The ALJ has a duty

to fully and fairly develop the record. See Frankl v. Shalala, 47 F.3d 935, 938 (8th Cir. 1995);

Freeman v. Apfel, 208 F.3d 687, 692 (8th Cir. 2000). It is incumbent upon the ALJ to establish

by medical evidence that the claimant has the requisite RFC and to question a claimant in detail

about his abilities. 

In the present case, the medical evidence reveals plaintiff has sought treatment for

chronic pain in his neck and back. In April of 2003, plaintiff was examined by Dr. Richard Kyle,

a neurologist, who did not recommend surgery but did recommend an examination by an

orthopedic surgeon should plaintiff continue to have problems in spite of physical therapy. (Tr.

162 ). Since April of 2003, plaintiff has continued to report experiencing pain in his neck and

back. (Tr. 164, 196-197, 210, 212-213, 216-217, 220, 254). Plaintiff’s examining physicians

have also noted plaintiff walks with a stooped posture and that he has a moderate to marked

limitation of cervical extension and lateral movements. (Tr. 210, 213, 255). 

1

The ALJ, in concluding that plaintiff could perform the exertional and non-exertional

requirements of a full range of medium work, relied on a RFC assessments completed by a nonexamining, medical consultants, indicating plaintiff could perform medium work. (Tr. 132-139).

We note that the opinion of a consulting physician who examined the plaintiff once or not at all

does not generally constitute substantial evidence. See Jenkins v. Apfel, 196 F.3d 922, 925 (8th

Cir. 1999). Furthermore, neither of these consultants had the benefit of reviewing the cervical

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MRI dated November 6, 2003, indicating plaintiff had a minimal disk protrusion which was

paracentral and slightly to the left at C6-7, moderate spondylosis of the anterior vertebral bodies

and disk narrowing at C3-4, C4-5 and C5-6. (Tr. 209). Cervical spine x-rays showing multilevel

degenerative disc disease taken in January of 2004, were also unavailable to these consultants.

Based on the all the medical evidence of record, we find that the ALJ’s determination that

plaintiff can perform a full range of medium work is not supported by substantial evidence. 

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, Drs. Borian B. Matinchev, Anne Miller and Richard

Kyle--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.

On remand the ALJ should also re-evaluate plaintiff's subjective allegations in

accordance with Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984), specifically discussing

each Polaski factor in the context of plaintiff's particular case. The ALJ should specifically

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address plaintiff's side effects to prescribed medication including Zanaflex which appears to have

caused a syncope episode. (Tr. 259-271).

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, such as limitations in sitting, standing and using his extremities.

Finally, on remand, we suggest that the ALJ address plaintiff's allegations of the lack of

finances to obtain treatment. 

Conclusion:

Based on the foregoing, we hereby reverse the decision of the ALJ and remand this case

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

DATED this 26 day of September 2005. th

/s/ Beverly Stites Jones 

HON. BEVERLY STITES JONES

UNITED STATES MAGISTRATE JUDGE

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