Court Opinion

ID: 159501
Source: CourtListenerOpinion
Date Created: 2010-08-14 06:26:25+00
Date Added: 2024-06-11T08:41:46.315820
License: Public Domain

F I L E D
                                                                   United States Court of Appeals
                                                                           Tenth Circuit
                     UNITED STATES COURT OF APPEALS
                                                                           APR 13 2000
                            FOR THE TENTH CIRCUIT
                                                                      PATRICK FISHER
                                                                               Clerk

    MICHAEL G. LEEPER,

                Plaintiff-Appellant,

    v.                                                   No. 99-6216
                                                    (D.C. No. 98-CV-1040)
    KENNETH S. APFEL, Commissioner,                      (W.D. Okla.)
    Social Security Administration,

                Defendant-Appellee.

                            ORDER AND JUDGMENT            *

Before TACHA , ANDERSON , and LUCERO , Circuit Judges.

         After examining the briefs and appellate record, this panel has determined

unanimously to grant the parties’ request for a decision on the briefs without oral

argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore

ordered submitted without oral argument.

*
      This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
       Plaintiff Michael G. Leeper appeals from the denial of social security

disability benefits. The claim was decided at step five.    See generally Williams v.

Bowen , 844 F.2d 748, 750-52 (10th Cir. 1988). The administrative law judge

(ALJ) decided in March 1997 that claimant retained the residual functional

capacity (RFC) to do a full range of light work and was therefore not disabled

under Rule 202.18 of the medical-vocational guidelines (the “grids”), 20 C.F.R.

pt. 404, subpt. P, app. 2. Claimant argues that the ALJ’s reliance on RFC

assessments from 1995 was improper for the time period after July 1996 because

claimant suffered a herniated disk in his back then which resulted in surgery.

Claimant maintains that the ALJ incorrectly implied that claimant’s 1996 injury

and surgery had no effect on his RFC, instead of determining based on substantial

evidence the effect of claimant’s 1996 injury and surgery on his RFC.

       We have jurisdiction under 42 U.S.C. § 405(g) and 28 U.S.C. § 1291. We

review the agency’s decision on the whole record to determine only whether the

factual findings are supported by substantial evidence and the correct legal

standards were applied.    See Goatcher v. United States Dep’t of Health & Human

Servs. , 52 F.3d 288, 289 (10th Cir. 1995). We may not reweigh the evidence or

substitute our judgment for that of the agency.     See Kelley v. Chater , 62 F.3d 335,

337 (10th Cir. 1995). In light of the record, we affirm in part and reverse in part

and remand the case for additional proceedings.

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       Claimant was born in August 1953 and has a ninth grade education. He

formerly worked construction, mainly doing flooring--carpet and tile.           See

Appellant’s App., Vol. II at 85. He sustained a herniated disk in his neck at C7 in

April 1992 when his helper dropped the other end of a sofa bed they were lifting

on a job. See id. at 70, 104, 113, 147, 165, 192. He had surgery in May 1992--an

anterior cervical diskectomy and fusion.     See id. at 81, 104, 108-09, 113-15,

135-36, 139-40, 192. He also had surgery for a carpal tunnel problem in his left

arm in November 1992.       See id. at 119-22, 137-38, 147. Claimant filed his claim

for disability benefits in January 1995, alleging that he became disabled in April

1992 due to residuals from his back and arm problems.

       Claimant worked for two weeks in Ardmore, Oklahoma, in 1994 but

stopped because of pain in his neck and in his left shoulder, arm, and hand.          See

id. at 192. He also went to Wake Island in an attempt to return to general

construction work for a couple of months in mid-1996 because his food stamps

were about to be cut off.   See id. at 190-91. He returned to the mainland when he

suffered a herniated disk in his lower back at L5-S1 in an on-the-job injury.         See

id. at 184, 190. In December 1996, after waiting several months for approval

from his insurance company, claimant was admitted to the hospital overnight for

another surgery--a hemilaminotomy, diskectomy, and neural foraminotomy.               See

id. at 184. Claimant submitted the discharge summary from this surgery to the

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ALJ. In it, claimant’s surgeon reported that claimant tolerated the procedure well

and that the surgery had reduced his left leg pain, but that he still complained of

numbness in his left foot. Claimant “was able to ambulate, eat, and void without

any difficulty,” and was sent home with Percocet for pain and Flexeril for muscle

spasms, a back postoperative instruction card, and instructions to return for a

check-up in three weeks.    Id. In January 1997, claimant reported that he was

taking Clonodine daily for high blood pressure, hydrocodone as needed for back

pain, and Aleve, Tylenol PM, and Medi-sleep for pain and sleeplessness.          See id.

at 183. We note that Percocet (oxycodone) and hydrocodone (in its various

preparations) are narcotic pain medications.      See, e.g. , Physician’s Desk

Reference at 974, 984, 1486 (53d ed. 1999).

      The administrative hearing was held in February 1997, after claimant’s

1996 back surgery but while he was still in follow-up.      See id. at 12, 193-94.

Claimant testified that he still experienced numbness in his left hip, left leg, and

left foot following his back surgery, and that he was in the middle of a course of

physical therapy ordered by his surgeon.       See id. at 193-94. He said that the

physical therapy had not helped.    See id. He also said that his doctor believed

that he may have sustained permanent nerve damage during the five months he

had to wait for his insurance company to approve the surgery.       See id. at 194.

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       The ALJ issued his decision denying benefits on March 10, 1997.           See id.

at 16. Claimant concedes that the denial is supported by substantial evidence up

to the date of his July 1996 back injury, based on the July 1995 opinion of an

examining physician that claimant could perform “moderate to light work” at that

time, id. at 173. Claimant contends that the ALJ’s decision is otherwise

inadequately supported. We agree.

       “It is axiomatic that all of the ALJ’s required findings must be supported by

substantial evidence.”   Haddock v. Apfel , 196 F.3d 1084, 1088 (10th Cir. 1999)

(citing 42 U.S.C. § 405(g)). As noted above, the ALJ decided that claimant was

not disabled under Rule 202.18 of the grids.         See Appellant’s App., Vol. II at 14,

15, 16. The grids rules are based on impairments that impact an individual’s

ability to meet the strength requirements of jobs.       See 20 C.F.R. pt. 404, subpt. P,

app. 2, § 200.00(e). “If an individual’s specific profile is not listed with [the

grids], a conclusion of disabled or not disabled is not directed.” 20 C.F.R.

pt. 404, subpt. P, app. 2, § 200.00(d). For this reason, “[a]utomatic application of

the grids is appropriate only when a claimant’s RFC, age, work experience, and

education precisely match a grid category.”         Gossett v. Bowen , 862 F.2d 802, 806

(10th Cir. 1988).

       The presence of a nonexertional impairment may preclude reliance on the

grids. See Thompson v. Sullivan , 987 F.2d 1482, 1488 (10th Cir. 1993). Pain

                                              -5-
and numbness are sensory impairments and therefore fall within the regulatory

description of nonexertional impairments.         See 20 C.F.R. pt. 404, subpt. P, app. 2,

§ 200.00(e). Claimant’s allegation of pain and numbness in his left hip, leg, and

foot reasonably could affect his ability to perform the full range of light work,

which requires “‘a good deal of walking or standing, or . . . involves sitting most

of the time with some pushing and pulling of arm or leg controls.’”        See

Thompson , 987 F.2d at 1487-88 (quoting 20 C.F.R. § 404.1567(b)). Therefore,

unless there is substantial evidence to support the ALJ’s implied finding that

claimant’s back injury had no effect on his RFC for a full range of light work,

claimant’s characteristics did not precisely match Rule 202.18, and the ALJ was

precluded from relying on the grids for a conclusive determination of

nondisability.   See Daniels v. Apfel , 154 F.3d 1129, 1132 (10th Cir. 1998).

       We have no difficulty deciding that evidence from July 1995 cannot support

the ALJ’s implied finding that claimant’s July 1996 back injury and surgery had

no effect on his RFC for a full range of light work. The ALJ is not allowed to

presume or speculate that claimant’s 1996 back surgery resolved the problems

associated with his injury.   See Social Security Ruling 86-8, 1986 WL 68636, at

*8. On the contrary, “[t]he adjudicator must consider all allegations of physical

and mental limitations or restrictions and make every reasonable effort to ensure

that the file contains sufficient evidence to assess RFC.” Social Security Ruling

                                            -6-
96-8p, 1996 WL 374184, at *5. The ALJ is bound by the agency’s rulings.          See

20 C.F.R. § 402.35(b)(1).

       There is no evidence in the record from which the ALJ could properly

conclude that there were no residual effects from claimant’s 1996 back injury

after his surgery. The medical evidence shows that claimant was left with some

pain and numbness after surgery.        See Appellant’s App., Vol. II at 184. There is

no indication on the discharge summary that these impairments were insignificant

or expected to resolve quickly.       See id. In fact, claimant was prescribed

narcotics, see id. , and his testimony at the hearing was that his surgeon had

ordered nine sessions of physical therapy and was planning to order another MRI

if his pain was not resolved by it,    see id. at 193. We find nothing in the record

concerning treatment for claimant’s numbness. As a result, the ALJ must further

investigate the effects of claimant’s 1996 injury and surgery on his RFC. To this

end, the ALJ should first attempt to obtain additional records from claimant’s

surgeon and physical therapist.       See 42 U.S.C. § 423(d)(5)(B); 20 C.F.R.

§§ 1512(f), 1519a(a)(1). If additional records either do not exist or are

insufficient to clarify the inconclusive evidence already in the record, then the

ALJ should order a consultative examination.        See 42 U.S.C. § 423(d)(5)(B);

20 C.F.R. §§ 1512(f), 1519a(a)(1).

                                              -7-
      The government suggests that additional treatment records must not exist

because claimant, who was represented by counsel, did not volunteer them. Of

course, a claimant is not well served by an attorney who abdicates his

responsibility to support his client’s claim to the fullest extent possible by

submitting all of his medical evidence. Nevertheless, “a social security disability

hearing is nonadversarial.”   Hawkins v. Chater , 113 F.3d 1162, 1164 (10th Cir.

1997). “[T]he presence of some objective evidence in the record suggesting the

existence of a condition which could have a material impact on the disability

decision requiring further investigation” triggers the ALJ’s duty to develop the

record, which may include ordering a consultative examination.       Id. at 1166-67.

The very real possibility that the ALJ should not have relied on the grids due to

the existence of significant nonexertional impairments after July 1996 constitutes

a “material impact” on his decision. This case therefore must be remanded for

further investigation into the effects of claimant’s 1996 back injury and surgery

on his ability to work.

      We note that the ALJ seems to have been convinced that claimant is

unmotivated to work and undeserving of benefits because of his admitted drinking

problem. See Appellant’s App., Vol. II at 14, 168-70, 172-73. The ALJ did not

make a finding that substance abuse is a “contributing factor material” to

claimant’s claim of disability, however. 42 U.S.C. § 423(d)(2)(C);     see also

                                           -8-
20 C.F.R. § 404.1435(a). Such a finding is required to deny disability benefits

based on substance abuse; claimant is entitled to benefits if he is disabled by his

impairments other than alcoholism.   See 20 C.F.R. § 404.1535(b)(2)(ii).

      The denial of disability benefits is AFFIRMED up to the date of claimant’s

back injury in July 1996. The district court’s judgment is otherwise REVERSED,

and the case is REMANDED WITH DIRECTIONS for the district court to remand

the case to the agency for additional proceedings consistent with this order and

judgment.

                                                     Entered for the Court

                                                     Stephen H. Anderson
                                                     Circuit Judge

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