McCool v. Social Security Administration Commissioner

Filing 16

FINAL JUDGMENT REVERSING THE DECISION OF THE COMMISSIONER AND REMANDING THIS CASE TO THE COMMISSIONER FOR FURTHER CONSIDERATION PURSUANT TO SENTENCE FOUR of 42 U.S.C. 405(g). Signed by Honorable Mark E. Ford on October 3, 2016. (lw)

IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FORT SMITH DIVISION

JACOB A McCOOL

V.

PLAINTIFF

CIVIL ACTION NO. 2:15-CV-2210-MEF

CAROLYN W. COLVIN, Commissioner,
Social Security Administration

DEFENDANT

FINAL JUDGMENT

This cause is before the Court on the Plaintiff’s complaint for judicial review of an
unfavorable final decision of the Commissioner of the Social Security Administration denying his
claim for both social security and disability benefits. The parties have consented to entry of final
judgment by the United States Magistrate Judge under the provisions of 28 U.S.C. § 636(c). The
Court, having reviewed the administrative record, the briefs of the parties, the applicable law, and
having heard oral argument, finds as follows, to-wit:
Consistent with the Court’s ruling from the bench following the parties’ oral argument, the
decision of the Commissioner of Social Security is reversed and remanded for further proceedings
pursuant to sentence four of 42 U.S.C. § 405(g).
The Court finds that the matter must be remanded for further development of the record
regarding the limitations imposed by the Plaintiff’s Lisfranc fracture dislocation with open
reduction internal fixation. Specifically, how the Plaintiff’s recent diagnosis of pes planus with

valgus alignment of his right foot and collapse of his arch would affect his ability to perform
sedentary work. Although the ALJ ordered an orthopedic consultative examination, he failed to
request the completion of a medical source statement.

On January 2, 2014, prior to the

administrative hearing, Plaintiff requested completion of a medical source statement; the ALJ did
not order one. The request was raised again by Plaintiff at the hearing and, while the ALJ agreed
to do so, no request for an RFC assessment or the completion of a medical source statement was
made by the ALJ during the six months between the hearing and decision. Accordingly, the Court
finds that absent a medical source statement or an RFC assessment, the record is incomplete with
respect to the functionality of the Plaintiff’s foot impairment. See Johnson v. Astrue, 627 F.3d
316, 320 (8th Cir. 2010) (ALJ is required to order medical examinations and tests if the medical
records presented to him do not give sufficient medical evidence to determine whether the claimant
is disabled).
Additionally, the Court finds that the matter must be remanded for reconsideration of the
RFC assessment. Dr. Honoghiran’s consultative examination did not clearly define what
impairments the Plaintiff had, nor did it include a RFC assessment or completed medical source
form. There are no assessments in the record and no clear evidence of the Plaintiff’s ability to
perform sedentary work, and specifically to sit for eight hours per work day, nor does the RFC
address whether Plaintiff would have to elevate his right foot throughout the work day.
Accordingly, the Court finds that the record lacks substantial evidence to support the RFC
determination.
The Court finds that remand is necessary to allow the ALJ to obtain a RFC assessment
from Dr. Honoghiran, and in addition, to send the Plaintiff to a foot specialist for the purpose of a
consultative examination, complete with RFC assessment regarding Plaintiff’s foot impairment.

With the additional RFC assessments, the ALJ is directed to reconsider the Plaintiff’s RFC and to
formulate appropriate hypotheticals for the vocational expert to determine whether there are jobs
in significant numbers in the national economy which the Plaintiff could perform.
IT IS SO ORDERED AND ADJUDGED on this the 3rd day of October, 2016.
/s/ Mark E. Ford
HON. MARK E. FORD
UNITED STATES MAGISTRATE JUDGE