Source: http://www.socialsecurity.gov/OP_Home/hallex/I-05/I-5-4-18.html
Timestamp: 2014-07-30 09:04:14
Document Index: 355867039

Matched Legal Cases: ['§ 404', '§ 404', '§ 404', '§ 404', '§ 404', '§ 553', '§ 553', '§ 404', '§ 404', '§ 404', '§ 404']

HALLEX I-5-4-18
I-5-4-18.Processing Pending Cases Under Samuels
Provisions of Court's Order
Hearing Office Adjudication of Pending Cases under the Samuels Order
Appeals Council Actions
Court Orders Dated August 19, 1986 and March 16, 1987
POMS DI 24515.060 Regarding Pain
Samuels Checklist
Order for Return of Case to Tennessee Disability Determination Section
Sample Medical Development Form
Sample Appeals Council Remand Order
ISSUED: August 24, 1987
This Instruction is being issued nationally for informational purposes; however, the provisions of the court's order apply only to the adjudication of cases involving residents of Tennessee. These instructions relate to the adjudication of pending and prospective cases of class members. Procedural instructions for processing claims of retroactive class members will be issued at a later date. I. Background
On December 13, 1985, in the case of Samuels, et. al. v. Bowen, et. al, the United States District Court for the Western District of Tennessee remanded Samuels class member cessation cases under Section 2 of P.L. 98-460, the Social Security Disability Benefits Reform Act of 1984. Subsequently, on August 19, 1986, the U. S. District Court issued a summary judgment order which provided specific relief for class members, including those with claims for initial entitlement. A copy of this order was provided to all hearing offices servicing Tennessee residents. On March 16, 1987, the district court issued a final judgment which incorporated by reference its August 19, 1986 order. Copies of the last two orders are provided at Attachment A. These instructions are being issued to comply with the terms of the order and to familiarize adjudicators with changes in Tennessee Disability Determination Section case development and adjudication procedures. II. Definition of Class
The Samuels class includes all title II and/or title XVI claimants who: A. Resided (reside) in the State of Tennessee on or after August 25, 1982; and Received a notice of an initial or reconsideration disability denial/cessation determination from the Tennessee Disability Determination Section, dated on or after August 25, 1982, or
Filed a request for reconsideration on a disability denial/cessation determination by the Tennessee Disability Determination Section or were still within the time frames to file a request for reconsideration, on or after October 29, 1982; or
Filed (pursued or were pursuing) an appeal to the Administrative Law Judge hearing level on a disability denial/cessation by the Tennessee Disability Determination Section, or were still within the time frames for filing an appeal to the Administrative Law Judge, on or after October 29, 1982.
A claimant who received an Administrative Law Judge decision on or after October 29, 1982, and appealed that decision to a higher level is a class member. A claimant who received an Administrative Law Judge decision on October 28, 1982, or earlier, is not a class member.)
Based on a stipulation agreement, the class includes title II disabled adult children whose claims for child disability benefits have been denied or whose entitlement to such benefits have been ceased. The class also includes title II disabled widow's, widower's, or surviving divorced wife's benefits and title XVI disabled child benefits for children under age 18 based on disability; whose entitlement to such benefits have been ceased, but excludes such individuals whose initial claims for such benefits were denied.
Further information regarding the class definition will be provided when instructions are issued with respect to processing class members' cases.
III. Provisions of Court's Order
The court's March 16, 1987 order grants relief with regard to a number of issues and requires class members be notified that they may request review of title II and/or title XVI cases denied or ceased by the Tennessee Disability Determination Section. The relief ordered is as follows.
The Tennessee Disability Determination Section must request “medical assessments” from all treating and consulting physicians from whom evidence is requested (or has been previously received).
Treating sources of class members must be used for consultative examinations whenever possible (in every instance in which the treating source is not used, the specific reason should be documented).
Opinions of treating sources as to the extent and severity of class members' impairments must be accorded the weight required by Sixth Circuit precedent when determining disability. (Note: The court found that SSA policy as reflected in SSR 82-48c is consistent with Sixth Circuit precedent.)
An individualized assessment of residual functional capacity must be performed on all claimants with obstructive airway disease who have a medically determinable impairment and are not found to be disabled under the Listing of Impairments. (A claimant who does not meet or equal the listings can not be presumed to have a residual functional capacity for at least a full range of sedentary work.)
Cases of class members involving allegations of pain adjudicated between August 25,1982 and August 1, 1985 must be reevaluated using standards consistent with Sixth Circuit precedent. (The court found that SSA policy reflected in the Program Operations Manual System DI 24515.060, Attachment B, is consistent with Sixth Circuit precedent.
Cases of class members that were denied or ceased on the basis of a nonsevere impairment on or after August 25, 1982, and before December 1, 1984, must be reopened and reconsidered in light of the combined effect of nonsevere impairments (in a manner consistent with Social Security Ruling 85-28).
Cases of class members that were denied or ceased on or after August 25, 1982, on the basis of the list of 20 impairments formerly considered to be not severe (published in Program Operations Manual System DI 00401.410 and Social Security Ruling 82-55, and rescinded in April 1985), must be reopened and reconsidered using individualized assessments of the severity of an impairment(s) (in a manner consistent with Social Security Ruling 85-28), and of the claimant's residual functional capacity if the claimant's impairment(s) is found to be severe
IV. Hearing Office Adjudication of Pending Cases under the Samuels Order
A. Tennessee Disability Determination Section Handling of Samuels Cases
The Tennessee Disability Determination Section will complete a checklist on unfavorable Samuels cases to document that all issues contained in the court's order have been considered (Attachment C). Cases adjudicated (date determination signed) by the Tennessee Disability Determination Section before November 17, 1986 will not contain a checklist because the Samuels procedures were not in effect prior to that date. In “pipeline” cases. The checklist will be annotated on its face that it is a pipeline case. Tennessee Disability Determination Section pipeline cases are those claims that were received by that office before November 17, 1986, the effective date of the Samuels instructions, and which were adjudicated (date determination signed) by the Tennessee Disability Determination Section on or after November 17, 1986, but before February 1, 1987, the date by which the State achieved full implementation of the Samuels instructions and documentation requirements. These pipeline cases may or may not contain complete Samuels documentation.
The effective date of implementation for Tennessee Disability Determination Section purchase of consultative examinations from treating physicians (when possible) was December 23, 1986. Some cases may have been released by the Tennessee Disability Determination Section after February 1, 1987 with consultative examinations that either were not performed or were not requested to be performed by treating sources. This would have occurred because the consultative examination was scheduled or purchased prior to December 23, 1986. In such circumstances, the record will not contain any documentation of why the Tennessee Disability Determination Section used a non-treating source. Procedures for addressing this problem are discussed in detail below.
The court's August 19, 1986 order and March 16, 1987 judgement do not prescribe the specific form in which a medical assessment must be requested. However, the orders provide that the medical assessment must be complete enough to allow the Tennessee Disability Determination Section to make a determination of the claimant's residual functional capacity and, “...at a minimum, shall request how many hours in an eight-hour day a claimant can walk, stand and sit and how much weight can be lifted for one-third and two-thirds of a work day.” Forms SSA-1151 (Medical Assessment of Ability to Do Work-Related Activities (Physical) and SSA-1152 (Medical Assessment of Ability to Do Work-Related Activities (Mental)) are consistent with the requirements of the court's order and may be utilized when requesting medical assessments from either treating or consulting physicians. Additional information regarding Tennessee Disability Determination Section handling of Samuels cases is contained in Program Operations Manuals System DI 32555.001ff.
B. Hearing Office Actions
1. Determining Need for Samuels Documentation
The initial OHA workup of Samuels cases should be directed toward determining compliance with Samuels development and documentation requirements. Any significant deficiencies should be brought to the attention of the Administrative law Judge for a determination of necessary development action. Cases should fall into one of three categories:
OHA pipeline cases, i.e., cases with initial or reconsideration determinations released by the Tennessee Disability Determination Section before November 17, 1986, the effective date of the implementation of the Samuels instructions, which will contain no Samuels documentation or checklist;
Tennessee Disability Determination Section pipeline cases, i.e, those pending on or after November 17, 1986, the effective date of the Samuels instructions, and released prior to February 1, 1987, which may or may not contain full Samuels documentation; and
Cases released by the Tennessee Disability Determination Section on or after February 1, 1987, when Samuels documentation was fully implemented, which should contain full Samuels documentation (except that a nontreating physician may have performed a consultative examination if it was scheduled or purchased prior to December 23, 1986, and there may be no explanation why a treating physician was not utilized).
As noted above, the court's order primarily affects case processing in the Tennessee Disability Determination Section; nonetheless, Administrative Law Judges must ensure that all of the requirements of the court's order have been met, e.g., that medical assessments have been requested from treating and consulting physicians when necessary. The Tennessee Disability Determination Section checklist should contain all necessary documentation with respect to Tennessee Disability Determination Section-initiated development and, because it is part of the official case record, the checklist should be marked as an exhibit along with any documents referred to on the checklist. However, since the Tennessee Disability Determination Section did not fully implement Samuels development and documentation procedures until February 1, 1987, some cases at the hearing level may require action to complete Samuels development and documentation, as indicated in sections 2. and 3. below.
2. Returning Cases to the Tennessee Disability Determination Section
Cases pending at the hearing level which were not processed by the Tennessee Disability Determination Section in accordance with Samuels procedures (i.e., the Tennessee Disability Determination Section did not satisfy Samuels development and documentation requirements), and which require extensive development which cannot be efficiently accomplished by the hearing office, may be returned to the Tennessee Disability Determination Section for Samuels development and/or documentation and a revised determination. The Tennessee Disability Determination Section must either obtain the appropriate development or document the record as to why it cannot be obtained. However, no court remand case, regardless of the date the case was remanded, may be returned. (A few court remands in which the court itself specified return to the Tennessee Disability Determination Section were sent directly to that location).
Generally, cases requiring extensive development will be cases which were released by the Tennessee Disability Determination Section before February 1, 1987, the date by which Samuels documentation was fully implemented. Cases should not be routinely returned based on the date of the Tennessee Disability Determination Section's action, although it is anticipated that many cases in which denial notices were released before February 1, 1987 will require some Samuels development. Each case must be carefully examined to determine its compliance with the requirements of the Samuels order. A case should not be returned unless extensive Samuels development cannot be efficiently accomplished by the hearing office. A case which requires only updated treatment information and medical assessments which can be obtained through direct purchase authority should not be returned. Cases which are remanded by the Appeals Council on or after the date of these instructions should not be returned to the Tennessee Disability Determination Section, since the Appeals Council will already have made the judgement as to whether extensive development is required. When a fully favorable on-the-record decision can be made, this action should be taken irrespective of the adequacy of the Samuels documentation. Additionally, if a case appears to meet Samuels requirements, including documentation, except that a consultative examination of record was not obtained from a treating source and there is no documentation why (e.g., because it was scheduled or purchased before December 23, 1986), return to the Tennessee Disability Determination Section would be inappropriate. Rather, the evidence, including any additional evidence received with the request for hearing should be evaluated to determine if a need exists to obtain another examination. (See IV.B.4., below, for a discussion of obtaining new consultative examinations from treating sources when the record is otherwise complete.) If it is determined that the record is complete and sufficient for adjudication, the reason why a treating source was not necessary should be documented in the decision as discussed in IV.B.4., below. If another consultative examination is necessary, but the record is otherwise sufficient, the Tennessee Disability Determination Section should be asked to obtain the necessary examination in accordance with OHA's standard development procedures.
If return to the Tennessee Disability Determination Section is warranted, use the sample order which appears at attachment D. The HA-5051 transmitting the case should be annotated regarding the development which the Administrative Law Judge believes is needed. Send copies of the order to the claimant, the representative, if any, the servicing Social Security office, the OHA Atlanta Regional Office, attn: Alice Jones, and to the Division of Litigation Coordination and Implementation, Room 302, Ballston Center Tower II, P.O. Box 10723, Arlington, VA 22210. See section V. for coding procedures for returned cases. If the Tennessee Disability Determination Section questions the propriety of a particular case, it will refer the inquiry to the Regional Commissioner's Office for coordination with the OHA Regional Office. The OHA Regional Office should refer questions to the Chief Administrative Law Judge.
3. Hearing Office Development of Medical Assessment under Samuels
If a necessary medical assessment or documentation regarding its absence is not already part of the record and extensive Samuels development is not necessary, undertake appropriate development. (This action is not necessary if the Administrative Law Judge has determined that the evidence of record justifies issuing a fully favorable decision.) If the medical report for which a medical assessment is needed was furnished more that 12 months before the date of adjudication, or, if in the judgement of the adjudicator, a new report is needed, request an updated medical report. The sample form at Attachment E may be used to obtain Tennessee Disability Determination Section assistance for this purpose, or the hearing office may contact the treating or nontreating source directly. Requests for medical reports and/or assessments, if not made through the Tennessee Disability Determination Section, need not be made in any specific manner, or on any specific form (although Forms SSA-1151 and/or SSA-1152 may be utilized, but must specify the requirements set forth for medical assessment information in the court's judgement of March 16, 1987 (see paragraph IV.A., above, and the court's March 16 judgement at Attachment A).
Because of the considerable Samuels workload in the Tennessee Disability Determination Section, the hearing office's direct purchase authority should be used whenever possible to obtain medical reports and assessments from treating sources. This is particularly so in cases requiring special handling, e.g., court remands or delayed cases. Information regarding direct purchase of medical evidence, including sample language, is contained in ADS Guide g135-1. Direct purchase should not be used to request a medical assessment from a consulting physician when the needed assessment is not furnished in connection with a current consultative examination requested by the Administrative Law Judge. Since the medical assessment should have been a part of the consulting physician's report, ordinarily the Disability Determination Section should be asked to contact the consulting physician for the assessment. If it is necessary to obtain a medical assessment (s) in connection with a consultative examination report which was previously of record, and special circumstances warrant, the assessment(s) may be obtained by direct purchase.
Frequently, treating or consulting sources will provide medical assessments as part of their narrative report. Such medical assessments may be sufficient, provided they furnish information upon which to make a determination of residual functional capacity and otherwise satisfy the requirements set forth in the court's order (see paragraph IV.A., above). When new evidence from a treating source is introduced at the hearing level without a medical assessment, a medical assessment must be requested unless the Administrative Law Judge has determined that the evidence of record justifies the issuance of a fully favorable decision.
4. Obtaining Consultative Examinations under Samuels
When the Administrative Law Judge concludes that a consultative examination(s) is needed, the development request to the Tennessee Disability Determination Section should identify the treating source(s) the Administrative Law Judge desires to perform the consultative examination. If the Administrative Law Judge has a specific preference as to which treating source should perform a consultative examination, it is important that this preference and the reason (s) for the preference be clearly stated in the request for Tennessee Disability Determination Section assistance. If the record reveals any facts which may require using a non-treating source to perform the consultative examination (e.g., any of the reasons provided in section 2 of Attachment C), such facts should be brought to the attention of the Tennessee Disability Determination Section so that an appropriate consultative examination source can be selected. Additionally, the decisional rationale must fully explain why a non-treating source was selected. The sample form at Attachment E may be used for the purpose of providing the above information.
If a consultative examination(s) of record was not obtained from a treating source and there is no documentation as to why (usually because it was scheduled or purchased prior to December 23, 1986), but the record is otherwise complete and sufficient for adjudication (including medical assessment from treating sources), and it would result in unnecessary expense and delay to obtain another examination, the Administrative Law Judge need not routinely undertake further development. However, careful consideration must be given in light of all of the available facts and evidence in the case as to whether a consultative examination from a treating source should be obtained. This should include consideration of whether the claimant has objected to the lack of a consultative examination from a treating source and whether an examination from a treating source might have an impact on the final decision. If a treating source consultative examination is not obtained, the decisional rationale must fully explain the reason why. If the reason is related to the treating source's qualifications, the record must contain a professional qualifications statement or other documentation of qualifications for both the treating source and for the source which was actually used.
5. Adjudication and Decisionmaking
The court indicated that Social Security Ruling 82-48c regarding consideration of treating sources' opinions is consistent with Sixth Circuit precedent. Therefore, when a conflict exists in the evidence as to the extent and severity of a claimant's impairment, treating source opinion evidence is entitled to great weight unless there are serious questions as to the treating source's qualifications, the nature and duration of the treating source's relationship to the claimant, or the extent to which the treating source's opinion is supported by the medical data. If the treating source opinion is not accepted, or not accorded great weight, the reason must be fully documented and explained in the Administrative Law Judge's decision. The Administrative Law Judge's decisional rationale should describe the opinion and medical findings provided by treating medical source(s), the pertinent nonmedical findings, and provide a full explanation as to why the total evidence clearly contradicts the opinion(s) of the treating source(s), if such is determined to be the case. Additionally, if the reason for not according great weight to a treating source's opinion is related to his/her qualifications, a professional qualifications sheet should be prepared and entered into the record.
The court found the current Program Operations Manual System instructions on pain, which were developed following enactment of the Social Security Disability Benefits Reform Act of 1984, to constitute the proper standard to be followed by the Secretary in the Sixth Circuit. Accordingly, Administrative Law Judges should follow these instructions (see Attachment B) until such time as revised regulations are published or a Social Security Ruling is issued.
The provisions of the court order with respect to the evaluation of nonsevere impairments are fully consistent with the provisions of SSR 85-28.
6. Determining Who is a Treating Source
For purposes of these instructions, a “treating source” is a licensed physician or osteopath, a licensed or certified psychologist, or a licensed optometrist (for the measurement of visual acuity and visual fields only), who has an ongoing treatment relationship with the claimant for an impairment or impairments alleged to cause disability. This longitudinal relationship is not determined merely by the number of visits or length of the relationship. In determining whether an ongoing relationship exists, we look at the nature of the medical conditions involved along with the need for and the number of medical visits over a period of time. All conditions may not require regular, ongoing treatment. A physician who has treated the claimant since onset, regardless of the recency of onset, could be considered to have a longitudinal relationship.
7. Special Decisional Language
The decisional rationale should clearly reflect how the Samuels criteria were applied. In addition to this individualized rationale, the decisional paragraph in unfavorable or partially favorable cases should include the following language:
My conclusion in this case complies with Sixth Circuit precedent with regard to the evaluation of pain and the weight to be afforded treating physician opinion, as well as the other adjudicative criteria set forth in the August 19, 1986 order and March 16, 1987 judgment of the U.S. District Court for the Western District of Tennessee in Samuels, et al. v. Bowen, et al.
V. Appeals Council Actions
Request for review, pre-effectuation own-motion review, and recommended decision cases must be examined for compliance with provisions of the Samuels court order, especially if they were processed by the Tennessee Disability Determination Section and/or an Administrative Law Judge prior to the receipt of full implementation of Samuels instructions (see discussion under IV.A. and IV.B.1., above). OHA pipeline cases will not necessarily be returned to the Tennessee Disability Determination Section for development or documentation, since action by the Administrative Law Judge may have brought the case into compliance with the Samuels order. However, when extensive Samuels development and reevaluation is required, a case pending at the review level may be returned directly to the Tennessee Disability Determination Section (but not court remands, unless the court has so directed). See the discussion above, in section IV.B.2, for guidance with respect to the circumstances under which returning a case to the Tennessee Disability Determination Section would be appropriate. Additionally, the extent of any non-Samuels deficiencies in the hearing decision which can be remedied only by remand to the Administrative Law Judge, will be an important factor in deciding whether the case should be remanded to an Administrative Law Judge or returned to the Tennessee Disability Determination Section. The sample order at Attachment D, which is for Administrative Law Judge use in returning cases to the Tennessee Disability Determination Section, may be modified as appropriate for use by the Appeals Council (“A” member).
B. Action Regarding Samuels Checklist
If the completed Tennessee Disability Determination Section Samuels checklist is in the claims folder but has not been entered as an exhibit along with any documents referred to in the checklist, corrective action should be taken even if there is no other basis for review, unless the Administrative Law Judge's decision adequately addresses the Samuels development and documentation requirements. When the necessary documentation is contained in the claims folder but has not been entered into the official hearing record and the decision does not address the issue, the Appeals Council should grant review to proffer the documentation. The Appeals Council will process the case unless there is a separate need to remand for further hearing development, independent of Samuels issues. If the record does not include a completed Samuels checklist, necessary action will depend upon the adequacy of Samuels development and documentation at the hearing level, if any. C. Adjudication
Generally, adjudication should follow the guidance in IV.B.4., above, with regard to consideration of treating source opinion and the evaluation of pain. In cases in which the Administrative Law Judge's decision does not clearly explain the reasons for rejecting or not fully accepting a treating source's opinion (including entering the treating source's professional qualifications into the record where they are material), or where it appears that the Sixth Circuit and SSA standard for the evaluation of pain (Program Operations Manual System DI 24515.060) has not been properly applied, the Appeals Council should take corrective action as indicated below. In any case where the only error requiring correction is a deficient decisional rationale, corrective action may be taken without remand.
Any case in which a necessary medical assessment(s) has not been obtained and there is no documentation or explanation as to why (in Tennessee Disability Determination Section Samuels checklist or in the Administrative Law Judge's decision), should be remanded for further hearing proceedings, or, if extensive redevelopment is required, to the Tennessee Disability Determination Section, at the discretion of the Appeals Council. (Return of court remands to the Tennessee Disability Determination Section is not appropriate unless the court has so directed.) The sample remand order at Attachment F may be used as a guide and modified as appropriate when the case is being remanded to an Administrative Law Judge. (Care must be taken in any remand order issued as a result of Samuels to also instruct the Administrative Law Judge regarding any action that the Administrative Law Judge must take as a result of deficiencies unrelated to Samuels.) Remand is not necessary, however, if the Council has determined that a fully favorable decision can be issued without further development.
If the record is complete and sufficient for purposes of adjudication but a consultative examination(s) was obtained by the Tennessee Disability Determination Section from a nontreating source(s) and there is no documentation (either on the checklist or in the decision rationale) as to why a treating source consultative examination was not requested, the Appeals Council will not always need to remand the case or return it to the Tennessee Disability Determination Section. However, careful consideration must be given in light of all the available facts and evidence in the case as to whether a consultative examination from a treating source should be obtained. This should include consideration of whether the claimant has objected to the lack of an examination from a treating source and whether an examination from a treating source might have an impact on the final decision. If a further examination is not considered necessary, the reason must be fully explained in the denial notice. If the reason relates to the treating source's professional qualifications and the request for review is being denied, the assessment of the treating source's qualifications must be based upon information already in the record.
For cases pending at the court level, procedures are being developed to provide an option to litigants which will permit them to remain in court or have their cases remanded for reprocessing under Samuels. Court remands involving individual Tennessee residents should be processed in accordance with the provisions of the Samuels court order, with full rights of reopening of the prior final decision, even if Samuels is not specifically mentioned in the order. Court remands may not be returned to the Tennessee Disability Determination Section unless the court has so directed.
D. General Notice Requirements
When the Administrative Law Judge does not mention the Samuels court order in the hearing decision but the record otherwise satisfies Samuels adjudicative criteria, the denial notice should contain the following language:
In considering this request for review, the Appeals Council finds that the Administrative Law Judge's decision complies with Sixth Circuit precedent with regard to the evaluation of pain and the weight to be afforded treating physician opinion, as well as the other adjudicative criteria set forth in the August 19, 1986 order and March 16, 1987 judgment of the U.S. District Court for the Western District of Tennessee in Samuels, et al. v. Bowen, et al.
Similarly, when the Appeals Council issues a decision and the basis for review is unrelated to Samuels, the rationale should reference consideration of the requirements of the Samuels order in the manner described above.
VI. Case Control Procedures
The hearing offices and central office should follow the usual coding procedures from the Case Control Handbook in processing Samuels cases. Cases which are returned to the Tennessee Disability Determination Section for a revised determination under Samuels should be coded “ADDI.” VII. Questions
Any hearing office question concerning this Interim Instruction should be directed to the OHA Regional Office Hotline. Regional office and central office questions should be directed to the Division of Litigation Coordination and Implementation on 235-3743. Attachments:
Sample order for return of case to Tennessee Disability Determination Section
Sample remand order for Appeals Council
Attachment A. Court Orders Dated August 19, 1986 and March 16, 1987
[DATE FILED 08/19/1986]
SAM SAMUELS, et al.,
No. 82-2827-M
Margaret Heckler and Herbert Brown,
There are several motions presently before the Court in this class action consisting of persons who were either denied or terminated from disability benefits under Title II (Social Security) or Title XVI (Supplemental Security Income) of the Social Security Act. The defendants in this case are Margaret Heckler, Secretary of the Department of Health and Human Services (the Secretary) and Herbert Brown (Brown), Administrator of the Tennessee Disability Determination Section (TDDS). The Court will address each motion separately.
The Court will first address the plaintiffs' and the defendants' Motions for Summary Judgment. Plaintiffs raise seven separate challenges to the policies or practices of the TDDS and/or Secretary Heckler. No material issues of fact are in dispute, and therefore the issues are ripe for adjudication. Each claim, along with any appropriate relief, will be discussed separately.
This document entered on docket sheet in compliance with Rule 58and/or Rule 79(a), F.R.Civ.P., on 8/20/86
A full understanding of the issues in this case requires a familiarity with the way the Social Security Administration (SSA) determines disability and how appeals are handled. Determinations of disability are made using a five-step “sequential evaluation process.” At step one,
the Secretary determines whether an individual is engaged in “substantial gainful activity”, if so, benefits are denied. If not, the Secretary determines whether the claimant's medical condition or impairment is “severe”; if found “not severe,” benefits are denied. Third, the Secretary determines whether the claimant suffers from an impairment acknowledged to be so severe that the claimant is presumed to be incapable of pursuing any gainful activity. If so, then the claimant meets or equals the Listing of Impairments and benefits are awarded. However, if the claimant's impairment does not satisfy the Listing of Impairments, the fourth step requires the Secretary to determine whether the individual has a sufficient “residual functional capacity” (RFC) to perform his former work. If so, benefits are denied. If an individual still has not been ruled ineligible for benefits, the fifth step requires the Secretary to take into account the additional considerations of age, education, and past work experience to determine whether the individual is capable of performing any other work available in the economy.
Mental Health Assn. of Minn. v. Heckler, 720 F.2d 965, 969 (8th Cir. 1983) (citations omitted). At the fifth step a chart (called a grid) is employed which, based on a given RFC, take into account the claimant's age, education, and past work experience to determine whether jobs exist in the national economy which he can perform. This grid, based on RFC, is used to determine whether disability benefits are paid.
There are four levels of evaluation within the agency before an appeal to federal court will lie. The first two levels, the initial determination and reconsideration stages, are administered by the TDDS according to policy statements issued by the SSA. These policy statements are called Program Operation Manual System (POMS) directives and are binding upon the agency. A de novo hearing before an Administrative Law Judge (ALJ) and review by the Appeals Council are the latter two stages of review. To guide decisions at these levels, the Secretary issues Social Security Rulings (SSR's) which mirror the content of the corresponding POMS directives used at the preceding levels.
2. Failure to Obtain Proper Medical Assessments
As part of its duty to secure evidence necessary to make disability determinations, TDDS obtains medical reports from both consultative and treating physicians. 20 C.F.R. § 404.1614(a). By regulation, these reports are required to include a medical assessment of the claimant's ability to do such work-related activities as standing, walking, lifting, etc. 20 C.F.R. § 404.1513. This information is to be complete enough to allow TDDS to make a determination of the claimant's residual functional capacity (RFC). Id. At one time, physician assessments were directly relied upon to fix RFC; however, in l982, it was announced that ability to work would thereafter be determined by non-examining state agency medical doctors (SAMD), who were more familiar with the proper criteria. Although this change in policy ended the direct role of examining doctors in setting the RFC, their assessment of the claimants' ability to function is still required by 20 C.F.R. § 404.1513 (above), and Social Security Rulings and POMS continue to “stress the importance of obtaining evidence from medical sources identified by the claimant.” Defendants' Motion for Summary Judgment at p. 25 Contrary to the protestations of the defendants, plaintiffs do not challenge this change. Rather, plaintiffs only object to the response of TDDS.
In March 1982, TDDS began instructing its consulting physicians not only to refrain from making assessments of RFC, but also to exclude from their reports any comments on the claimant's abilities to walk, lift, etc. Request for Admissions, Brown's Response to No. 1, p. 5. Nor was any effort made to obtain this information from treating physicians. This results in making the conclusions of the non-examining agency doctor the only evidence of a claimant's work abilities. Consequently, erroneous determinations of RFC are difficult to overturn since there is no substantial evidence to the contrary. Such practices clearly violate Social Security regulations and the affected class members are entitled to relief. On remand, defendant Brown shall obtain the medical assessments required by 20 C.F.R. § 404.1513 and 416.913 from all treating and consulting physicians from whom they obtain evidence.
3. Failure to Obtain Consultative Examinations from Treating Physicians
Both Sixth Circuit law and SSA directives prefer reports from treating physicians over those of doctors merely consulted to examine a claimant for purposes of disability. Allen v. Califano, 613 F.2d 139, 145 (6th Cir. 1980); Miracle v. Celebrezze, 351 F.2d 361, 379 (6th Cir. 1965); 20 C.F.R. §§ 404.1517, 416.917. When the evidence is not sufficient to make a determination, TDDS is directed to obtain further information from attending physicians, whenever possible. POMS 401.085.
Plaintiffs maintain that TDDS ignores these instructions and obtains supplemental information almost exclusively from consulting doctors. While admitting that treating physicians are rarely used, defendant Brown states that most such physicians lack the facilities to perform the necessary tests, or otherwise do not meet federal standards. Brown Deposition at pp. 98-100. However, he also admits that no inquiries are made to determine whether the qualifications of any particular doctor are inadequate. Although failure to meet federal standards is a legitimate excuse for using a non-attending physician, such a determination must not be made arbitrarily or simply out of a desire for expediency. The admissions of Director Brown make it clear that TDDS has not followed SSA directives. Therefore, on remand, the treating physicians of class members should be used for consultative examinations whenever possible, in accordance with POMS 401.085 and other applicable directives.
4. Comparative Weight Afforded Opinions of Attending Physicians
The plaintiffs contend that the defendants give insufficient weight to the medical reports of treating physicians, in violation of established, Sixth Circuit precedent. The parties agree that a treating physician's opinion is entitled to more weight than that of either an examining physician, consulted by the SSA or of a non-examining, state agency medical doctor (SAMD). See also, King v. Heckler, 742 F.2d 968, 973 (6th Cir. 1984); Stomper v. Harris, 650 F.2d 108, 111 (6th Cir. 1981); Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978). Pointing to Social Security Ruling (SSR) 82-48(c), which notes that greater weight should be given to treating physician's testimony, the Secretary argues that she is already in compliance with this Sixth Circuit law. If all levels of the TDDS are applying SSR 82-48(c), then the Secretary would be correct; however, it is clear that such is not the case. Administrator Brown has admitted that TDDS gives no greater weight to the reports of treating or attending physicians than it gives to the statements of other physicians. Plaintiff's First Request for Admissions (First RFA) No. 20, p. 41. TDDS employees at the initial and redetermination levels have no indication of the superior weight reports of treating physicians should receive. Indeed, it appears that in certain situations, it is actually TDDS policy to accept the opinions of non-examining SAMD's over those of treating doctors. First RFA No. 17, p. 44.
Treating physicians are neither entitled nor competent to make ultimate determinations of disability since such decisions rest on both medical and non-medical considerations. King, 742 F.2d 968. However, in situations where there are conflicting medical opinions as to the extent or severity of a claimants impairment, the opinion of the treating physician, absent special circumstances, should prevail. Only where there are serious questions as to: 1) the treating physician's qualifications, 2) the nature or duration of his relationship to the claimant, or 3) the sufficiency of the treating physician's medical data, would a different result lie. King, 742 F.2d at 973; Montigo v. Secretary of Health and Human Services, 729 F.2d 599, 602 (9th Cir. 1984).
The plaintiffs have shown that injunctive relief is necessary. On remand, the opinions of treating physicians should be afforded the weight required by the Sixth Circuit precedent cited herein.
5. Objective Evidence of the Severity of Pain
Originally, plaintiffs sought to enjoin the Secretary from applying POMS 401.570 and the identical SSR-82-58; both established agency policy for the evaluations of pain. However, on August 1, 1985, in response to the Social Security Disability Benefits Reform Act of 1984, the defendant replaced the contested directives with ones the plaintiffs do not find objectionable. Although the original issue is now moot, plaintiffs still seek relief in the form of an order requiring the Secretary to reconsider her denial of benefits in light of these new standards. Such an order would be appropriate only if POMS 401.570 and SSR 82-58 were illegal when applied.
POMS 401.570 provided that complaints of pain would not be considered for purposes of determining disability unless there was both 1) objective proof of a medical condition capable of producing the pain, and 2) objective proof of the severity of the pain. Consequently, complaints of pain out of proportion to the diagnosed medical condition were ignored. The plaintiffs maintain that such a standard violated the established precedent of the Sixth Circuit. The Court agrees. This circuit has repeatedly recognized that pain may be intense enough to disable without objective medical evidence to establish its severity. King v. Heckler, 742 F.2d 968, 974-5 (6th Cir. 1984); Beavers v. Sec. of H.E.W., 577 F.2d 383, 386 (6th Cir. 1978). The plaintiffs are therefore entitled to the relief sought. On remand defendants shall process plaintiffs' applications for disability benefits under standards consistent with the Sixth Circuit precedent cited herein.
6. Consideration of the Combined Effect of Nonsevere Impairments
The plaintiffs also attack the validity of the Secretary's decisions based on POMS 401.410 and its corresponding Social Security Ruling, SSR-82-55. These directives, which listed a number of impairments considered “nonsevere,” stated that “[lsqb ]i[rsqb ]nasmuch as a nonsevere impairment is one which does not significantly limit basic work-related functions, neither will a combination of two or more such impairments.” This policy was rescinded effective December 1, 1984. The defendants maintain that this rescision was made in response to changes made by the 1984 Disability Benefits Reform Act, and that their prior policy was legal. The Court disagrees. The plain wording of the Social Security Act itself undermines the defendants' arguments. In defining disability, it states that:
[a]n individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot engage in any other kind of substitute gainful work.
42 U.S.C. 423(d)(2)(A) (emphasis supplied); See also, Johnson v. Heckler, 593 F. Supp. 375, 381 (M.D. Ill. 1984), aff'd 769 F.2d 1202, 1213-15 (7th Cir. 1985). In addition, the rulings in this and other circuits make it clear that the combined effect of a claimant's multiple impairment must be considered in reaching a determination. Mowery v. Heckler, 771 F.2d 966, 971 (6th Cir. 1985) (impairments in this Circuit must be viewed in combination); Johnson v. Heckler, 769 F.2d 1202, 1213-15 (7th Cir. 1985); Allen v. Califano, 613 F.2d 139, 147 (6th Cir. 1980).
Because POMS 401.410 and SSR-82-55 violated the Social Security Act and the law of this Circuit, determinations based thereon must be reopened and reconsidered in light of the combined effect of nonsevere impairments.
7. Individualized Assessments of the Severity of an Impairment and of Residual Functional Capacity (RFC)
The plaintiffs next attack six of the Secretary's disability directives on the basis that they prevent an individualized assessment of each claimant's disability. It is clear that determinations of disability must be made on a case by case basis. Heckler v. Campbell, 461 U.S. 458, 467 (1983); Beavers v. Sec. of HEW, 577 F.2d 383 (6th Cir. 1979); Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978). The effect of a given impairment on a hypothetical “average man” is not sufficient since “different people can react in markedly different ways to the same injury.” Landess v. Weinberger, 490 F.2d 1187 1190 (8th Cir. 1974); Walston v. Gardner, 381 F.2d 580 (6th Cir. 1967).
Plaintiffs first attack POMS 401.410 and its corresponding SSR-82-55, which contain a list of twenty (20) impairments always considered nonsevere. However, in April of 1985, these directives were rescinded and replaced with standards which actually consider the degree an impairment interferes with a claimant's ability to work. Although the present standards are not objectionable, the Court recognizes that this change was of little benefit to affected class members denied benefits under the prior illegal standards. Therefore on remand, plaintiffs who were excluded from benefits due to a reliance on POMS 401.410 or SSR-82-55 shall have their cases redetermined under the new standards.
Plaintiffs next challenge POMS 401.545 and Informational Digest (ID) 82-5. These directives involve the determination of an applicant's residual functional capacity (RFC) — the level of work a claimant can perform in spite of his severe impairment. RFC is divided into five categories of work ability: sedentary, light, medium, heavy and very heavy. POMS 40l.655, see Plaintiff Motion, n.5 p. 147. Once RFC is determined, it is evaluated along with the claimant's age, education and work experience to reach an ultimate decision as to disability. The more limited the RFC, the more likely an applicant will be found disabled. The challenged directives, however, provide that a person with obstructive airway disease, who does not automatically qualify as disabled under the Listing of Impairments, (Step 3 of the sequential evaluation), is always precluded from receiving a RFC for sedentary work. Obviously these rules do not allow for the individualized assessment required by law and therefore are unacceptable. Claimants who were affected by these directives are entitled to a redetermination which includes an individualized assessment of their RFC.
Finally, plaintiffs attack POMS 401.590 and SSR-82-51, which set RFC guidelines for sixteen (16) musculoskeletal and cardiovascular impairments. Plaintiffs maintain that these directives make required findings of RFC without assessing the claimant individually. The Court disagrees. RFC levels are cumulative; each succeeding level includes the ability to do work at the preceding level unless there are additional limiting factors. POMS 401.655, Plaintiffs' Motion, FNS at pp. 147-48. Thus the ability to do heavy work generally includes the ability of perform sedentary, light and medium work as well. The guidelines challenged here are not objectionable since they only operate to exclude RFC levels at the upper ends of the scale.
POMS 401.590(b)(5), which the plaintiffs specifically challenge in their brief states:
5. Amputation of lower extremity at or above the tarsal region, but below the knee, with ability to use prothesis effectively. Heavy work activity would be preluded. Usually there is no significant restriction in the ability to walk or stand unless there is a complication of the amputation site. There would be a limitation on excessive climbing of stairs and walking on grossly uneven terrain and operating foot controls with the affected extremity.
(emphasis supplied.) It is clear that this POMS only precludes a claimant from being found fit to do heavy work. It therefore operates in his favor since it automatically prevents him from being considered for heavy work. This differs from the POMS previously discussed, which automatically excluded claimants from the most favorable RFC rating. Moreover, these guidelines do not make standardized assessments of a claimant's remaining capacity is clear from the wording of (b)(5) and its companion sections that subjective differences are taken into account. In describing an individual's expected remaining ability, the directives speak in indefinite terms, using such words as “usually” (b)(5) or “ordinarily” (b)(10), or stating that consideration must be given to the way in which the impairment actually affects the claimant.
Because POMS 401.490 and SSR-82-51 do allow for an individualized assessment of the affect of the claimant's impairments, plaintiffs' Motion for Summary Judgment is denied and defendants' Motion for Summary Judgment is granted.
8. Publication of POMS Directives in the Federal Register
The plaintiffs next challenge the validity of several POMS directives on the basis that they are substantive rules requiring publication in the Federal Register. Only the validity of POMS 401.490 is at issue since the other challenged directives have either been rescinded by the SSA (POMS 401.410 and 401.570) or previously addressed and voided by the Court (401.545). Although the Administrative Procedures Act (APA) requires most rules to first be published in the Federal Register, it does make an exception for “interpretive rules, general statements of policy, or rules of agency organization, procedure, or practice.” 5 U.S.C. § 553(b)(A). The defendants invoke this exception, maintaining that POMS 401.490 merely interprets the underlying regulation. The Court disagrees. Sections 20 C.F.R. 404.1546 and 416.946 (the identical SSR provision) state that RFC is to be determined by a state agency medical doctor (SAMD) based upon all available “medical evidence.” In contrast, POMS 401.590 excludes a finding of certain RFC levels at the outset, no matter what the available medical evidence may show. The Court cannot say that this is merely an interpretation of the regulation. Unlike cases which have found a rule interpretative, there is no word or phrase which is being more precisely defined by the agency. See, American Postal Workers Union v. United State Postal Service, 707 F.2d 548, 559 (D.C. Cir. 1983) (interpreted the phrase “annual basic salary”); Allen v. Bergland, 661 F.2d 1001 (4th Cir. 1981) (interpreting the word “income”). Therefore the Court finds that POMS 401.590 is void since, as a substantive rule, it was not published for notice and comment under 4 U.S.C. § 553. However, since the Court believes this POMS to have been beneficial to applicants, since it operated to automatically exclude claimants from less favorable RFC ratings, no injunctive relief will be ordered.
The Court has found that defendants have: 1) failed to obtain proper medical assessments of claimants' work-related abilities; 2) failed to obtain consultative examinations from treating physicians; 3) failed to place appropriate weight on the opinions of treating physicians; 4) employed standards which improperly required objective evidence of the severity of pain; 5) employed standards which improperly failed to consider the combined effects of nonsevere impairments; and 6) employed standards which failed to allow individualized assessments of RFC and of the actual severity of impairments. The Court has already stated that affected plaintiffs are entitled to new determinations based upon proper standards. See Branham v. Gardener, 383 F.2d 614, 626-27 (6th Cir. 1967).
Plaintiffs are also entitled to the following relief:
full retroactive benefits if the re-evaluation shows that benefits were improperly denied. See Johnson v. Heckler, 593 F. Supp. 375, 382 (N.D. I11. 1984) aff'd 769 F.2d 1202, 1215 (7th Cir. 1985). notification by certified mail informing class members both of their right to request a redetermination and their responsibility for making such a request within 120 days of receipt of their notice.
defendants shall issue written instructions to the affected personnel, informing them of the contents of this Court's order and instructing them on the procedures to be used in its implementation.
B. Defendant's Motion to Remand and Dismiss
Also pending before the Court is the defendants' motion to remand and dismiss the claims of class members who were terminated from the disability rolls. Under the terms of the Agreed Order for Remand, the cases of terminated class members have recently been sent back to the Secretary for redetermination according to the medical improvement standards set forth by Congress in the Social Security Disability Benefits Act of 1984 (1984 Act). However, the defendants continue to seek the dismissal of all remanded claims, maintaining that such a result is mandated by the 1984 Act. The terminated plaintiffs oppose dismissal since they have raised other claims not related to medical improvement.
It is well settled that a court does not normally lose jurisdiction of remanded cases. Avery v. Secretary of HHS, 762 F.2d 158 (1st Cir. 1985); Zambrona v. Califano, 651 F.2d 842, 844 (2d. Cir. 1981). Likewise, “[a]bsent the clearest command to the contrary from Congress, federal courts retain their equitable power to issue injunctions in suits over which they have jurisdiction” Califano v. Yamasaki, 442 U.S. 682, 705 (1979). The portion of the 1984 Act which requires remand addresses medical improvement cases only; it does not speak to the plaintiffs' other claims. Presented with the same question, the First Circuit stated: “The conclusive answer to this argument, however, is that the act says the court shall “remand” the case; it does not say the court must dismiss the action.” Avery, 762 F.2d at 163. See also, Heckler v. Kuehner, 105 S.Ct. 376 (1984) (the Court ignored an opportunity to dismiss and only remanded instead); Lopez v. Heckler, 753 F.2d 1464 (9th Cir. 1985); Holder v. Heckler, 615 F. Supp. 682 (M.D. Ohio 1985). Standards for redetermination should not vary according to whether the case was previously remanded. Absent pre-emption by Congress, the Court has a duty to award the same relief for each plaintiff. Therefore, on re-evaluation, the remanded cases shall be reviewed in light of both: 1) the new medical improvements standards embodied in the 1984 Act, and 2) the injunctive relief granted in response to the parties' motions for summary judgment.
C. Motion to Decertify the Class
Also before the Court is defendants' Motion to Decertify the Class. The defendants argue that plaintiffs have met neither the commonality nor typicality requirements of Rule 23 and that the need for the class has been mooted by passage of the Social Security Disability Benefits Reform Act of 1984 (1984 Act). All of these contentions are without merit.
Two of the requirements for maintaining a class action are that there be “questions of law or fact common to the class” and that the “claims or defenses of the representative parties are typical of the claims and defenses of the class.” Fed. R. Civ. P. 23(a)(2) and (3). The plaintiffs clearly meet both of these criteria. The plaintiffs claim that the policies and practices of the defendants have resulted in the wrongful denial or termination of class members' disability benefits. The admissions of defendant Brown and the policies of the defendant Heckler speak for themselves. The acts complained of were uniformly applied throughout Tennessee and this obviously raises common questions of law for the entire class.
The typicality requirement is also satisfied. The defendants complain that each of the named plaintiffs attack different rules or practices. However, this misses the point. Rule 23 requires that the claims of the class representatives be similar to those of the class members not that the claims of the class representatives themselves be similar. General Telephone Co. of the Southwest v. Falcon, 457 U.S. 142 (1982) (the class representatives must possess the same interest and suffer the same injury as the class). As the plaintiffs point out, defendants have confused the requirements for joinder with those for class action.
As a final justification for decertification, the defendants raise the 1984 Act. They claim that “in large part, Congress has mooted the class claims in this case.” Defendants' Motion to Decertify at 4. However, this very statement exposes the fallacy of defendants' argument since it admits that the 1984 Act does not address all of the plaintiffs' claims. The plaintiffs' case has not been mooted.
The defendants' Motion to Decertify is denied.
D. The Payment of Interim Benefits
The final controversy before the Court concerns the payment of interim benefits and stems from the plaintiff's “Notice” of December 23, 1985.
On December 13, 1985, the Court remanded all “medical improvement” claims to the Secretary for redeterminations pursuant to the Social Security Disability Benefits Reform Act of 1984 (1984 Act). The 1984 Act allows “any individual whose case is remanded” to elect to receive interim benefits “beginning with the month in which he makes such election,” Sec. 2(e). On December 18, 1985, counsel for the plaintiffs made a blanket election for the class, thereby attempting to lock in December benefits for the class. The defendants object to this “protective filing date,” maintaining that the 1984 Act requires individual class members, not the class action attorney, to make the election. The Court agrees.
Both the wording and the structure of the 1984 Act indicate Congress' intent to require individual claimants to make the election. The 1984 Act itself states that “Any individual ... may elect ... to have payments made beginning with the month in which he makes such election,” Sec. 2(e) (emphasis supplied). Likewise, Sec. 2(d), which mandates the terms of the remand, requires the Secretary to notify each “individual” that he may request a review of the previous determination. Sec. 2(d)(4). Moreover, the Court is mindful that the very purpose of the remand was to end class action litigation on the subject of medical improvement. Congress intended each individual redetermination to be “regarded as a new decision.” Sec. 2(d)(4). Continued orchestration by class attorneys is inconsistent with this goal.
In support of their position, plaintiffs' attorney point to 20 C.F.R. § 404.630 and 416.340 which they claim “directly address the issue.” Plaintiffs' Memorandum of January 17, 1986. These regulations adopt the date of filing as the date of application in cases where third parties have applied for benefits on behalf of another. However, these general regulations, which are apparently intended to apply only to the initial application process, 20 C.F.R. § 404.601, are in direct conflict with the specific terms of the 1984 Act. Under the plaintiffs' theory, 20 C.F.R. § 404.630(c) allows a claimant six (6) months following the protective filing of the class attorney to make his individual filing for benefits. However, the 1984 Act specifies that an individual has 120 days to request review after he has been notified of the remand. See also, 416.340(c) (requires submission of application within sixty (60) days). It is clear that these regulations were not designed to apply in this situation.
The defendant need only pay interim benefits from the month in which an individual's request is received.
Plaintiff's Motion for Summary Judgment is granted in part and denied in part (see part A). Defendants' Motion to Dismiss and Motion for Decertification are denied (see parts B and C, respectively). Interim benefits need only be paid from the month an individual's request is received (see part D).
IT IS SO ORDERD
ENTER: This 14th day of August, 1986.
ROBERT M. McRAE, JR.UNITED STATES DISTRICT JUDGE
IN THE UNITED STATES DISTRICT COURTSFOR THE WESTERN DISTRICT OF TENNESSEWESTERN DIVISION
[DATE FILED 03/16/1987
This document entered on docket in compliance with Rule 58and/or 79(a), F.R.Civ.P., on 3/16/87
OTIS BOWEN, Secretary of
On August 19, 1986, this Court entered an order granting in part plaintiffs' Motion for Summary Judgment. This judgment is entered to implement the Court's August 19, 1986 order, which is incorporated herein by reference.
On December 13, 1985, an agreed order was entered in this cause setting forth the notice procedures applicable to members of the plaintiff class who had been terminated from disability benefits. Those same procedures are adopted herein and shall be followed by the Secretary of Health and Human Services (the Secretary) in providing notice to all class members of this Court's order of August 19, 1986, except those class members who previously requested reevaluation pursuant to this Court's order of December 13, 1985.
The defendants shall prepare a notice clearly informing class members of their rights under this judgment. In addition, plaintiffs' counsel will also be allowed to include a notice of their own in the mailing to be sent out by the defendants.
1. Duty to Obtain Medical Assessments
The Tennessee Disability Determinations Section (TDDS) shall obtain the medical assessments required by 20 C.F.R. §§ 404.1513 and 416.913 from each treating and consulting physician from whom evidence is acquired. These assessments shall be complete enough to allow a determination of residual functional capacity and, at a minimum, shall request how many hours in an eight-hour day a claimant can walk, stand and sit and how much weight can be lifted for one-third and two-thirds of a work day.
2. Duty To Obtain Consultative Examinations From Treating Physicians
When the medical evidence is not sufficient to make a disability determination, TDDS shall obtain consultative examinations from treating physicians whenever possible, in accordance with POMS 401.085 and other applicable directives. 3. Duty to Give Greater Weight to the Opinion of Treating Physicians
TDDS shall give greater weight to the testimony of treating physicians when there are conflicting medical opinions as to the extent of severity of claimant's impairments. See King v. Heckler, 742 F .2d 968, 973 (6th Cir. 1984). Only where there are serious questions as to: 1) the treating physicians' qualifications; 2) the nature or duration of his relationship to the claimant; or 3) the sufficiency of the treating physicians' medical data, would a different result lie. King at 973.
4. Duty to Evaluate Pain
Complaints of pain, even if not supported by objective medical evidence, shall be considered by TDDS in evaluating disability claims. See King v. Heckler, 742 F.2d 968 (6th Cir. 1984), Beavers v. Secretary of H.E.W., 577 F.2d 383 (6th Cir. 1978).
5. Duty to Consider the Combined Effect of Non-Severe Impairments
TDDS, in determining whether a claimant has a severe impairment, shall consider the combined effect of all non-severe impairments in reaching a disability decision.
6. Duty to Individually Assess Severity of Impairments and Residual Functional Capacity
TDDS shall make decisions on a case by case basis in determining the severity of impairments or the residual functional capacity of claimants.
C. Implementation of Substantive Standards
The Secretary and TDDS shall issue written instructions to the affected personnel, informing them of this Court's order and instructing them on the procedures to be used in its implementation.
Affected plaintiffs are entitled to new determinations based upon the standards outlined in this judgment and full retroactive benefits if reevaluation shows that benefits were improperly denied.
D. Monitoring of Compliance
The defendants shall provide plaintiffs' counsel copies of instructions and Program Operations Manual System (POMS) directives, issued to TDDS and Social Security Administration (SSA) components for use in determining whether individuals are class members and in processing their claims in accordance with the Court's judgment at least ten days prior to their effective date. However, when instructions are issued on an emergency basis, the ten-day requirement shall not apply. In such cases, SSA will send copies to plaintiffs' counsel as far in advance as is possible and not later than the effective date of the instructions.
In addition, the defendants shall provide statistical information to plaintiffs' counsel on a quarterly basis regarding: the number of notices sent to potential class members; and the number of claims reviewed by the defendants pursuant to the August 19, 1986 order. The defendants shall also provide plaintiffs' counsel a copy of the screening sheet used to determine class membership for each individual claiming membership in the Samuels class but not found to be a class member.
Entered this 16th day of March, 1987, at the direction of Robert M. McRae, Senior United States District Judge, Western District of Tennessee
O. Franklin Reid, ClerkUnited States District CourtWestern District of Tennessee
Attachment B. POMS DI 24515.060 Regarding Pain
4&#160;&#160;&#160;&#160;&#160;10-86&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;DI
24515.060
24515.060 Evaluation of Pain and Other Symptoms
Proper consideration of the effect of pain (and other symptoms) on an individual's ability to work is an important part of the disability evaluation process. Because pain is subjective, the existence of pain and the extent to which pain affects the individual's functional ability to do basic work activities is difficult to evaluate.
The Social Security Disability Benefits Reform Act of 1984, included statutory language which, as explained by Congress, mirrors the basic policies for the evaluation of pain in disability cases. The legislation also called for the establishment of a commission on the Evaluation of Pain to conduct a study, in consultation with the National Academy of Sciences, concerning the evaluation of pain in determining disability. The report of this Commission may lead to changes in our policy for evaluating pain.
B. Need to Establish a Medically Determinable Impairment
Under existing guidelines (see DI 24501.025), pain cannot be found to have a significant effect on a disability determination or decision unless medical signs or findings show that a medically determinable physical or mental impairment is present that could reasonably be expected to produce the pain alleged. This policy has now been codified by the legislative language in Pub. L. 98-460, section 3(a)(1), which states, in part, “there must be medical signs and findings, established by medically acceptable clinical or laboratory diagnostic techniques, which show the existence of a medical impairment that results from anatomical, physiological, or psychological abnormalities which could reasonably be expected to produce the pain or other symptoms alleged....”
When medical findings do not substantiate any physical impairment capable of producing the alleged pain (and a favorable determination cannot be made on the basis of the total record), the possibility of a mental impairment as the basis for the pain should be investigated.
C. Consideration of Pain in Establishing the Severityof a Medically Determinable Impairment
Once a medically determinable physical or mental impairment is documented, the effects of pain must be considered as you proceed through each step of the sequential evaluation.
To be found disabled, an individual must have a medically determinable severe impairment(s). To be considered severe the impairment, or combination of impairments, must significantly limit the individual's physical or mental ability to do basic work activities. In determining whether an impairment is severe, full consideration is given to all material evidence, including signs, symptoms (such as pain), and laboratory findings. Where the degree of pain reported is consistent with a level that can reasonably be associated with the objective findings presented, the conclusion that the impairment is severe must be based on a determination that the total evidence, including the alleged pain, establishes that the individual's ability to do basic work activities is significantly limited. However, where the degree of pain alleged is significantly greater than that which can be reasonably anticipated based on the objective physical findings, the allegation of pain must be carefully explored further in terms of any additional limitation(s) imposed by the pain on the individual's functional ability beyond those limitations indicated by the objective findings before any conclusions about severity can be reached (See DI 24501.025.)
Disability may be established on a medical basis alone if the criteria of an impairment cited in the Listing of Impairments are met or equaled. Some listed impairments include symptoms among the requisite criteria. For example, Listing 1.04 requires a history of joint pain and stiffness. When a symptom, such as pain, appears as a criterion (as in Listing 1.04), it is ordinarily essential only that the symptom be present in combination with the remaining criteria. Unless specifically indicated (as in Listing 1.04A, which requires that abduction of both arms at the shoulders, including scapular motion, be restricted to less than 90 degrees), quantification or evaluation of the intensity or of the functionally limiting effects of that symptom is not required to determine whether the documented findings meet the requisite criteria. (See DI 2450.025.)
In considering whether documented findings and symptoms are of equivalent severity to the requisite findings and symptoms of a listed impairment, look to see whether the set of symptoms, signs, and findings present are of equal or greater significance than those in the listed criteria. However, an alleged or reported increase in the intensity of a symptom, cannot be substituted no matter how severe, for a missing or deficient sign or finding to elevate impairment severity to equivalency to the listed impairment. For example, a history of severe, persistent joint pain cannot be substituted for the required x-ray evidence of either joint space narrowing with osteophytosis or bony destyruction (with erosions or cysts) in Listing 1.04 to draw a conclusion of “equal”.
D. Consideration of the Intensity and Persistence of Pain in Determining Functional Capacity
If the listing is not met or equaled, a residual functional capacity (RFC) assessment is necessary to determine the effects of the impairment, including any additional limitations imposed by pain, on the claimant's capacity to perform former work or other work. Medical history and objective medical findings, such as evidence of muscle atrophy, reduced joint motion, muscle spasm, sensory and motor disruption, are usually reliable indicators from which to draw reasonable conclusions about the intensity and persistent of pain and the effect such pain may have on the individual's work capacity. Whenever available, this type of objective medical evidence must be obtained and, as expressed in Pub. L. 98-460 “must be considered in reaching a conclusion as to whether the individual is under a disability.” There are situations in which an individual's alleged on reported symptoms, such as pain, suggest the possibility of a greater restriction of the individual's ability to function than can be demonstrated by objective medical findings alone (see DI 24501.025). In such cases, reasonable conclusions as to any limitation on the individual's ability to do basic work activities can be derived from the consideration of other information in conjunction with medical findings. This is consistent with recent court decisions, as well as with the statutory language which requires that statements of the claimant or his/her physician as to the intensity and persistence of pain or other symptoms “which may reasonably be accepted as consistent with the medical signs and findings” are to be included in the evidence to be considered in making a disability determination. When the claimant indicates that pain is a significant factor of his/her alleged inability to work, and the allegation is not supported by objective findings in file, the adjudicator shall obtain detailed descriptions of daily activities by directing specific inquiries about the pain and its effects to the claimant, his/her physicians from whom medical evidence in being requested, and other third parties who would be likely to have such knowledge.
In developing evidence of pain or other symptoms, it is essential to investigate all avenues presented that relate to subjective complaints, including the claimant's prior work record and information and observations by treating and examining physicians and third parties, regarding such matters as: The nature, location, onset, duration, frequency, radiation, and intensity of any pain;
Type, dosage, effectiveness, and adverse side effects of any pain medication;
Functional restrictions; and The claimant's daily activities.
E. Importance of Considering Allegations of Pain and Explaining Conclusions Reached
In the SSA-4734-F4 RFC assessment, the medical consultant is to describe the relationship between the medically determinable impairment and his/her conclusions of RFC which have been derived from the evidence, including a discussion of why reported daily activity restrictions are or are not reasonably consistent with the medical evidence.
In instances in which the adjudicator has observed the individual, the adjudicator is not free to accept or reject that individual's subjective complaints solely on the basis of such personal observations. Rather, in all cases in which pain is alleged, the determination rationale is to contain a thorough discussion and analysis of the objective medical and nonmedical evidence, including the individual's subjective complaints and the adjudicator's personal observations. The rationale is then to provide a resolution of any inconsistencies in the evidence as a whole and set forth a logical determination of the individual's capacity to work. F. Consideration of Pain In Determining RFC
The following two examples show the kind of information and discussion which should be included in RFC assessment in cases involving pain.
Example 1 presents a picture of an individual with a severe medically determinable impairment who alleges pain with attendant limitations of function as reflected in his stated restrictions in daily activities. In this example, the clinical findings are consistent with both the complaints of pain and with the individual's stated limitations. Thus, the adjudicator, in reviewing all of the available evidence, including the statements of the claimant and his treating physician, is free to conclude that the individual's allegations of pain are reasonably consistent with the medical signs and findings and would result in the stated restrictions in the individual's ability to work in consideration of his RFC, and his age, education, and work experience.
In example 2, a different situation is presented. In this example, the objective medical evidence supports a finding that the claimant has a severe physical impairment but does not substantiate the alleged degree of limitation due to pain. As is proper, consideration has been given to the possibility of a mental impairment, but the treating physician states there is no psychiatric condition and the evidence supports this statement. A further review of the medical evidence fails to establish the presence of any objective findings. (e.g., muscle spasm, sensory or motor loss, leg pain, or muscle wasting), typically associated with the type of functionally limiting back pain alleged by the claimant. Thus, the evidence does not support a reasonable conclusion that additional pain-related physical or functional restrictions exist beyond those imposed by the effects of the documented spinal fusion. However, the adjudicator, as explained in DI 24501.025, must be aware that symptoms, such as pain, can result in greater severity of impairment than may be clearly demonstrated by the objective physical manifestations of a disorder. Thus, before a complete evaluation of this individual's RFC can be made, a full description of the individual's prior work record, daily activities and any additional statement from the claimant, his or her treating physician or other third party relative to the alleged pain must be considered. Only then is it possible to fully assess whether the pain is reasonably consistent with the objective medical findings and to determine RFC.
1. Effects of Pair Supported by the Evidence
History of a ruptured disc, with a hemilaminectomy and disc excision at L4-5. Postoperatively, continues to have back pain. Repeated examination to date reveal consistent findings, including limitation of forward bending of the spine to 45 degrees, extension to 5 degrees, no limp on walking or significant difficulty in heel or toe walking, difficulty in climbing on to examining table, with back pain when lying flat; straight-leg raising positive at 30 degrees on right; 70 degrees on left; depressed right achilles reflex; marked tenderness over right lumbar spine, with marked spasm of the paraspinal muscles; increased back pain on forward flexion, with splinting of lower spine to the left; no motor or sensory loss or other neurological abnormality. Wears a chairback brace and takes 8-10 aspirin daily and codeine occasionally.
Treating physician states that pain is a significant factor in the individual's current activity restrictions and that he advised the claimant to avoid lifting heavy or bulky objects. In addition, claimant states that the continued pain prevents walking more than two blocks, prevents his lifting his two-year-old grandson, and limits him to light household chores.
The objective findings, by themselves, support a conclusion that the individual should not lift or carry more than 50 lbs or frequently lift or carry more than 25 lbs. Frequent bending is also precluded. The clinical findings are consistent with both the complaints of pain and with the individual's stated limitations. Therefore, it is concluded that, due to pain, the individual's functional capacity to stand and walk is restricted to less than 6 hours (but more than 2 hours) per day. Sitting is unlimited.
Although the individual's lifting and carrying ability is part of medium work, the vast majority of medium jobs also would require being on one's feet for a total of about 6 hours of an 8-hour workday, with frequent bending at the waist as well as bending of the knees. Since the individual cannot do frequent bending and further can stand and walk only between 2 and less than 6 hours a day, most jobs at both the medium and light levels of exertion are ruled out by the effects of the impairment. Jobs compatible with the RFC would be those at the sedentary level of exertion, as well as light and medium jobs which are performed in a sealed position.
2. Effects of Pain Unsupported by the Evidence
History of disc excision at L3-4 2 years ago; subsequent disc excisions at L4-5 and L5-SI, with spinal fusion of L3-S1. Current examination by treating physician, shows forward bending of the spine to 50 degrees, extension to 10 degrees; all movements guarded but no actual difficulty in heel and toe walking or climbing on to the examining table, complaints of back pain on straight-leg raising at 60 degrees bilaterally, but no radiation of pain into legs; moderate tenderness to deep palpation of lumbar paraspinous muscles, but no muscle spasm; no sensory or motor loss, absent left achilles reflex, but no other neurological deficit, leg circumferences equal; X-rays show solid fusion with no movement; wears chairback brace and takes 15-20 aspirin daily, Darvon 4X daily. Treating physician states that there is no psychiatric condition (the evidence supports this) and that spinal fusion and continued complaints of back pain alone prevent all work activity indefinitely. Claimant states that he has constant pain, worse on walking or standing, and is unable to do any household chores. On the basis of the spinal fusion, lifting and carrying is limited to 50 pounds. Frequent lifting and carrying is limited to 50 pounds. Activities involving frequent bending of the back are precluded. In spite of the claimant's statements and the physician's opinion, the objective medical evidence establishes the absence of any findings (e.g., muscle spasm, sensory or motor loss, leg pain, or muscle wasting, etc.) that are typically associated with functionally limiting back pain. Although claimant does have back pain, the medical evidence, including physical examination, demonstrates no pain related physical or functional limitations beyond those imposed by the effects of the spinal fusion. The capacity to stand, walk, and sit is unlimited. Here, again, the capacity to lift 50 pounds maximum with frequent lifting or carrying of objects weighing up to 25 pounds is part of medium work capacity. However, this is compromised by inability to bend the back frequently. Having unlimited capacity to stand, walk, and sit, and being able to meet the lifting and carrying demands of light work, where frequent bending of the back is not required for the majority of light jobs, the individual can be expected to do sedentary work and substantially all light jobs. He could also do medium jobs which are performed in a seated position or which do not require frequent stooping or bending (such a might have been the case in a past job.
Attachment C. Samuels Checklist
32555.020 Exhibit - SAMUELS COURT ORDER CHECKLIST
(TO BE COMPLETED ON ALL DENIALS AND CESSATIONS)
Name_________________________________ SSN______________________________
If not, documentation of attempts to obtain each missing assessment (initial request and at least one follow-up required) can be found in the claims folder in: (e.g., Report of Contact (SSA-5002), Annotation on initial development letter dated _____________ sent to the physician)
The attending physician prefers not to perform such an examination. Documented in ________________
There are material conflicts or inconsistencies in file which cannot be resolved by going back to the attending physician, specifically _______________
The attending physician does not have the equipment to provide the specific data needed (_____________) and does not wish to make arrangement to obtain these tests. Documented in __________________________________________
The claimant prefers a source other than the attending physician in _________________________________________
The DDS knows from experience through purchase that the physician is not a productive source. Documented in __________________________________________
The treating source's qualifications. Explain ______
The nature or duration of the source's relationship to the claimant. Explain _________________________
The sufficiency of the source's medical data (i.e., the opinion must be supported by the evidence (medically acceptable clinical and laboratory diagnostic techniques) on which it is based). Explain in ________________________
If yes, an individualized assessment of residual functional capacity must be done in all cases involving a medically determinable impairment in which the individual is not found to be disabled under the Listing of Impairments. See DI 32555.010A.4. ______________________
If yes, where is impact of pain on function addressed per POMS DI 24515.060? _________________________________________
Where are severity of impairment and effect on function assessed in file per DI 24505.001ff.? _______________.
Is more than one nonsevere impairment present? If yes, where is combined effect evaluated per POMS DI 24505.001ff.? _________________________________________
Attachment D. Order for Return of Case to Tennessee Disability Determination Section
On March 16, 1987, the U.S. District Court for the Western District of Tennessee issued a final judgment in Samuels, et al. v. Bowen, et al., which incorporated by reference its previous order of August 19, 1986. This court action affects certain Tennessee residents who have filed disability claims and includes specific requirements for obtaining medical development. The claimant has been found to be a member of the class certified under Samuels, and (his/her) pending claim must be adjudicated under the terms of the court's order. Substantial development is needed to satisfy the requirements of the Samuels order. Accordingly, the case is being returned to the Tennessee Disability Determination Section for this purpose in accordance with Samuels. In view of the foregoing, the prior determination dated _________, finding that the claimant is not disabled, and any subsequent determinations or decisions on this issue are hereby vacated. A new determination will be made as to whether the claimant is disabled. The claimant will be notified of this new determination and of the right to a hearing if (he/she) thinks the decision is wrong. Notice of this action is hereby given by mailing a copy to the claimant (and the representative).
Claimant's Name and Address:
Representative's Name and Address
Attachment E. Sample Medical Development Form
REQUEST FOR TENNESSEE DISABILITY DETERMINATION SECTION ASSISTANCEUNDER Samuels COURT ORDER
Please obtain a medical report and medical assessment from the following physician(s). Additional names are listed on a separate attached page: Yes____ No____.
Tennessee Disability Determination Section Samuels Documentation in Response to Hearing Office Request
Attachment F. Sample Appeals Council Remand Order
This case is before the Appeals Council based on the claimant's request for review of the Administrative Law Judges's decision issued on _______________.
On August 19, 1986, the U.S. District Court for the Western District of Tennessee issued an order in Samuels, ate al. v. Bowen, et al., which was incorporated by reference in a final judgment issued on March 16, 1987. This order applies statewide in Tennessee for disability claims under titles II and XVI. The court required that specific criteria and procedures be followed in evaluating disability claims for members of the class. Since the claimant is a member of the Samuels class, (his/her) claim must be adjudicated under the provisions of the court's order.
[Describe problem(s) with hearing decision.] (Further, the Appeals Council is of the opinion that is/are needed before a decision can be reached in this case.) The Appeals Council, therefore, in accordance with the court's order and pursuant to (20 CFR 404.970 and 404.977,) OR (20 CFR 416.1470 and 416.1477,) OR (20 CFR 404.970, 404.977, 416.1470, and 416.1477,) grants the request for review, vacates the hearing decision and remands this case to the Administrative Law Judge for further proceedings, including a new decision which will address all the pertinent adjudicative criteria of the Samuels order.
[Add any special instructions to the Administrative Law Judge.]
The Administrative Law Judge may take any action not inconsistent with this order of remand.