Musteen v. Social Security Administration Commissioner

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IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FAYETTEVILLE DIVISION
CHRISTOPHER MUSTEEN 	PLAINTIFF
vs. 	Civil No. 5:24-cv-05243
COMMISSIONER, SOCIAL
SECURITY ADMINISTRATION 	DEFENDANT
REPORT AND RECOMMENDATION
OF THE UNITED STATES MAGISTRATE JUDGE
Christopher Musteen (“Plaintiff”) brings this action pursuant to § 205(g) of Title II of the
Social Security Act (“The Act”), 42 U.S.C. § 405(g), seeking judicial review of a final decision of
the Commissioner of the Social Security Administration (“SSA”) denying his application for
Disability Insurance Benefits (“DIB”) under Title II of the Act.
Pursuant to the provisions of 28 U.S.C. § 636(b)(1) and (3) (2009), the Honorable Timothy
L. Brooks, Chief United States District Judge, referred this case to the undersigned for the purpose
of making a report and recommendation. In accordance with that referral, and after reviewing the
arguments in this case, the undersigned recommends Plaintiff’s case be AFFIRMED.
1. 	Background:
Plaintiff filed his disability application on January 22, 2021. 	(Tr. 300-306).0F
1 	In his
application, Plaintiff alleges being disabled due to PTSD, lumbosacral injury, left and right lower
radiculopathy, tension headaches, TBI, right lateral collateral ligament sprain, left shoulder
impingement syndrome, and arthritis. (Tr. 348). Plaintiff alleged an onset date of December 30,
2020. (Tr. 344). Plaintiff’s application was denied initially and again upon reconsideration. Id.
1 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.” and refer to the document filed at ECF
No. 8. 	These references are to the page number of the transcript itself not the ECF page number.
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Plaintiff requested a hearing on his denied application which was held on August 18, 2022.
(Tr. 3521-3544.) 	Following the hearing, the ALJ denied Plaintiff’s claim on September 6, 2022.
(Tr. 98-120). 	Plaintiff then filed a Request for Review of Hearing with the ALJ on October 11,
2022, which was remanded by the Appeals Council on August 9, 2023. (Tr. 121-127).
Following remand, Plaintiff had a second hearing which was held on February 8, 2024. (Tr.
46-65). 	At this hearing, Plaintiff was present and represented by Kenneth Kieklak. 	Id. Plaintiff
and Vocational Expert (“VE”) Katrina Mason testified at the hearings. Id.
The ALJ entered an unfavorable decision on May 13, 2024. (Tr. 10-30). In this decision,
the ALJ determined Plaintiff met the insured status of the Act through June 30, 2024. 	(Tr. 12,
Finding 1). The ALJ also determined Plaintiff had not engaged in substantial gainful activity
(“SGA”) since December 30, 2020. (Tr. 12, Finding 2).
The ALJ determined Plaintiff had severe impairments of unspecified trauma-related
disorder; unspecified anxiety; degenerative disc disease of the cervical and lumbar spine; left
clavicle acromioplasty with ongoing pain; right ankle stress fracture; tenosynovitis, right elbow
pain; and headaches. 	(Tr. 12-13, Finding 3). 	Despite being severe, the ALJ determined those
impairments did not meet or medically equal the requirements of any of the Listings of Impairments
in 20 CFR Part 404, Subpart P, Appendix 1 (“Listings”). (Tr. 13, Finding 4).
The ALJ indicated he considered Plaintiff’s subjective complaints and determined his RFC.
(Tr. 15-28). The ALJ evaluated Plaintiff’s subjective complaints and found the claimed limitations
were not entirely consistent with the medical evidence and other evidence in the record. Id. The
ALJ also determined Plaintiff retained the RFC to perform sedentary work except he could
occasionally climb, balance, stoop, kneel, crouch, and crawl; could occasionally overhead reach
bilaterally; could have no concentrated exposure to hazards such as dangerous machinery and
unprotected heights; limited to work where interpersonal contact is routine but superficial; the
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complexity of tasks is learned by experience with several variables and judgment within limits; and
where the supervision required is little for routine, but detailed for non-routine tasks. Id.
The ALJ then evaluated Plaintiff’s Past Relevant Work (“PRW”). (Tr. 28, Finding 6). The
ALJ determined Plaintiff was not capable of performing his PRW. Id. However, the ALJ found
there were jobs in significant numbers in the national economy that Plaintiff could perform. (Tr.
29, Finding 10). With the help of the VE, the ALJ found Plaintiff could perform the representative
occupations of (1) table worker with approximately 30,000 jobs in the nation, (2) touch up screener
with approximately 40,000 jobs in the nation, and (3) clerical mailer with approximately 30,000
jobs in the nation. Id. Based upon this finding, the ALJ determined Plaintiff had not been disabled
under the Act from December 30, 2020, through the date of the decision. (Tr. 30, Finding 11).
On November 26, 2024, Plaintiff filed the present appeal. ECF No. 1. Both Parties have
filed appeal briefs. ECF Nos. 10, 13. This case is now ready for decision.
2. 	Applicable Law:
In reviewing this case, the Court is required to determine whether the Commissioner’s
findings are supported by substantial evidence on the record as a whole. See Ramirez v. Barnhart,
292 F.3d 576, 583 (8th Cir. 2002); 42 U.S.C. § 405(g). 	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
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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).
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3. 	Discussion:
In his appeal brief, Plaintiff claims the ALJ’s disability decision is not supported by
substantial evidence in the record. ECF No. 7. In making this claim, Plaintiff argues the ALJ erred
in the RFC determination by disregarding the Plaintiff’s testimony and in the evaluation of medical
evidence. Id. The Defendant argues substantial evidence supports the ALJ decision. ECF No. 13.
In this matter, the ALJ determined Plaintiff retained the RFC for sedentary work with several
postural, manipulative, environmental, and mental restrictions. (Tr. 15, Finding 5). Plaintiff argues
the ALJ erred in this RFC determination. ECF No. 10, Pgs. 3-20. However, substantial evidence
supports the ALJ’s RFC determination.
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 at 1206; 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). 	The mere fact a
claimant has a long list of medical conditions does not demonstrate that person is disabled; instead,
the RFC determination is a function-by-function analysis. See SSR 96-8P, 1996 WL 374184 (July
2, 1996). 	“The RFC assessment considers only functional limitations and restrictions that result
from an individual’s medically determinable impairment or combination of impairments, including
the impact of any related symptoms.” Id.
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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).
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. 	The ALJ provided a thorough summary of Plaintiff’s medical records and subjective
complaints in this matter. 	The mere fact Plaintiff suffers from several impairments does not
demonstrate he has more limitations than those found in the RFC assessment.
In his opinion, the ALJ considered Plaintiff’s alleged impairments and discounted those he
found were not credible. (Tr. 15-28). The ALJ considered the results of objective diagnostic tests
and examination findings and discussed these in his decision. 	Id. 	The ALJ also considered the
findings of medical consultants and considered Plaintiff’s testimony and function reports in
assessing his RFC. Id.
In assessing the RFC, Plaintiff claims the ALJ erred in evaluating his testimony and
subjective allegations of disability. In assessing the subjective allegations 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. § 416.929.1F
2 See Shultz v. Astrue, 479 F.3d 979,
2 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
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983 (8th Cir. 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 allegations
of pain. 	See id. 	The ALJ is not required to methodically discuss each factor if the ALJ
acknowledges and examines these factors prior to discounting the claimant’s subjective allegations.
See Lowe v. Apfel, 226 F.3d 969, 971-72 (8th Cir. 2000). 	If the ALJ properly applies these five
factors and gives sound reasons for finding that the Plaintiff’s subjective allegations are not entirely
valid, the ALJ’s 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 allegations “solely
because the objective medical evidence does not fully support them [the subjective complaints].”
Polaski, 739 F.2d at 1322.
In the present action, the ALJ fully complied with Polaski in his evaluation of Plaintiff’s
subjective allegations. Indeed, the ALJ opinion outlined Plaintiff’s subjective allegations and noted
inconsistencies between those allegations and the record. 	The ALJ also noted Plaintiff’s daily
activities and set forth reasons for finding those activities not as limiting as described by Plaintiff.
(Tr. 24-26). Furthermore, the ALJ carefully summarized Plaintiff’s medical records and noted how
Plaintiff was receiving treatment and medication for his impairments that appeared to be effective.
The ALJ discussed Plaintiff’s regular Botox injections and other medication which were helpful,
and how the Botox injections reduced the frequency and severity of his headaches. (Tr. 25).
analysis of these additional factors. 	See Shultz v. Astrue, 479 F.3d 979, 983 (8th Cir. 2007). Thus,
this Court will not require the analysis of these additional factors in this case.
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Plaintiff also argues the ALJ erred in his evaluation of medical evidence when formulating
the RFC. 	For claims like Plaintiff’s that are filed on or after March 27, 2017, an ALJ evaluates
medical opinions and administrative medical findings pursuant to 20 C.F.R. § 404.1520c. 	These
rules provide that the Social Security Administration “will not defer or give any specific evidentiary
weight, including controlling weight, to any medical opinion(s) or prior administrative medical
finding(s), including those from [Plaintiff’s] medical sources.” 20 C.F.R. § 404.1520c(a).
An ALJ is to evaluate the persuasiveness of medical opinions and prior administrative
medical findings in light of the following factors: (1) supportability; (2) consistency; (3) relationship
with the claimant, which includes: (i) length of the treatment relationship, (ii) frequency of
examinations, (iii) purpose of the treatment relationship, (iv) extent of the treatment relationship,
and (v) examining relationship; (4) specialization, and (5) other factors, such as “evidence showing
a medical source has familiarity with the other evidence in the claim or an understanding of our
disability program’s policies.” 20 C.F.R. § 404.1520c(a)-(c). The regulation goes on to clarify that
supportability and consistency “are the most important factors” to consider when determining
persuasiveness of a medical source’s medical opinions and, therefore, an ALJ must explain how she
considered the factors of supportability and consistency in the administrative decision. 20 C.F.R.
§ 404.1520c(b)(2).
Plaintiff argues the ALJ improperly rejected the opinion of his physician Dr. Jean-Louis
Gottfried. However, a review of the record shows the ALJ properly evaluated the opinions of Dr.
Gottfried. 	The ALJ noted and discussed how the opinions of Dr. Gottfried were not persuasive
based on inconsistency with treatment records. (Tr. 27-28). The ALJ also discussed that Plaintiff’s
daily activities were inconsistent with Dr. Gottfried’s findings. Id. The ALJ also pointed out that
Dr. Gottfied provided no supporting evidence for his assessment. Id.
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Substantial evidence supports the ALJ’s RFC determination. 	Plaintiff has the burden of
establishing his 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 this
burden in this case and because the ALJ’s RFC determination is supported by sufficient medical
evidence, the ALJ’s RFC determination should be affirmed.
4. 	Conclusion:
Based on the foregoing, the undersigned submits that the decision of the ALJ, denying
benefits to Plaintiff, is supported by substantial evidence and recommends it be AFFIRMED.
The Parties have fourteen (14) days from receipt of this 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. See Thompson v. Nix, 897 F.2d 356, 357 (8th Cir. 1990).
ENTERED this 16th 	day of December 2025.
/s/ Spencer G. Singleton
HONORABLE SPENCER G. SINGLETON
UNITED STATES MAGISTRATE JUDGE
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