Waid v. Social Security Administration Commissioner
MEMORANDUM OPINION. Signed by Honorable Mark E. Ford on June 8, 2015. (lw)
IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FORT SMITH DIVISION
Civil No. 14-2079
CAROLYN W. COLVIN, Commissioner,
Social Security Administration
Plaintiff, John Waid, brings this action under 42 U.S.C. §405(g), seeking judicial review
of a decision of the Commissioner of Social Security Administration (Commissioner) denying his
claim for a period of disability, disability insurance benefits (“DIB”), and supplemental security
income (“SSI”) under Titles II and XVI of the Social Security Act (hereinafter “the Act”), 42
U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). In this judicial review, the court must determine whether
there is substantial evidence in the administrative record to support the Commissioner’s decision.
See 42 U.S.C. § 405(g).
Plaintiff filed his applications for DIB and SSI on May 17, 2012, alleging an onset date of
May 30, 2012, due to a heart attack, stent placement, diabetes, and high blood pressure. Tr. 69,
233-241, 273, 289-290. The Commissioner denied his application initially and on reconsideration.
Tr. 73-79. At the Plaintiff’s request, an Administrative Law Judge (“ALJ”) held an administrative
hearing on June 3, 2013. Tr. 87-129. Plaintiff was present and represented by counsel.
At the time of the hearing, Plaintiff was 44 years old and possessed a tenth grade education.
Tr. 94-95. He had past relevant work (“PRW”) experience as an appliance assembler, forklift
operator, and off road driver. Tr. 80, 97-102, 281-288.
On June 21, 2013, the ALJ concluded that the Plaintiff’s coronary artery disease status post
myocardial infarction and two stent placements, obesity, diabetes mellitus, degenerative joint
disease (“DJD”), ACL and PCL tears of the left knee, hypertension, and obstructive sleep apnea
were severe, but concluded they did not meet or medically equal one of the listed impairments in
Appendix 1, Subpart P, Regulation No. 4. Tr. 71-73. He concluded that the Plaintiff could perform
sedentary work involving only occasional climbing ramps and stairs, balancing, kneeling,
stooping, crouching, and crawling. Tr. 73. Further, he also determined that he could never climb
ladders, ropes or scaffolds, should avoid concentrated exposure to hazards, and should not drive
as a part of his work. Tr. 73. With the assistance of a vocational expert, the ALJ found the Plaintiff
could perform work as a compact assembler and a clip loading machine operator. Tr. 81.
The Appeals Council denied the Plaintiff’s request for review on March 14, 2014. Tr. 14. Subsequently, Plaintiff filed this action. ECF No. 1. This matter is before the undersigned by
consent of the parties. Both parties have filed appeal briefs, and the case is now ready for decision.
ECF Nos. 9, 10.
This court’s role is to determine whether substantial evidence supports the Commissioner’s
findings. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir. 2002). Substantial evidence is less
than a preponderance but it is enough that a reasonable mind would find it adequate to support the
Commissioner's decision. We must affirm the ALJ’s decision if the record contains substantial
evidence to support it. Edwards v. Barnhart, 314 F.3d 964, 966 (8th Cir. 2003). As long as there
is substantial evidence in the record that supports the Commissioner’s decision, the court may not
reverse it simply because substantial evidence exists in the record that would have supported a
contrary outcome, or because the court would have decided the case differently. Haley v.
Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other words, if after reviewing the record it is
possible to draw two inconsistent positions from the evidence and one of those positions represents
the findings of the ALJ, we must affirm the ALJ’s decision. Young v. Apfel, 221 F.3d 1065, 1068
(8th Cir. 2000).
A claimant for Social Security disability benefits has the burden of proving his disability
by establishing a physical or mental disability that has lasted at least one year and that prevents
him from engaging in any substantial gainful activity. Pearsall v. Massanari, 274 F.3d 1211, 1217
(8th Cir.2001); see also 42 U.S.C. § § 423(d)(1)(A), 1382c(a)(3)(A). The Act defines “physical
or mental impairment” as “an impairment that results from anatomical, physiological, or
psychological abnormalities which are demonstrable by medically acceptable clinical and
laboratory diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A Plaintiff must show
that his or her disability, not simply their impairment, has lasted for at least twelve consecutive
The Commissioner’s regulations require her to apply a five-step sequential evaluation
process to each claim for disability benefits: (1) whether the claimant has engaged in substantial
gainful activity since filing his or her claim; (2) whether the claimant has a severe physical and/or
mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal
an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past
relevant work; and, (5) whether the claimant is able to perform other work in the national economy
given his or her age, education, and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003). Only
if he reaches the final stage does the fact finder consider the Plaintiff’s age, education, and work
experience in light of his or her residual functional capacity. See McCoy v. Schweiker, 683 F.2d
1138, 1141-42 (8th Cir. 1982); 20 C .F.R. § § 404.1520, 416.920 (2003).
When, as in this case, the Plaintiff submits additional medical evidence to the Appeals
Council (“AC”), the AC must consider the evidence if it is new and material and relates to the
period before the ALJ’s decision. See 20 C.F.R. § 404.970(b); Williams v. Sullivan, 905 F.2d 214,
215-216 (8th Cir. 1990). However, the timing of the evidence is not dispositive of whether the
evidence is material. Id. To be material, evidence obtained after an ALJ decision need only relate
to the claimant’s condition on or before the date of the ALJ’s decision. See Basinger v. Heckler,
725 F.29 1166, 1169 (8th Cir. 1984). Therefore, medical evidence dated after the ALJ’s decision
is material if it relates to the claimant’s condition on or before the date of the ALJ’s decision. See
Cunningham v. Apfel, 222 F.3d 496, 502 (8th Cir. 1990)
Once it becomes evident that the Appeals Council considered the additional evidence, the
role of the reviewing court “is limited to deciding whether the administrative law judge’s
determination is supported by substantial evidence on the record as a whole, including the new
evidence submitted after the determination was made.” Riley v. Shalala, 18 F.3d 619, 622 (8th
Cir.1994); see Nelson, 966 F.2d at 366, Browning v. Sullivan, 958 F.2d 817, 822 (8th Cir.1992);
O’Donnell v. Barnhart, 318 F.3d 811, 816 (8th Cir.2003). “Substantial evidence is relevant
evidence that a reasonable mind would accept as adequate to support the Commissioner's
decision.” Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir.2000). In order to evaluate the new
evidence, the reviewing court needs to “determine how the ALJ would have weighted the newly
submitted evidence if it had been presented at the original hearing.” Jenkins v. Apfel, 196 F.3d
922, 924 (8th Cir.1999); see Riley v. Shalala, 18 F.3d 619, 622 (8th Cir.1994). If the reviewing
court finds that the ALJ’s decision is supported by the record as a whole, including the new
evidence, then the ALJ’s final decision remains.
In the present case, the Plaintiff submitted additional medical evidence documenting
further hospitalization and treatment for his heart problems. As it is clear the AC considered this
evidence, but denied review, we include this evidence in our substantial evidence analysis.
The record reveals that the Plaintiff was hospitalized in May 2012, following a myocardial
infarction. Tr. 337-423. A heart catheterization revealed three-vessel coronary artery disease with
severe impairment of the right coronary artery, segmental wall abnormality, and an ejection
fraction rate of 55 percent. Accordingly, Plaintiff underwent stenting. Initially, his condition
stabilized on medication therapy. However, in September 2012, he was again hospitalized for
unstable angina. A repeat catheterization revealed 95 percent intrastent stenosis in the right
coronary artery and 50 percent stenosis of the left descending artery. Tr. 504-506. Plaintiff voiced
continued complaints of atypical chest pain in January 2013. At that time cardiologist, Dr. Parris,
opined it was likely due to mild cardio ischemia. Tr. 442, 492-495. Dr. Parris prescribed additional
medications to treat this pain, but the chest pain continued. Plaintiff reported pressure-like chest
pain and exertional dyspnea, ultimately resulting in a third hospitalization in November 2013. Tr.
18-63. At that time, heart catheterization revealed continued three vessel coronary artery disease
with severe involvement in the right coronary and an ejection fraction rate of 50 percent. Further,
a myocardial stress test showed a trivial to mild reversible apical perfusion defect suggestive of
ischemia and a fixed interior wall perfusion defect consistent with a prior myocardial infarction.
Records from Dr. Parris in December 2013 revealed continued chest pain requiring medication
management. Tr. 12-16.
The record contains two RFC assessments from Plaintiff’s treating physician, Dr. Brandi
Guthrie. She completed the first assessment in July 2012, after Plaintiff’s heart attack and stent
placement, but before doctors diagnosed him with intrastent stenosis. Tr. 456-458. Dr. Guthrie
assessed minimal limitations standing, stooping, kneeling, walking, pushing, and pulling, moderate
limitations carrying, and no lifting over 20 pounds. In May 2013, after the Plaintiff’s intrastent
stenosis was discovered, Dr. Guthrie imposed the following limitations:
1) No use of hands for repetitive action in a competitive environment for
2) No use of hands to handle/grasp
3) No pushing/pulling
4) No fine manipulation
5) No use of feet for repetitive operation of foot controls in a competitive environment
6) No squat, crawl, climb, crouch or kneel
7) Only occasional bend, reach above head and stoop
8) No exposure to unprotected heights; moving machinery; marked temperature changes;
or, dust, fumes and gases
9) Only occasional driving automotive equipment and exposure to noise.
10) Patient would need to take unscheduled breaks during an 8-hour work shift
11) Patient would need to lie down at unpredictable times to rest
12) Patient’s symptoms and pain are severe enough to interfere with attention and
concentration and tolerate work stress
13) Patient would miss more than 4 days per month from work if employed
14) Patient would need to elevate periodically during the day
15) Patient would need a sit/stand/walk option at will if employed
The ALJ dismissed Dr. Guthrie’s 2013 assessment, stating that it was inconsistent with her
first assessment and with the overall evidence of record. He concluded that the Plaintiff could
perform sedentary work, relying on Dr. Guthrie’s first assessment and the December 2010 and
September 2012 assessments of two non-examining consultants who concluded the Plaintiff could
perform light work. Tr. 132-151. We note, however, that each of these assessments were
completed before the Plaintiff’s severe intrastent stenosis was discovered in September 2012. And,
following said diagnosis, Plaintiff was prescribed additional medications to treat his chest pain and
required further hospitalization. This raises concerns regarding possible absenteeism, the need for
unscheduled breaks, his ability to tolerate work stress, and his ability to attend to and concentrate
on the tasks before him. As the ALJ failed to address these issues in the RFC assessment, remand
is necessary to allow the ALJ to consider the additional evidence submitted to the AC documenting
the Plaintiff’s ongoing treatment for coronary artery disease. On remand, the ALJ is directed to
obtain an RFC assessment from Plaintiff’s treating cardiologist, Dr. Parris, to determine the exact
limitations imposed by his cardiac impairment. If Dr. Parris is unavailable or otherwise unwilling
to provide an assessment, then the ALJ should order a consultative examination with a cardiologist,
complete with a thorough RFC assessment.
Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence
and should be reversed and remanded to the Commissioner for further consideration pursuant to
sentence four of 42 U.S.C. § 405(g).
DATED this 8th day of June, 2015.
/s/Mark E. Ford
HONORABLE MARK E. FORD
UNITED STATES MAGISTRATE JUDGE
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