Guinn v. Social Security Administration Commissioner

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IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FORT SMITH DIVISION
TRACY LANAL GUINN 	PLAINTIFF
v. 	CIVIL NO. 24-2131
LELAND DUDEK,1 Acting Commissioner
Social Security Administration 	DEFENDANT
MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION
Plaintiff, Tracy Lanal Guinn, brings this action pursuant to 42 U.S.C. § 405(g), seeking
judicial review of a decision of the Commissioner of the Social Security Administration
(Commissioner) denying her claims for a period of disability and disability insurance benefits
(DIB) under the provisions of Title II of the Social Security Act (Act). 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).
I. 	Procedural Background:
Plaintiff protectively filed her current application for DIB on August 24, 2021, alleging an
inability to work since October 1, 2020, due to Bell’s Palsy, nausea, post-traumatic stress disorder
(PTSD), general anxiety disorder and depression. 	(Tr. 71, 190). 	An administrative telephonic
hearing was held on July 12, 2023, at which Plaintiff appeared with counsel and testified. (Tr. 38-
69).
1 Leland Dudek, has been appointed to serve as Acting Commissioner of the Social Security
Administration, and is substituted as Defendant pursuant to Rule 25(d)(1) of the Federal Rules of
Civil Procedure.
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By written decision dated October 13, 2023, the ALJ found that during the relevant time
period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 19).
Specifically, the ALJ found Plaintiff had the following severe impairments: obesity, mild
degenerative changes of the cervical spine, major depressive disorder, generalized anxiety
disorder, and PTSD. However, after reviewing all of the evidence presented, the ALJ determined
that Plaintiff’s impairments did not meet or equal the level of severity of any impairment listed in
the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 21). The ALJ
found Plaintiff retained the residual functional capacity (RFC) to:
[P]erform medium work as defined in 20 CFR 404.1567(c) except able to perform
work where interpersonal contact is incidental to work performed, e.g., assembly
work, complexity of tasks is learned and performed by rote, few variables, little
judgment, and supervision required is simple, direct, and concrete.
(Tr. 23). With the help of a vocational expert, the ALJ determined Plaintiff could perform other
work as a hand packager, an industrial cleaner, and a store laborer. (Tr. 30).
Plaintiff then requested a review of the hearing decision by the Appeals Council, who
denied that request on August 22, 2024. (Tr. 1-6). Subsequently, Plaintiff filed this action. (ECF
No. 2). Both parties have filed appeal briefs, and the case is before the undersigned for report and
recommendation. (ECF Nos. 9, 11).
The Court has reviewed the entire transcript. The complete set of facts and arguments are
presented in the parties’ briefs and are repeated here only to the extent necessary.
II. 	Applicable Law:
The court reviews “the ALJ’s decision to deny disability insurance benefits de novo to
ensure that there was no legal error that the findings of fact are supported by substantial evidence
on the record as a whole.” Brown v. Colvin, 825 F. 3d 936, 939 (8th Cir. 2016). Substantial
evidence is less than a preponderance, but it is enough that a reasonable mind would find it
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adequate to support the Commissioner’s decision. Biestek v. Berryhill, 139 S.Ct. 1148, 1154
(2019). We must affirm the ALJ’s decision if the record contains substantial evidence to support
it. Lawson v. Colvin, 807 F.3d 962, 964 (8th Cir. 2015). 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. Miller v. Colvin, 784 F.3d 472, 477
(8th Cir. 2015). 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, the court
must affirm the ALJ’s decision. Id.
It is well established that a claimant for Social Security disability benefits has the burden
of proving her disability by establishing a physical or mental disability that has lasted at least one
year and that prevents her 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). 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). A Plaintiff must show that her disability,
not simply her impairment, has lasted for at least twelve consecutive months.
The Commissioner’s regulations require him 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 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
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given her age, education, and experience. See 20 C.F.R. § 404.1520. Only if the final stage is
reached does the fact finder consider the Plaintiff’s age, education, and work experience in light
of her residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42 (8th Cir.
1982), abrogated on other grounds by Higgins v. Apfel, 222 F.3d 504, 505 (8th Cir. 2000); 20
C.F.R. § 404.1520.
III. 	Discussion:
In her appeal brief, Plaintiff claims the ALJ’s disability determination is not supported by
substantial evidence in the record. (ECF No. 9). Plaintiff raises the following issues on appeal: A)
The ALJ erred in failing to fully and fairly develop the record; B) The ALJ erred at Step Two of
the sequential analysis; and C) The ALJ erred in determining Plaintiff’s RFC. Defendant argues
the ALJ properly considered all the evidence, and that the decision is supported by substantial
evidence. (ECF No. 11). The Court will consider each of Plaintiff’s arguments.
A. 	Duty to Develop the Record:
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 is 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 she must also show that she was
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prejudiced or treated unfairly by the ALJ's failure. See Onstad v. Shalala, 999 F.2d 1232, 1234
(8th Cir. 1993).
Plaintiff claims that the ALJ erred by failing to fully and fairly develop the medical record
regarding Plaintiff’s alleged impairments and the ALJ should have obtained an additional
neurological consultative examination. (ECF No. 9).
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 her limitations
and impairments. See Barrett v. Shalala, 38 F.3d 1019 at 1023. While the ALJ has an independent
duty to develop the record in a social security disability hearing, the ALJ is not required “to seek
additional clarifying statements from a treating physician unless a crucial issue is undeveloped.”
Stormo v. Barnhart, 377 F.3d 801, 806 (8th Cir. 2004).
Likewise, the 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). Thus, the proper inquiry for this Court is not whether a consultative examination should
have been ordered; rather, it is whether the record contained sufficient evidence for the ALJ to
make an informed decision. See Id. After reviewing the entire 892-page administrative record, the
Court finds nothing which establishes the record was inadequate for the ALJ to make his decision.
The medical record includes treating physician records; four non-examining medical consultant
opinions; two consultative mental evaluations; an assessment from Plaintiff’s therapist; physical
exam reports; and objective testing to include x-rays, MRIs, and case analysis. A review of the
medical record also shows Plaintiff’s Bell’s Palsy was noted as stable with medication. (Tr. 419-
420, 422, 694).
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Further, Plaintiff must not only show the ALJ failed to fully and fairly develop the record,
but that she was prejudiced or treated unfairly by the ALJ’s alleged failure to develop the record.
Plaintiff has made no demonstration that any further record development would have changed the
outcome of the ALJ’s determination. Accordingly, Plaintiff has failed to demonstrate that the
record was not fully developed and that she was prejudiced by any perceived failure to develop
the record.
B. 	Step Two Analysis:
A claimant suffers from a severe impairment if that impairment is more than slight and if
that impairment affects the claimant’s ability to do his or her basic work activities. See
Householder v. Bowen, 861 F.2d 191, 192 n.1 (8th Cir. 1988). The Supreme Court has also held
that a claimant does not suffer from a severe impairment where the claimant only suffers from
“slight abnormalities that do not significantly limit any ‘basic work activity.’” See Bowen v.
Yuckert, 482 U.S. 137, 155 (1987) (O’Connor, S., concurring); see also Brown v. Bowen, 827 F.2d
311, 311-12 (8th Cir. 1987) (adopting Justice O’Connor’s language from Bowen v. Yuckert); see
also Kirby v. Astrue, 500 F.3d 705, 707-09 (8th Cir. 2007).
Plaintiff argues the ALJ erred in failing to find Plaintiff’s Bell’s Palsy, trigeminal neuralgia,
right arm sensory neuropathy, left shoulder joint arthrosis and headaches to be severe impairments.
(ECF No. 9, p. 6). In determining Plaintiff’s severe impairments, the ALJ addressed several alleged
impairments (gastroesophageal reflux disease, chest pain with negative cardiac workup, Bell’s
Palsy, low back pain, benign hypertension, headaches, mild sensory neuropathy of the right upper
extremity, and mild left shoulder AC arthrosis), but found the evidence supported a conclusion
that these impairments would impose no more than a minimal effect on her ability to perform basic
work activities. The ALJ further found Plaintiff’s alleged trigeminal neuralgia was not a medically
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determinable impairment. In doing so, the ALJ acknowledged that trigeminal neuralgia was a
diagnosis when Plaintiff established care with Dr. Christopher Orendorff in January of 2019;2
however, he also noted that subsequent diagnosis, symptoms and treatment for trigeminal
neuralgia were not found in the medical evidence of record for the time period in question. (Tr.
21, 441). In making these severity findings, the ALJ noted that medical records revealed these
alleged impairments were stabilized with medication and treatment and did not significantly limit
Plaintiff’s ability to perform basic work activity. Johnston v. Apfel, 210 F.3d 870, 875 (8th Cir.
2000) (alleged impairments may not be considered severe when they are stabilized by treatment
and otherwise are generally unsupported by the medical record).
While the ALJ did not find every medical diagnosis to be a severe impairment, the ALJ
specifically and thoroughly discussed the alleged impairments in the decision, and clearly stated
that he considered all of Plaintiff’s impairments, including the impairments that were found to be
non-severe. Parker v. Kijakazi, No. 4:21-CV-00547-NCC, 2022 WL 3585610, at *4 (E.D. Mo.
Aug. 22, 2022) (even if the ALJ erred in failing to find an alleged impairment severe, the error was
harmless in light of the ALJ’s consideration of the impairment in the RFC analysis). After
reviewing the record as a whole, the Court finds the ALJ did not commit reversible error in setting
forth Plaintiff’s severe impairments during the relevant time period.
C. 	RFC Determination:
Plaintiff argues the ALJ erred in determining Plaintiff retained the RFC to perform medium
work with limitations. (ECF No.9, p. 8). However, after review, the Court finds substantial
evidence supporting the ALJ's RFC determination.
2 The Court notes trigeminal neuralgia is also a diagnosis in Dr. Orendorff’s treatment notes dated
August 28, 2019, and December 16, 2019. (Tr. 433, 437). After December of 2019, this is no
longer a diagnosis of trigeminal neuralgia.
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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). RFC is the most a
person can do despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). It is assessed using all
relevant evidence in the record. Id. This includes medical records, observations of treating
physicians and others, and the claimant’s own descriptions of her limitations. Guilliams v.
Barnhart, 393 F.3d 798, 801 (8th Cir. 2005); Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th
Cir. 2004). Limitations resulting from symptoms such as pain are also factored into the assessment.
20 C.F.R. § 404.1545(a)(3). The United States Court of Appeals for the Eighth Circuit has held
that a “claimant’s residual functional capacity is a medical question.” Lauer v. Apfel, 245 F.3d
700, 704 (8th Cir. 2001). “Because a claimant’s RFC is a medical question, an ALJ’s assessment
of it must be supported by some medical evidence of the claimant’s ability to function in the
workplace.” Cox v. Astrue, 495 F.3d 614, 619 (8th Cir. 2007). However, there is no requirement
that an RFC finding be supported by a specific medical opinion. See Myers v. Colvin, 721 F.3d
521, 526-27 (8th Cir. 2013) (affirming RFC without medical opinion evidence). 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).
Based upon this standard and a review of Plaintiff's records and allegations in this case, the
Court cannot find Plaintiff has demonstrated having any greater limitations than those found by
the ALJ. While Plaintiff disagrees with the ALJ’s reasoning when discussing the evidence,
Plaintiff does not point to any evidence in the record that the ALJ should have considered, but
failed to consider, in calculating Plaintiff’s RFC. The ALJ provided a thorough summary of
Plaintiff's medical records and subjective complaints in this matter. (Tr. 17-31). The ALJ addressed
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a form Plaintiff completed in October of 2021 indicating that she was able to prepare simple meals,
do some cleaning and indoor chores, drive, shop by mail and in stores, spend time with family,
and pay bills. The ALJ also noted that in this form Plaintiff did not report any exertional or postural
restrictions or difficulty walking, but did report difficulty with memory, concentration and
following instructions. While Plaintiff indicated that she was trying to get disability for her stress
and anxiety in September of 2021, a review of the medical record reveled Plaintiff was found to
interact appropriately, have normal muscle strength and tone, have normal gait and station, have
normal speech, organized and coherent thoughts, intact associations, fair judgment, adequate
insight, adequate recent and remote memory, adequate attention span and concentration, sad mood
and flat affect on October 26, 2022, November 30, 2022, December 21, 2022, March 15, 2023,
and April 19, 2023. (Tr. 419, 746-750 760-764, 776-780, 794-798, 834-838).
The mere fact Plaintiff suffers from a number of impairments does not demonstrate she has
more limitations than those found in the RFC assessment above. In his opinion, the ALJ considered
Plaintiff's alleged impairments and discounted those he found were not credible. (Tr. 17-31). The
ALJ considered the results of objective diagnostic tests and examination findings and discussed
these in the decision. Id. The ALJ also considered the findings of medical consultants and treating
medical providers and considered Plaintiff's testimony and function reports in assessing the RFC.
Regarding the medical opinions, the ALJ articulated the supportability and consistency of each
opinion with the record as a whole and determined the level of persuasiveness. The ALJ also took
Plaintiff’s obesity into account when determining that Plaintiff could perform medium work.
Heino v. Astrue, 578 F.3d 873, 881-882 (8th Cir. 2009) (when an ALJ references the claimant's
obesity during the claim evaluation process, such review may be sufficient to avoid reversal).
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Plaintiff has the burden of establishing her claimed RFC. See Perks v. Astrue, 687 F. 3d
1086, 1092 (8th Cir. 2012) (burden of persuasion to demonstrate RFC and prove disability remains
on claimant). Because Plaintiff has not met this 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.
IV. 	Conclusion:
Based on the foregoing, the undersigned recommends affirming the ALJ's decision, and
dismissing Plaintiff's case with prejudice. The parties have fourteen days from receipt of our
report and recommendation in which to file written objections pursuant to 28 U.S.C. §
636(b)(1). 	The failure to file timely objections may result in waiver of the right to appeal
questions of fact. The parties are reminded that objections must be both timely and specific
to trigger de novo review by the district court.
DATED this 20th day of March 2025.
/s/____________________________________
HON. CHRISTY COMSTOCK
UNITED STATES MAGISTRATE JUDGE
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