Haycook v. Colvin
ORDER. The Commissioner's decision is affirmed. Signed on 4/26/17 by District Judge Nanette K. Laughrey. (Matthes Mitra, Renea)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF MISSOURI
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
Plaintiff Robert Haycook appeals the Commissioner of Social Security’s final decision
denying his application for disability insurance benefits under Title II of the Social Security Act.
The decision is affirmed.
Haycook was born in 1959. He alleges he became disabled beginning 11/30/2013. He
worked intermittently as a paramedic until April 2015. Haycook first applied for Disability
Insurance Benefits on 12/27/2013 and was denied on 5/20/2014. Haycook filed a Request for
Hearing on 7/3/2014. The Administrative Law Judge held a hearing on 6/11/2015 and denied his
application on 10/23/2015. Haycook submitted additional evidence to the Appeals Council,
which denied his request for review on 6/6/2016.
1. History Considered by the Administrative Law Judge
In January 2013, Haycook visited his primary care physician, Michael Knapp, D.O.,
where he reported experiencing depression, anxiety, diabetes, neck pain, difficulty sleeping,
troubled feelings, isolation, lack of appetite, and feelings of depression. Tr. 452. Haycook
presented with similar symptoms in April 2013 as well as presenting muscle spasms. Dr. Knapp
noted Haycook’s diabetes was uncontrolled. Tr. 470, 475.
In August 2013 Haycook twice presented to the emergency room with abdominal pain,
nausea, and vomiting. He also saw Dr. Knapp for treatment regarding neck and lower cervical
spine pain. On August 16, 2013, Haycook underwent a C4-5 and C5-6 anterior cervical
discectomy and fusion. At his follow-up appointments, Haycook reported the left arm pain and
numbness he felt pre-surgery was gone but that he still experienced neck muscle spasm pain. Tr.
667, 669. He was admitted through the emergency room again in October and November 2013
presenting abdominal pain, vomiting and severe neck pain. Tr. 615, 622. He was diagnosed with
hypokalemia, uncontrolled diabetes and chronic neck pain.
In December 2013, Haycook was admitted and underwent a psychological evaluation
after telling his sister he was going to harm himself. Tr. 641. After evaluation, Haycook was
diagnosed with adjustment disorder with disturbance of emotion and conduct, and was noted to
have poor coping skills. Tr. 648. He was discharged two days later. Haycook was seen by Dr.
Knapp and later presented to the emergency room with continued neck pain and spasms made
worse with certain movements. Tr. 492, 359.
In January 2014, Haycook reported problems with his left arm jerking, causing him to
drop items. Tr. 677. He reported improvement with his neck pain, but that he stopped working as
a paramedic due to the physical activity it required. Id. In April 2014 Haycook saw Dr. Knapp
and Dr. Curtis reporting muscle spasms in his neck and “dragging of his left foot.” Tr. 704, 787.
In May 2014 Haycook saw Dr. Knapp for diabetes management where he reported he had not
been monitoring his blood sugars at home despite Dr. Knapp’s referral to a website where he
could obtain test strips for free. Tr. 781, 792. In October 2014 Haycook presented to the
emergency room with elevated blood sugar levels, confusion, and slurred speech. Tr. 716.
Haycook also reported lightheadedness, tunnel vision, general weakness, abdominal pain,
nausea, and vomiting. Tr. 716.
In March 2015 Haycook was taken to the emergency room by EMS after experiencing
near-syncope. Tr. 748. Haycook also reported abdominal pain, dizziness, lightheadedness,
nausea, and weakness. Id. An ECG revealed a right bundle branch block and sinus tachycardia.
Tr. 750. He was diagnosed with abdominal pain, near syncope, dehydration, and hypokalemia
and was discharged.
In April 2015 Haycook began seeing Cynthia Lungstrum, LSCSW at Trinity Life
Counseling Center, for individual therapy. Tr. 757. Ms. Lungstrum completed a mental medical
in which she indicated Haycook had been diagnosed with Post Traumatic Stress Disorder that
impaired his ability to work. Tr. 760.
2. Additional History Submitted to the Appeals Council
On June 2, 2015, Haycook saw William Nicholas, M.D., at the Bentlage Heart and
Vascular Institute, for an evaluation of a progressive dyspnea. Tr. 799. A stress ECG revealed
normal results, but did indicate a resting heart rate of 100. Id. In September 2015, Haycook
presented to the emergency room with dysuria, bladder pressure and left flank pain. Tr. 868.
Haycook returned to the emergency room in October 2015 with neck pain radiating into
his arms. Tr. 812. He reported difficulty with grasping and gripping objects as well as abnormal
facial movements and difficulty swallowing. Id. A cervical CT revealed mild to moderate
degenerative disc changes and facet joint arthritis at multiple levels, as well as mild to moderate
overall central spinal canal stenosis at C5-6. Tr. 818. He was admitted and saw Daniel Dagen,
D.O. for a neurologic evaluation of his involuntary facial movements. Tr. 889. Dr. Dagen noted
a myelogram and CT revealed recurrent cervical canal stenosis causing Haycook to likely need
repeat surgery. Id.
The hearing before the ALJ
At the June 11, 2015 hearing held before Administrative Law Judge Rhonda Greenburg,
Haycook testified to disabling impairments of a neck injury, heart condition, bowel obstruction,
and depression. Haycook testified that despite undergoing a cervical fusion and bone spur
removal several years prior he continued to experience chronic neck spasms, as well as
numbness and weakness in his left arm and leg on a “nearly constant basis.” Tr. 71; 68; 69.
Haycook testified that this would cause him difficulty in picking up items, gripping with his
hands, reaching and pushing/pulling. Tr. 69. Haycook stated that he had been prescribed pain
medication and medication for his muscle spasms that did not fully relieve his symptoms. Id.
Haycook also testified to having a heart condition, which caused him to experience
sudden onsets of syncopal episodes, as well as weakness and light headedness. Tr. 72. Haycook
stated that he experienced chest palpitations and shortness of breath and lightheadedness with
exertion four to five times a week, and that he had a pacemaker put in during 2010. Tr. 72–74.
Haycook also testified that he had bowl obstructions which caused him to have nausea, diarrhea
and abdominal pain, and that these symptoms could last for several days at a time. Tr. 77. Lastly,
Haycook testified to having symptoms of depression causing him to lose interest in previously
enjoyed activities. Tr. 93, 96.
Regarding his activities of daily living, Haycook testified that he spent most of the day
watching television, reading newspapers and magazines, or visiting with friends or family who
stopped by or called him on the phone. Tr. 88; 86. Haycook testified that he did not help out with
household chores but could get ready on his own, although he had to take breaks, especially
when shaving. Tr. 82; 83; 89. Haycook testified that he could sit for several hours before needing
to stand; he could stand for four hours before needing to sit; he could only walk for twenty to
thirty feet at one time; and he could only lift ten pounds. Tr. 78; 81; 82.
A vocational expert testified at the hearing. The ALJ proposed a hypothetical individual
who was capable of medium exertion and was able to frequently climb ladders, ropes and
scaffolding; could frequently crawl; could occasionally reach overhead; should avoid even
moderate exposure to vibration; and who should not work around unprotected heights, dangerous
moving machinery or operate heavy industrial equipment. Tr. 98. The vocational expert testified
that an individual with these limitations would not be able to perform Haycook's past relevant
work, but could perform work as janitor, hand packer, or dishwasher. Tr. 100. The vocational
expert further testified that Plaintiff had skills that would transfer to other light and sedentary
work, and that there existed various unskilled, light exertional level jobs that he could also
perform, such as arcade attendant, small products assembler, and electronics assembler. Tr. 47,
The ALJ found that during the relevant period, Haycook had severe impairments of a
history of coronary disease with placement of a peacemaker and degenerative disease of the
cervical spine status-post surgery. The ALJ did not conclude that any of these conditions met or
equaled a listed impairment despite Haycook’s argument that he met listing 1.04.
The ALJ concluded Haycook has the residual functional capacity:
[T]o perform medium work as defined in 20 C.F.R. 404.1567(c)
except with frequent climbing of ladders, ropes, and scaffolding;
frequent crawling; occasional reaching overhead; avoid even
moderate exposure to vibrations; no working around unprotected
heights, dangerous moving machinery and operating heavy
Tr. 42. Relying on vocational expert testimony, the ALJ concluded Haycook’s impairments
would not preclude him from performing work that exists in significant numbers in the national
economy, including work as janitor, hand packer, or dishwasher. Tr. 100.
This suit involves an application for disability insurance benefits (DIB) under Title II of the
Act, 42 U.S.C. §§ 401, et seq. Section 205(g) of the Act, 42 U.S.C. § 405(g), provides for judicial
review of a “final decision” of the Commissioner of the Social Security Administration (SSA). The
Court’s review of the Commissioner’s decision is limited to a determination of whether the decision
is supported by substantial evidence on the record as a whole. Milam v. Colvin, 794 F.3d 978, 983
(8th Cir. 2015). Substantial evidence is less than a preponderance but enough that a reasonable mind
might accept as adequate to support the Commissioner’s conclusion. Id. The specific issues raised by
Plaintiff in this case are: (1) In finding Haycook did not qualify for a listed impairment, did the
Commissioner make a proper decision at step three of the evaluation process?; and (2) Is the ALJ’s
RFC supported by substantial evidence? [Doc. 9, p.1].
The Court must consider evidence that both supports and detracts from the
Commissioner’s decision but cannot reverse the decision because substantial evidence also exists
in the record that would have supported a contrary outcome, or because the Court would have
decided the case differently. Andrews v. Colvin, 791 F.3d 923, 928 (8th Cir. 2015). If the Court
finds that the evidence supports two inconsistent positions and one of those positions represents
the Commissioner’s findings, then the Commissioner’s decision must be affirmed. Wright v.
Colvin, 789 F.3d 847, 852 (8th Cir. 2015).
A. The Commissioner made a proper decision at step three.
Under the authority of the Social Security Act, the Social Security Administration has
established a five-step sequential evaluation process for determining whether an individual is
disabled. 20 C.F.R. 404.1520(a). At step one, the ALJ must determine whether the claimant is
engaging in substantial gainful activity, which is work activity that involves doing significant
physical or mental activities. Id. at 404.1520(b); 404.1572(a). At step two, the ALJ must
determine whether the claimant has a medically determinable impairment that is “severe” or a
combination of impairments that is “severe.” Id. at 404.1520(c). An impairment or combination
of impairments is “severe” within the meaning of the regulations if it significantly limits an
individual’s ability to perform basic work activities. Id.
At step three, the ALJ must determine whether the claimant’s impairment or combination
of impairments is of a severity to meet or medically equal the criteria of an impairment listed in
20 C.F.R. Part 404, Subpart P, Appendix 1. If the claimant’s impairment or combination of
impairments is of a severity to meet or medically equal the criteria of a listing and meets the
duration requirement, the claimant is disabled. If not, the ALJ proceeds to the next step.
At step three, the ALJ found that Haycook has severe impairments of a “history of
coronary disease with placement of a pacemaker and degenerative disease of the cervical spinepost surgery,” as well as a number of non-severe impairments, including diabetes, abdominal
complaints, and depression. Tr. 40–41. In finding Haycook did not meet the criteria for 1.04
listing, the ALJ stated that Haycook did not “have nerve root compression, spinal arachnoiditis
or lumbar spinal stenosis” and while the evidence showed some degenerative disease of the
cervical spine, there was no evidence of compression or stenosis. Tr. 42.
Haycook first argues that the record before the ALJ contained evidence that Haycook
suffered from cervical spinal stenosis. [Doc. 9, p. 14]. Haycook’s primary argument, however, is
based on evidence he submitted to the Appeals Council after the ALJ rendered her unfavorable
decision. Haycook argues that that record shows his cervical condition meets all of the
requirements of Listing 1.04A. See [Doc. 9, pp. 14-18].
If the Appeals Council finds that the ALJ’s actions, findings, or conclusions are contrary
to the weight of the evidence, including the new evidence, it will review the case. See 20 C.F.R.
§ 404.970(b). Here, the Appeals Council considered the new evidence, adopted it as part of the
administrative record, then denied review, finding that the new evidence did not provide a basis
for changing the ALJ’s decision. Tr. 2. Because the Appeals Council denied review the Court
does not evaluate the Appeals Council’s decision to deny review, but whether the record as a
whole, including the new evidence, supports the ALJ’s determination. Nelson v. Sullivan, 966
F.2d 363, 366 (8th Cir. 1992).
Listing § 1.04 provides for evaluation of disorders of the spine, including herniated
nucleus pulposus, spinal stenosis, and degenerative disc disease, “resulting in compromise of a
nerve root . . . or the spinal cord.” 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.04. Subsection A of
Listing § 1.04 requires:
Evidence of nerve root compression characterized by neuroanatomic distribution of pain, limitation of motion of the spine,
motor loss (atrophy with associated muscle weakness or muscle
weakness) accompanied by sensory or reflex loss and, if there is
involvement of the lower back, positive straight-leg raising test
(sitting and supine)[.]
Id. The regulations relating to musculoskeletal impairments require that examination of the spine
should include a detailed description of gait, range of motion of the spine or straight leg-raising
in both the sitting and supine positions, and any motor and sensory abnormalities, any muscles
spasm, and deep tendon reflexes. 20 C.F.R. Part 404, Subpart P, Appendix 1, § 1.00.E. Evidence
of atrophy is not acceptable as evidence of significant motor loss without circumferential
measurements of both thighs and lower legs. Id.
With respect to evidence of a nerve root compression, a CT scan dated October 23, 2015
submitted to the Appeals Council showed (1) moderate central canal stenosis with cord
flattening, but opacified CSH surrounding the cord; (2) moderate right and moderate to severe
left foraminal stenosis, with slight progressive narrowing on the right, similar degree of
narrowing on the left at C5-6; (3) slightly increased cord deformity with compression of the right
half of the cord at C6-7; and (4) mild cord deformity with mild central canal stenosis and mild to
moderate bilateral foraminal stenosis at C7-T1. Tr. 847. After reviewing the CT scan, Dr. Dagan
stated that Haycook’s “recurrent cervical canal stenosis” would “likely need  repeat surgery.”
Tr. 889. The CT scan represents some evidence of the first requirement of Listing 1.04A.
To meet the listing criteria, Haycook also must submit evidence of “limitation of motion
of the spine” and “motor loss (atrophy with associated muscle weakness or muscle weakness)
accompanied by sensory or reflex loss.” See 20 C.F.R. Part 404, Subpart P, Appendix 1, §
1.04(A). Haycook argues the evaluation submitted to the Appeals Council showed that Haycook
suffered from neuroanatomic distribution of pain, limitation of motion, muscle weakness, and
sensory or reflex loss. Tr. at 830. However, Plaintiff’s citation to his own subjective report of his
symptoms—here his subjective report to emergency room personnel—does not meet his burden
to show, by medical evidence, that he meets all of the specified medical criteria as required by
the Listing. See Sullivan v. Zebley, 493 U.S. 521, 530 (1990); 20 C.F.R. Part 404, Subpart P,
Appendix 1, § 1.00D (explaining that “physical findings must be determined on the basis of
objective observation during [an] examination and not simply a report of the individual’s
allegation; e.g., ‘He says his leg is weak, numb’”).
While Dr. Lawrence’s October 21, 2015 examination revealed slightly diminished left
extremity deltoid strength (4+/5), triceps (4/5), and biceps (4/5), and his assessment included
“proximal left upper extremity weakness,” Plaintiff’s reflexes were normal, and sensation was
grossly normal. Tr. 830-31. Likewise, Dr. Dagen’s October 22, 2105 examination showed
limited range of motion of the neck, mild weakness in hand intrinsic muscles, positive
Hoffman’s sign (evidence of abnormal reflexes), and mild diminution in rapid alternating
movements in the hands. Tr. at 890. However, Dr. Dagen’s exam also showed he had good
strength in the upper extremities and moderate vibratory sense loss in both feet compatible with
neuropathy, but no motor loss. Tr. 890-91.
Plaintiff has the burden at this step of demonstrating through medical evidence that his
impairments “meet all of the specified medical criteria” contained in a particular listing. Igo v.
Colvin, 839 F.3d 724, 729 (8th Cir. 2016). In this case, Haycook has not done so. The records
Haycook submitted to the Appeals Council indicated the existence of only some of the required
medical criteria for a step three listing determination. While Haycook argues the October 23,
2015 CT scan and Dr. Dagen’s examination the next day provides findings sufficient to satisfy
Listing 1.04A, [Doc. 17, p. 3], the exam also showed good strength in the upper extremities and,
crucially, no motor loss. Tr. 890–91. See 20 C.F.R. Part 404, Subpart P, Appendix 1, § 1.04. Dr.
Lawrence’s October 21, 2015 examination similarly revealed normal reflexes and sensation.
The burden on the claimant to produce evidence that his impairments meet all of the
specified listing criteria is high. As the U.S. Supreme Court recognized, “[t]he [Commissioner]
explicitly has set the medical criteria defining the listed impairments at a higher level of severity
than the statutory standard [of disability],” as they “define impairments that would prevent an
adult, regardless of his age, education, or work experience, from performing any gainful activity,
not just ‘substantial gainful activity.’” Sullivan v. Zebley, 493 U.S. 521, 532 (1990). “The reason
for this difference between the listings’ level of severity and the statutory standard is that, for
adults, the listings were designed to operate as a presumption of disability that makes further
inquiry unnecessary.” Id. Thus, the listings inquiry at “step three streamlines the decision process
by identifying those claimants whose medical impairments are so severe that it is likely they
would be found disabled regardless of their vocational background.” Bowen v. Yuckert, 482 U.S.
137, 153 (1987).
Haycook has not met this high burden. Accordingly, the Court finds that the record as a
whole including the new evidence submitted to the Appeals Council does not establish that he
met all of the requirements of Listing § 1.04A such that he should have been found
presumptively disabled at step three of the sequential process during the time period at issue on
B. The RFC was supported by substantial evidence.
The ALJ’s RFC concluded Haycook retained the ability to perform a range of medium
work despite evidence of greater physical limitations. Haycook argues the RFC is not supported
by substantial evidence. [Doc. 9, p. 18].
1. The record is properly developed.
As a preliminary matter, Haycook maintains his record is underdeveloped because it was
never reviewed by a medical professional and “contains treatment notes documenting Haycook’s
chronic pain, but does not contain sufficient evidence of Haycook’s functional abilities.” [Doc. 9,
p. 20]. An ALJ has an independent duty to fairly and fully develop the record. Vossen v. Astrue,
612 F.3d 1011, 1016 (8th Cir. 2010) (citing Snead v. Barnhart, 360 F.3d 834, 838 (8th Cir.
2004)). However, Haycook “bears the burden of proving disability and providing medical
evidence as to the existence and severity of an impairment.” Kamann v. Colvin, 721 F.3d 945,
950 (8th Cir. 2013). A claimant’s failure to provide evidence in support of his claimed workrelated restrictions “should not be held against the ALJ when there is medical evidence that
supports the ALJ’s decision.” Steed v. Astrue, 524 F.3d 872, 876 (8th Cir. 2008). See Moore v.
Astrue, 572 F.3d 520, 524 (8th Cir. 2009) (lack of physician-imposed work-related limitations
supported the ALJ’s RFC finding and determination that claimant could return to her past
relevant work); Choate v. Barnhart, 457 F.3d 865, 870 (8th Cir. 2006) (“There is no indication in
the treatment notes that . . . any of Choate’s  doctors restricted his activities, or advised him to
avoid prolonged standing or sitting.”); Young v. Apfel, 221 F.3d 1065, 1069 (8th Cir. 2000) (lack
of significant, long-term restrictions imposed by treating physicians supported ALJ’s
determination of no disability).
Defendant argues that Haycook “could have obtained and provided a medical opinion
regarding his specific work-related physical functional capabilities, but he did not.” [Doc. 13, p.
17]. As the ALJ noted, the lack of any medical opinion classifying Haycook as disabled or
seriously incapacitated was in itself telling. Tr. 45, 670, 711. Plaintiff cites Nevland v. Apfel for
support that this case must be remanded to further develop the record. [Doc. 9, pp. 19–20] (citing
204 F.3d 853 (8th Cir. 2000)). However, as the Eight Circuit recognized in Nevland, the
formulation of the RFC is a medical question and must be based on some medical evidence.
Nevland, 204 F.3d at 858-59. In that case, “there [was] no medical evidence about how
Nevland’s impairments affect his ability to function now.” Id. (emphasis in original). That is not
true in this case. Here, the ALJ explicitly considered and discussed the medical evidence in
evaluating Plaintiff’s claim and in assessing limitations as part of his RFC. Tr. 40-46.
When the evidence is insufficient to make a determination about disability, the Agency
may request additional records, obtain a consultative examination, ask the claimant for more
information, or recontact a medical source. See 20 C.F.R. § 404.1520b(c). But, as here, “when
there is no indication that the ALJ felt unable to make the assessment [she] did and [her]
conclusion is supported by substantial evidence,” the ALJ did not need to further develop the
record. The RFC is a determination based on all the record evidence, not just the medical opinion
evidence. See Miller, 784 F.3d at 479; Wildman, 596 F.3d at 969; see also 20 C.F.R. § 404.1545.
The RFC formulation is a part of the medical portion of a disability adjudication—as opposed to
the vocational portion—but it is not based only on “medical” evidence. Rather, an ALJ has the
duty to formulate the RFC based on all the relevant, credible evidence of record and the record
here is properly developed.
2. The RFC is supported by substantial evidence.
Residual functional capacity is what a claimant can still do despite physical or mental
limitations. 20 C.F.R. § 404.1545(a); Masters v. Barnhart, 363 F.3d 731, 737 (8th Cir. 2004);
Social Security Ruling 96-8p, 1996 WL 374184, *5 (July 2, 1996). An ALJ must formulate the
RFC based on all of the relevant, credible evidence of record. See Perks v. Astrue, 687 F.3d
1086, 1092 (8th Cir. 2012) (“Even though the RFC assessment draws from medical sources for
support, it is ultimately an administrative determination reserved to the Commissioner.”)
(quoting Cox v. Astrue, 495 F.3d 614, 619 (8th Cir. 2007)). Evidence relevant to the RFC
determination includes medical records, observations of treating physicians and others, and a
claimant’s own description of his limitations. McKinney v. Apfel, 228 F.3d 860, 863 (8th Cir.
2000) (citation omitted). The claimant has the burden to prove his or her RFC. Pearsall v.
Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001).
Haycook argues the RFC is not supported by substantial evidence. [Doc. 9, p. 20–24].
Haycook points to the following facts in the record that he feels detract from the ALJ’s
conclusion that Haycook could perform medium work:
(1) Haycook underwent a C4-5 and C5-6 anterior cervical discectomy and fusion
in August 2013 and after discharge, he reported that the symptoms in his left arm
had resolved, but he continued to have neck muscle spasm pain;
(2) Two months after his surgery, a nurse practitioner told Haycook that he could
return to work by the end of the month, but when Haycook returned to the
neurosurgeon he reported continued neck pain, he had difficulty holding his head
up without supporting his chin, and he was prescribed a bone stimulator and
TENS unit for pain control;
(3) After Haycook attempted to return to work, he missed work and was
concerned with losing his job;
(4) By January 2014, Haycook had developed involuntary jerking in his left arm
and reported that he had to stop working because of the reactivity his job as a
(5) By April 2014, Haycook was diagnosed with dystonia, degenerative cervical
spinal stenosis, and referred to Washington University to a movement specialist.
(6) Although he again returned to work, that job also ended;
(7) The additional evidence submitted to the Appeals Council showed that
Haycook suffered from cervical myelopathy, upper extremity weakness,
diminution in rapid alternating movements of the hands, decreased sensation in
both feet, and involuntary movements; and
(8) His conditions were described as chronic and ongoing and there was no cure
for the impairments.
[Doc. 9, pp. 20 – 21].
Contrary to Haycook’s contention, the ALJ explicitly noted the medical record items that
were in the record at the time of the hearing in formulating the RFC. The ALJ reviewed the
records concerning the pacemaker placement and cervical fusion. Id. The record contains no
evidence that the medication prescribed in conjunction with those procedures “was ineffective or
causes significant side effects. [Haycook] has used a TENs unit. Otherwise, there are no other
measures used to relieve pain or other symptoms.” Id. After the most recent near syncope
episode, the ALJ noted the record showed Haycook “had not been eating or drinking for the past
three to four days due to lack of funds” and that “CT scan of the abdomen was unremarkable.”
Reviewing Haycook’s medical record, the ALJ noted the C4-C5 was “fusing nicely,” that
C5-C6 appeared to be fusing but was not solid yet, and there was no halo around the screw
which would indicate instability. Tr. 44, 678, 705. The ALJ further recognized that in April
2014, Plaintiff reported some involuntary facial movements to Dr. Knapp. Tr. 44, 788. Dr.
Knapp noted that his dystonia was mildly affecting his lifestyle activities, but that Plaintiff had
no pain or discomfort associated with the movements. Tr. 44, 788. On February 17, 2015, the
ALJ pointed out, Plaintiff underwent a work physical, which revealed no restrictions in any of
the listed body areas/systems including chest, heart, and spine. Tr. 44, 710-11. He was
recommended to work without restrictions. Tr. 44, 710-11.
Haycook challenges the ALJ’s conclusion that Haycook could perform medium work
because he believes it is contrary to his upper extremities limitations. [Doc. 9, p. 24]. Yet the
strongest evidence of extremity limitations, which was not available to the ALJ and first
submitted to the Appeals Council, does not support this claim. Dr. Lawrence’s October 21, 2015
examination notes only “slightly diminished left extremity deltoid strength (4+/5)” with
“proximal left upper extremity weakness.” Tr. 830–31 (emphasis added). Similarly, Dr. Dagen’s
examination a few days later revealed that Haycook had good strength in the upper extremities
with mild weakness in hand intrinsic muscles, mild diminution in rapid alternating movements in
his hands, and no motor loss. Tr. 890-91 (emphasis added).
Further, there is no requirement that an RFC be supported by a specific medical opinion
so long as it is based on some medical evidence. See Meyers v. Colvin, 721 F.3d 526, 527 (8th
Cir. 2013); Chapo v. Astrue, 682 F.3d 1285, 1288089 (10th Cir. 2012). Rather, it is the ALJ’s
responsibility to formulate Plaintiff’s RFC based on the evidence as a whole—including the
medical and non-medical evidence of record. See, e.g., Cox v. Astrue, 495 F.3d 614, 619 (8th Cir.
2007) (“[I]n evaluating a claimant’s RFC, an ALJ is not limited to considering medical evidence
exclusively.”); Brown v. Colvin, 14-03497-CV-S-NKL, 2015 WL 5039378, at *7 (W.D. Mo.
Aug. 26, 2015) (that there was no medical opinion specifically supporting the RFC was “not a
reason to set aside the RFC” when it was based on substantial evidence on the record as a
The ALJ, relying on 20 C.F.R. 404.1529(c), 416.929(c), and Social Security Ruling 967p, considered non-medical evidence in addition to the medical record when assessing the
credibility of Haycook’s statements. Tr. 45–46. The ALJ found Haycook’s “activities of daily
living are not significantly limited,” noting his January 2014 function report evinced his ability
to reside alone and care for himself, his home and his dog, including chores, driving, shopping,
and handling finances. Although Haycook reported his now live-in girlfriend helped with those
activities at the June 2015 hearing, the ALJ found Haycook’s employment history likewise
relevant to his ability to functionality, as he “has worked as a paramedic for most of the period
during which he alleged disability.” Tr. 45.
Thus, considering the medical record and hearing testimony, the ALJ found Haycook
could not return to his previous work as a paramedic, but was capable of performing work
consistent with the residual function capacity established in her decision. Tr. 46. The additional
evidence submitted to the Appeals Council does not alter that decision. Haycook had a fair
hearing and full administrative consideration in accordance with applicable statutes and
regulations. Substantial evidence on the record as a whole supports the Commissioner’s decision.
The Commissioner’s decision is affirmed.
s/ Nanette K. Laughrey
NANETTE K. LAUGHREY
United States District Judge
Dated: April 26, 2017
Jefferson City, Missouri
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?