Billy v. Social Security Administration Commissioner
MEMORANDUM OPINION. Signed by Honorable Barry A. Bryant on July 20, 2012. (cap)
IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
Civil No. 4:11-cv-04037
MICHAEL J. ASTRUE
Commissioner, Social Security Administration
Melissa Billy (“Plaintiff”) brings this action pursuant to § 205(g) of Title II of the Social
Security Act (“The Act”), 42 U.S.C. § 405(g) (2006), seeking judicial review of a final decision of
the Commissioner of the Social Security Administration (“SSA”) denying her applications for
Disability Insurance Benefits (“DIB”), Supplemental Security Income (“SSI”) under Titles II and
XVI of the Act. The parties have consented to the jurisdiction of a magistrate judge to conduct any
and all proceedings in this case, including conducting the trial, ordering the entry of a final judgment,
and conducting all post-judgment proceedings. ECF No. 8.1 Pursuant to this authority, the Court
issues this memorandum opinion and orders the entry of a final judgment in this matter.
Plaintiff’s original application for DIB and SSI, was filed on January 31, 2000. (Tr. 16, 419).
These applications allege an onset date of May 13, 1999. (Tr. 419). These applications were initially
denied and were denied again on reconsideration. (Tr. 16). Plaintiff requested an administrative
hearing on her applications, and following the hearing, the ALJ entered unfavorable decision finding
The docket numbers for this case are referenced by the designation “ECF. No.___” The transcript pages
for this case are referenced by the designation “Tr.”
Plaintiff was not disabled. This decision was made on May 30, 2003. (Tr. 16). Plaintiff requested
that the Appeals Council review the ALJ’s unfavorable decision, but the record could not be located
or reconstructed. (Tr. 287).
Plaintiff filed subsequent applications for DIB and SSI on June 25, 2003. (Tr. 287). These
applications were initially denied on September 30, 2003 and were denied again on reconsideration
on December 22, 2003. (Tr. 44-51).
Plaintiff requested an administrative hearing on her
applications, and a hearing was held on April 15, 2005 in Texarkana, Arkansas. (Tr. 308-340). On
September 21, 2005, the ALJ entered an unfavorable decision denying Plaintiff’s request for DIB
and SSI. (Tr. 279-284).
On October 17, 2005, Plaintiff requested that the Appeals Council review the ALJ’s
unfavorable decision. (Tr. 285). On February 24, 2006, the Appeals council ordered these claims
be joined and the case was remanded to the same ALJ for further action necessary to complete the
administrative record and render a new decision. (Tr. 287-288).
A subsequent hearing was held on April 28, 2006 in Texarkana, Arkansas. (Tr. 341-372).
Plaintiff was present and was represented by counsel Evelyn Brooks, at this hearing. See id.
Plaintiff, Vocational Expert (“VE”) William Elmore, and Medical Expert Dr. Henry Hamilton
testified at this hearing. See id. On the date of this hearing, Plaintiff was thirty-two (32) years old,
which is defined as a “younger person” under 20 C.F.R. § 404.1563(c) (2008), and had a high school
education. (Tr. 71, 332).
On June 22, 2006, the ALJ entered an unfavorable decision denying Plaintiff’s applications
for DIB and SSI. (Tr. 16-22). Plaintiff requested the Appeals Council review the adverse decision
of the ALJ on August 11, 2006. (Tr.11-12). On November 9, 2007, the Appeals Council issued a
decision denying Plaintiff’s request for review and accepting the ALJ's conclusion that she was not
disabled. (Tr.7-9). Plaintiff subsequently filed a complaint in this court for judicial review of her
claims and judgment was entered in her favor by the undersigned on March 25, 2009, remanding her
case for further consideration pursuant to sentence four of 42 U.S.C. Section 405(g). (Tr.394-403).
Pursuant to this Court Order, the Appeals Council remanded Plaintiff’s case on May 12, 2009
and instructed the ALJ to offer her the opportunity for a new hearing and to take any further action
necessary to complete the administrative record and issue a new decision. (Tr. 405-407). Thereafter,
hearing was held on October 7, 2009 in Texarkana, Arkansas. (Tr. 417-440). Plaintiff was present
and was represented by an attorney, Evelyn Brooks, at this hearing. See id. Plaintiff and Vocational
Expert (“VE”) Dianne Smith testified at this hearing. See id. At the time of this hearing, Plaintiff
was thirty-six (36) years old, which is classified as a “younger individual” under 20 C.F.R. §
404.1563(c) (2007), and had a high school education. (Tr. 71, 332).
On April 28, 2010, the ALJ entered an unfavorable decision denying Plaintiff’s request for
DIB and SSI. (Tr. 383-393). In this opinion, the ALJ determined Plaintiff met the insured status of
the Act through December 31, 2004. (Tr. 385, Finding 1). The ALJ also found Plaintiff had not
engaged in Substantial Gainful Activity (“SGA”) since January 1, 2001. (Tr. 385, Finding 2). The
ALJ determined Plaintiff suffered from the severe impairments of back disorder and migraines. (Tr.
386, Finding 3). The ALJ determined that, although severe, these impairments or combination of
impairments did not meet or medically equal one of the listed impairments in 20 C.F.R. Part 404,
Subpart P, Appendix 1 (20 C.F.R. § 416.920(d), 416.925, and 416.926) (“Listings”). (Tr. 386,
The ALJ also evaluated Plaintiff’s subjective complaints and determined Plaintiff’s Residual
Functional Capacity (“RFC”). (Tr. 387-391, Finding 5). First, the ALJ evaluated Plaintiff’s
subjective complaints and determined Plaintiff’s testimony was not fully credible. See id. Second,
the ALJ determined Plaintiff’s RFC and concluded Plaintiff could perform a wide range of sedentary
work with restrictions of no more than occasional stair climbing, balancing, stooping, crouching,
kneeling, or crawling. (Tr. 387, Finding 5).
The ALJ also determined that Plaintiff could not perform her Past Relevant Work (“PRW”).
(Tr. 391, Finding 6). The ALJ, however, determined that Plaintiff would be able to perform work
that exists in significant numbers in the national economy. (Tr. 391-392, Finding 10). The VE
testified at the hearing regarding this issue. (Tr. 434-439). The VE testified that a hypothetical
person the same age as Plaintiff and with the same RFC and education could perform work as an
information clerk with 2,500 such jobs locally and 75,000 such jobs in the nation and telemarketer
with 3,500 such jobs locally and 350,000 such jobs in the nation. Id. Based upon the VE’s
testimony, the ALJ determined that Plaintiff was not disabled. (Tr. 392, Finding 11).
On February 25, 2011, the Appeals Council declined to review the ALJ’s April 28, 2010
hearing decision. (Tr. 373-375). Subsequently, Plaintiff filed the present action. ECF No. 1.
Plaintiff and Defendant have both filed appeal briefs. ECF Nos. 9, 10. This case is now ready for
2. Applicable Law:
In reviewing this case, this Court is required to determine whether the Commissioner’s
findings are supported by substantial evidence on the record as a whole. See 42 U.S.C. § 405(g)
(2006); Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir. 2002). Substantial evidence is less than
a preponderance of the evidence, but it is enough that a reasonable mind would find it adequate to
support the Commissioner’s decision. See Johnson v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001).
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. See
Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). 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, the decision of the ALJ must be affirmed. See Young v. Apfel, 221 F.3d 1065,
1068 (8th Cir. 2000).
It is well established that a claimant for Social Security disability benefits has the burden of
proving his or her disability by establishing a physical or mental disability that lasted at least one
year and that prevents him or her from engaging in any substantial gainful activity. See Cox v. Apfel,
160 F.3d 1203, 1206 (8th Cir. 1998); 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). The Act defines
a “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 his or her impairment, has lasted for at least twelve consecutive
months. See 42 U.S.C. § 423(d)(1)(A).
To determine whether the adult claimant suffers from a disability, the Commissioner uses
the familiar five-step sequential evaluation. He determines: (1) whether the claimant is presently
engaged in a “substantial gainful activity”; (2) whether the claimant has a severe impairment that
significantly limits the claimant’s physical or mental ability to perform basic work activities; (3)
whether the claimant has an impairment that meets or equals a presumptively disabling impairment
listed in the regulations (if so, the claimant is disabled without regard to age, education, and work
experience); (4) whether the claimant has the Residual Functional Capacity (RFC) to perform his
or her past relevant work; and (5) if the claimant cannot perform the past work, the burden shifts to
the Commissioner to prove that there are other jobs in the national economy that the claimant can
perform. See Cox, 160 F.3d at 1206; 20 C.F.R. §§ 404.1520(a)-(f). The fact finder only considers
the plaintiff’s age, education, and work experience in light of his or her RFC if the final stage of this
analysis is reached. See 20 C.F.R. §§ 404.1520, 416.920 (2003).
Plaintiff brings the present appeal claiming the ALJ erred by: (A) failing to consider the
combination of Plaintiff’s impairments; (B) in assessing Plaintiff’s credibility, (C) in assessing
Plaintiff’s RFC and, (D) failing to fully develop the record. ECF No. 9, Pages 2-20. In response,
the Defendant argues the ALJ did not err in any of his findings. ECF No. 10.
A. Combination of Impairments
Plaintiff argues the ALJ erred by failing to consider all of her impairments in combination.
However, under the facts in the present case and after a thorough review of the ALJ’s opinion and
the record in this case, this Court finds the ALJ properly considered Plaintiff’s impairments in
The Social Security Act requires the ALJ to consider the combined effect of all of the
claimant’s impairments without regard to whether any such impairment, if considered separately,
would be of sufficient severity. See 20 C.F.R. § 404.1523 (2006). In the present action, in reviewing
these claimed impairments, the ALJ stated Plaintiff “does not have an impairment or combination
of impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1.” (Tr. 386, Finding 4) (emphasis added). The ALJ also found, “after
consideration of the entire record,” the Plaintiff had the RFC to perform sedentary work. (Tr. 387,
Finding 5). The ALJ went on to state Plaintiff’s RFC would not preclude her from performing other
work that exists in significant numbers in the national economy. (Tr. 391, Finding 10). These
statements are sufficient under Eighth Circuit precedent to establish that the ALJ properly considered
the combined effect of a claimant’s impairments. See Hajek v. Shalala, 30 F.3d 89, 92 (8th Cir.
1994) (holding that statements such as “the evidence as a whole does not show that the claimant’s
symptoms . . . preclude his past work as a janitor” and “[t]he claimant’s impairments do not prevent
him from performing janitorial work . . .” sufficiently establish that the ALJ properly considered the
combined effects of the plaintiff’s impairments).
Thus, pursuant to the Eighth Circuit’s holding in Hajek, this Court finds the ALJ properly
considered Plaintiff’s impairments in combination. Plaintiff has alleged she suffers from a number
of impairments. However, this Court is not required to find a claimant is disabled simply because
he or she has alleged a long list of medical problems. The ALJ’s opinion sufficiently indicates the
ALJ properly considered the combined effect of Plaintiff’s impairments, and the ALJ properly
considered the severity of the combination of Plaintiff’s impairments. See Hajek, 30 F.3d at 92.
B. ALJ’s Credibility Determination
Plaintiff also claims the ALJ erred in his credibility determination. ECF No. 9, Pages 17-18.
Specifically, Plaintiff claims the ALJ erred by failing to make specific findings as to the relevant
evidence considered in deciding to discredit Plaintiff’s testimony. See id. In response, Defendant
argues that the ALJ properly evaluated and discredited Plaintiff’s subjective complaints pursuant to
the directives of Polaski. ECF No. 10, Pages 17-18.
In assessing the credibility of a claimant, the ALJ is required to examine and to apply the
five factors from Polaski v. Heckler, 739 F.2d 1320 (8th Cir. 1984) or from 20 C.F.R. § 404.1529
and 20 C.F.R. § 416.929.2 See Shultz v. Astrue, 479 F.3d 979, 983 (2007). The factors to consider
are as follows: (1) the claimant’s daily activities; (2) the duration, frequency, and intensity of the
pain; (3) the precipitating and aggravating factors; (4) the dosage, effectiveness, and side effects of
medication; and (5) the functional restrictions. See Polaski, 739 at 1322.
The factors must be analyzed and considered in light of the claimant’s subjective complaints
of pain. See id. The ALJ is not required to methodically discuss each factor as long as the ALJ
acknowledges and examines these factors prior to discounting the claimant’s subjective complaints.
See Lowe v. Apfel, 226 F.3d 969, 971-72 (8th Cir. 2000). As long as the ALJ properly applies these
five factors and gives several valid reasons for finding the Plaintiff’s subjective complaints are not
entirely credible, the ALJ’s credibility determination is entitled to deference. See id.; Cox v.
Barnhart, 471 F.3d 902, 907 (8th Cir. 2006). The ALJ, however, cannot discount Plaintiff’s
subjective complaints “solely because the objective medical evidence does not fully support them
[the subjective complaints].” Polaski, 739 F.2d at 1322.
When discounting a claimant’s complaint of pain, the ALJ must make a specific credibility
determination, articulating the reasons for discrediting the testimony, addressing any
inconsistencies, and discussing the Polaski factors. See Baker v. Apfel, 159 F.3d 1140, 1144 (8th
Cir. 1998). The inability to work without some pain or discomfort is not a sufficient reason to find
a Plaintiff disabled within the strict definition of the Act. The issue is not the existence of pain, but
whether the pain a Plaintiff experiences precludes the performance of substantial gainful activity.
Social Security Regulations 20 C.F.R. § 404.1529 and 20 C.F.R. § 416.929 require the analysis of two
additional factors: (1) “treatment, other than medication, you receive or have received for relief of your pain or other
symptoms” and (2) “any measures you use or have used to relieve your pain or symptoms (e.g., lying flat on your
back, standing for 15 to 20 minutes every hour, sleeping on a board, etc.).” However, under Polaski and its progeny,
the Eighth Circuit has not yet required the analysis of these additional factors. See Shultz v. Astrue, 479 F.3d 979,
983 (2007). Thus, this Court will not require the analysis of these additional factors in this case.
See Thomas v. Sullivan, 928 F.2d 255, 259 (8th Cir. 1991).
Plaintiff argues the ALJ erred in assessing her credibility as it related to the limiting effects
of her impairments and did not fully consider her subjective complaints as required by Polaski. The
Defendant argues the ALJ properly evaluated Plaintiff’s subjective complaints of pain in compliance
In the present action, this Court finds the ALJ properly addressed and discounted Plaintiff’s
subjective complaints. In his opinion, the ALJ addressed the factors from Polaski and 20 C.F.R. §
416.929, and stated inconsistencies between Plaintiff’s testimony and the record. (Tr. 388-390).
Specifically, the ALJ noted the following: (1) Absence of objective medical findings to support
Plaintiff’s alleged disabling pain, (2) Plaintiff’s described activities of daily living are not limited
to any serious degree, (3) No physician has placed a level of limitation on Plaintiff’s activities
comparable to those described by Plaintiff, (4) Plaintiff’s medication has been effective in
controlling her symptoms with no side effects, and (5) Plaintiff received little treatment outside of
medication to address her physical impairments. Id.
These findings are valid reasons supporting the ALJ’s credibility determination, and this
Court finds the ALJ’s credibility determination is supported by substantial evidence and should be
affirmed. See Lowe, 226 F.3d at 971-72. Accordingly, the ALJ did not err in discounting Plaintiff’s
subjective complaints of pain.
Prior to Step Four of the sequential analysis in a disability determination, the ALJ is required
to determine a claimant’s RFC. See 20 C.F.R. § 404.1520(a)(4)(iv). This RFC determination must
be based on medical evidence that addresses the claimant’s ability to function in the workplace. See
Stormo v. Barnhart, 377 F.3d 801, 807 (8th Cir. 2004). The ALJ should consider “‘all the evidence
in the record’ in determining the RFC, including ‘the medical records, observations of treating
physicians and others, and an individual’s own description of his limitations.’” Stormo v. Barnhart,
377 F.3d 801, 807 (8th Cir. 2004) (quoting Krogmeier v. Barnhart, 294 F.3d 1019 (8th Cir. 2002)).
The Plaintiff has the burden of producing documents and evidence to support his or her claimed
RFC. See Cox, 160 F.3d at1206; 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A).
The ALJ, however, bears the primary responsibility for making the RFC determination and
for ensuring there is “some medical evidence” regarding the claimant’s “ability to function in the
workplace” that supports the RFC determination. Lauer v. Apfel, 245 F.3d 700, 703-04 (8th Cir.
2001). Furthermore, this Court is required to affirm the ALJ’s RFC determination if that
determination is supported by substantial evidence on the record as a whole. See McKinney v. Apfel,
228 F.3d 860, 862 (8th Cir. 2000).
In this matter, the ALJ determined Plaintiff retained the RFC for a wide range of sedentary
work. (Tr. 387, Finding 5). Plaintiff argues the ALJ erred in this RFC determination. ECF No. 9,
Pgs. 18-19. However, substantial evidence supports the ALJ’s RFC determination finding Plaintiff
capable of performing a wide range of sedentary work.
On April 19, 2000, Plaintiff was admitted to Christus St. Michael Hospital after she was
involved in a motor vehicle accident. (Tr. 158). Plaintiff complained of injuries to her neck and
back. Id. An MRI exam of Plaintiff’s thoracic spine showed no evidence of a fracture; very mild
bulging of the T5-T6 disc; no evidence of spinal stenosis; and minimal degenerative disc disease.
Plaintiff was treated by Dr. Rodney Chandler from January 11, 2001 through April 19, 2002,
for complaints of back and neck pain. (Tr. 181-190). Plaintiff was also treated for headaches,
nausea, muscle spasms, and pain and numbness in her legs. Id. It appears Dr. Chandler treated
Plaintiff’s symptoms with pain medication. Id.
On May 10, 2002, Plaintiff underwent an MRI exam of her cervical spine. This exam
showed a very small posterior central disc protrusion at the C5-6 level, which did not produce
significant effect upon the canal or neural exit foramen. (Tr. 145). On July 7, 2003, Plaintiff had
a subsequent MRI scan of the cervical spine. (Tr. 141). This exam showed a progression of the
previous C5-6 protrusion, now with a greater degree of ventral cord impingement and possibly a
mild extruded component on the sagittal series; and a mild right paracentral protrusion at the 6-7
level without associated canal or foraminal compromise. (Tr. 141).
On September 11, 2003, Plaintiff was seen by Dr. John L. Fox, a neurosurgeon at the UAMS
Medical Center. (Tr. 232). Dr. Fox recommended Plaintiff have an anterior microcervical
discectomy and fusion and possible insertion of a stabilizing plate to fix Plaintiff’s back and neck
impairments. (Tr. 232). On September 15, 2003, Dr. Fox performed an anterior cervical discectomy
and fusion at the C5-C6 level. (Tr. 223-224, 388).
Following this surgery, on October 9, 2003, an x-ray examination of Plaintiff’s cervical spine
showed an apparent anterior displacement of bone graft; and no solid fusion of the superior margin
of the craft. (Tr. 203). On December 4, 2003, an x-ray examination of Plaintiff’s cervical spine
showed some apparent vascular in-growth of the bone graft with little change from the previous
examination. (Tr. 201).
On July 22, 2004, Dr. Fox completed a Medical Source Statement of Ability To Do
Work-Related Activities (Physical) form. (Tr. 303-305). Dr. Fox indicated Plaintiff could
occasionally lift and carry less than ten pounds, and frequently lift and carry less than ten pounds.
(Tr. 303). He also found Plaintiff must periodically alternate between sitting and standing; had a
limited ability to push and pull controls with her arms; could frequently kneel, crouch, and crawl;
could never climb or balance; and had no manipulative, visual, or environmental limitations. (Tr.
On May 25, 2005, Dr. William Blankenship performed a consultative physical examination
of Plaintiff. (Tr. 265-268). The physical examination showed no evidence of muscle spasms in the
cervical or lumbar spine area; normal reflexes; and no intrinsic weakness or atrophy of either arm.
(Tr. 265-266). Plaintiff had a slightly reduced range of motion in her spine, and normal range of
motion in her shoulders, elbows, hands, wrists, knee, hip, and ankle. (Tr. 267). An x-ray
examination of Plaintiff’s lumbar spine showed a mild scoliosis with no evidence of fracture,
spondylolysis or spondylolisthesis, or osteophyte formation. (Tr. 266). An x-ray examination of
Plaintiff’s cervical spine showed normal alignment; no evidence of abnormal widening or narrowing
of the intervertebral joints; and normal cervical lordosis with a solid fusion between C5-C6. (Tr.
266). Dr. Blankenship’s impression was status post-operative interbody fusion of C5-C6 healed and
low-back pain. (Tr. 266).
At that same time, Dr. Blankenship also completed a Medical Source Statement of Ability
To Do Work-Related Activities (Physical) form. (Tr. 268). Dr. Blankenship indicated Plaintiff
could occasionally lift and carry twenty to fifty pounds, and frequently lift and carry ten pounds;
could stand, walk, or sit for eight hours in an eight-hour workday; and could frequently grasp,
perform fine manipulation, handle objects, feel objects, push and pull controls with hands and feet,
and reach. (Tr. 268). Dr. Blankenship also found Plaintiff could frequently climb, balance, stoop,
kneel, crouch, and crawl; and had no environmental limitations. (Tr. 268).
On December 2, 2009, Dr. Harold Chakales performed a consultative examination of
Plaintiff. (Tr. 411-413). Dr. Chakales indicated an x-ray examination of Plaintiff’s cervical spine
showed a cervical arthrodesis of C5-C6; and an x-ray examination of Plaintiff’s lumbar spine
showed normal results. (Tr. 411). On physical exam, Plaintiff had a satisfactory gait and limited
range of motion in her spine, but normal range of motion in her shoulders, elbows, writs, hands,
knee, hip, and ankle. (Tr. 412-413). Dr. Chakales’ impression was status post-operative anterior
cervical fusion with restriction motion and pain and a possible disc protrusion in the lower lumbar
spine on the right side. (Tr. 412).
Dr. Chakales also completed a Medical Source Statement of Ability To Do Work-Related
Activities (Physical) form. (Tr. 414). Dr. Chakales indicated Plaintiff could occasionally lift and
carry twenty pounds, and frequently lift and carry ten pounds. (Tr. 414). Dr. Chakales also found
Plaintiff could stand, walk, or sit for one hour in an eight-hour workday; and could frequently grasp,
perform fine manipulation, handle objects, feel objects, push and pull controls with hands and feet,
and reach. (Tr. 414). Finally, Dr. Chakales indicated Plaintiff could occasionally climb and balance;
but could never stoop, kneel, crouch, and crawl; and had environmental limitations. (Tr. 414).
As shown by the above medical evidence, substantial evidence supports the ALJ’s RFC
determination finding Plaintiff capable of performing a wide range of sedentary work. Plaintiff has
the burden of establishing her claimed RFC. See Goff v. Barnhart, 421 F.3d 785, 790 (8th Cir. 2005)
(quoting Eichelberger v. Barnhart, 390 F.3d 584, 590 (8th Cir. 2004)). Because Plaintiff has not met
her burden in this case and because the ALJ’s RFC determination is supported by sufficient medical
evidence, this Court finds the ALJ’s RFC determination should be affirmed.
D. Duty To Develop
The ALJ has the duty to fully and fairly develop the record, even where the Plaintiff is
represented by counsel. If a physician’s report of a claimant’s limitations are stated only generally,
the ALJ should ask the physician to clarify and explain the stated limitations. See Vaughn v.
Heckler, 741 F. 2d 177,179 (8th Cir. 1984). Furthermore, the ALJ is required to order medical
examinations and tests if the medical records presented do not provide sufficient medical evidence
to determine the nature and extent of a claimant’s limitations and impairments. See Barrett v.
Shalala, 38 F. 3d 1019, 1023 (8th Cir. 1994). The ALJ must develop the record until the evidence
is sufficiently clear to make a fair determination as to whether the claimant is disabled. See Landess
v. Weinberger, 490 F. 2d 1187, 1189 (8th Cir. 1974). In addition, a claimant must show not only that
the ALJ failed to fully and fairly develop the record, but he must also show that he was prejudiced
or treated unfairly by the ALJ's failure. See Onstad v. Shalala, 999 F.2d 1232, 1234 (8th Cir. 1993).
Plaintiff argues the ALJ failed to properly consider Plaintiff’s alleged mental impairments
and should have obtained additional psychological consultants, and as a result of not doing so, the
ALJ failed in his duty to properly develop the record. Defendant argues substantial evidence shows
the ALJ met his duty to fairly develop the record.
Initially the Court notes Plaintiff has failed to establish that the medical records presented
did not provide sufficient medical evidence to determine the nature and extent of his limitations and
impairments. See Barrett v. Shalala, 38 F. 3d 1019, 1023 (8th Cir. 1994). An ALJ is not required
to order a consultative evaluation of every alleged impairment; he simply has the authority to do so
if the existing medical sources do not contain sufficient evidence to make an informed decision. See
Matthews v. Bowen, 879 F.2d 422, 424 (8th Cir. 1989).
On January 31, 2003, Dr. Chandler diagnosed Plaintiff with depression and prescribed Paxil.
(Tr. 169). Plaintiff returned to Dr. Chandler on March 3, 2003 for a follow-up of her symptoms,
including her depression. (Tr. 168). Dr. Chandler prescribed Lexapro, which records show was
refilled through August 2003. (Tr. 162-168).
Plaintiff was also seen for a consultative examination by Dr. Michael Inman on June 11,
2005. (Tr. 252-264). Dr. Inman prepared a Complete Battery and Evaluation of Adaptive
Functioning on Plaintiff. Id. Dr. Inman indicated Plaintiff reported no history of psychiatric
treatment, but indicated her primary care physician prescribed her psychiatric medications. (Tr.
According to Dr. Inman, Plaintiff was pleasant and polite throughout the evaluation, appeared
relaxed, and demonstrated no evidence of overt distress. (Tr. 254). Plaintiff’s thought processes
were goal directed and easily understood, and her thought content was always topic related. Id. Dr.
Inman indicated Plaintiff’s memory was good and her intelligence was within the low average range
Dr. Inman diagnosed Plaintiff with major depression, recurrent, moderate, without psychotic
features; pain disorder associated with psychological factors and general medical condition; and
personality disorder. (Tr. 257).
In the Evaluation of Adaptive Functioning portion of the exam, Dr. Inman indicated Plaintiff
had no dangerous behaviors; could drive and prepare simple meals, although her husband performed
most of the household chores. (Tr. 257-258). According to the evaluation, Plaintiff’s immediate and
sustained concentration and attention were intact; was able to remain focused and persistent
throughout the three-hour evaluation; her latencies were within normal limits; was easily able to
switch topics; and keep pace with the evaluation. (Tr. 258).
Dr. Inman also completed a Medical Source Statement of Ability To Do Work-Related
Activities (Mental). (Tr. 262-264). Dr. Inman indicated Plaintiff’s ability to understand, remember,
and carry out instructions in a typical work environment were intact. (Tr. 262). Also, Dr. Inman
found Plaintiff was able to deal with and respond appropriately to supervisors and coworkers. (Tr.
263). Dr. Inman also indicated Plaintiff’s ability to cope with work pressures in a typical work
environment would be moderately impaired by depression and a pain disorder, but should not
preclude her ability to do so, particularly in a less demanding environment. (Tr. 259).
This medical evidence is sufficient to allow the ALJ to make an informed decision in this
case. Additionally, Plaintiff has failed to show she was in anyway prejudice or treated unfairly by
the ALJ, if the record was not in fact fully and fairly developed.
I find the ALJ satisfied his duty to fully and fairly develop the record in this matter.
Based on the foregoing, the undersigned finds that the decision of the ALJ, denying benefits
to Plaintiff, is supported by substantial evidence and should be affirmed. A judgment incorporating
these findings will be entered pursuant to Federal Rules of Civil Procedure 52 and 58.
ENTERED this 20th day of July 2012.
/s/ Barry A. Bryant
HON. BARRY A. BRYANT
U. S. MAGISTRATE JUDGE
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