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Combs v. Berryhill

United States Court of Appeals, Eighth Circuit

December 28, 2017

Carolyn Combs Plaintiff- Appellant
Nancy A. Berryhill, Commissioner, Social Security Administration Defendant-Appellee

          Submitted: January 11, 2017 [1]

         Appeal from United States District Court for the Eastern District of Arkansas - Helena

          Before SMITH, Chief Judge, [2] KELLY, Circuit Judge, and SIPPEL, [3] District Judge.

          KELLY, Circuit Judge.

         Carolyn Combs appeals from the district court's order affirming the Administrative Law Judge's (ALJ) denial of her application for disability insurance benefits and supplemental security income. Because we conclude that the ALJ failed to fully and fairly develop the record, we reverse and remand for further factual findings.

         I. Background

         Combs applied for disability benefits on July 2, 2012, alleging a disability onset date of May 17, 2012. She claims she is disabled as a result of the combined effects of rheumatoid arthritis, osteoarthritis, asthma, and obesity. Combs was born on December 24, 1961, and has a ninth grade education. She last worked as a hotel housekeeper and was fired for talking on her cell phone.

         The ALJ held a hearing on Combs' application on January 9, 2014, at which Combs and a Vocational Expert (VE) testified. Combs provided the following information. She is 5'3" tall and weighs 240 pounds. She was first told by a doctor that she had arthritis in August 2011; a little later, she was diagnosed with rheumatoid arthritis by a doctor who prescribed meloxicam for the arthritis and tramadol for pain. The medications "eased the pain whereas [she] can basically deal with it a little bit, but it didn't take the pain away, but it made it bearable a little bit." She has swelling "from [her] knees all the way down to [her] foot, " which is worsened by walking and standing. She can walk for about five minutes at a time, but then she has to stop because of the pain in her lower back, knees, and feet. She can only stand for two or three minutes before having to sit down and prop up her legs, which sometimes lessens the swelling. She can sit for one hour but spends the day changing positions. Her hands sometimes cramp up so much she cannot use them-"they just get stuck."

         She has pain daily, and has restless leg syndrome, which disturbs her sleep. She is prescribed amitriptyline, which helps but does not eliminate the problem.

         Combs' daily activities consist mostly of sitting on her couch or walking around the house in an effort to keep her legs from stiffening. She sometimes goes to her daughter's house, but because she has trouble getting up from her daughter's couch, she prefers to sit at home where she can be more comfortable. She can shop only if a motorized cart is available. She can make herself a sandwich, but can only cook for her family if she has a chair in the kitchen, where she can sit down after standing for two or three minutes. She sometimes does dishes. She does not have the strength in her hands to wring mops or wipe surfaces, and she can no longer play with her grandchildren.

         Combs presented medical records spanning the time period from July 2011 to September 2014 from St. Bernards Regional Medical Center, AR Care, Jonesboro Church Health Center, and NEA Baptist Clinic. Henry Allen, M.D., of AR Care, diagnosed Combs with rheumatoid arthritis in November 2011 and prescribed meloxicam, cyclobenzaprine, and tramadol to treat the arthritis and accompanying pain. Combs has continued treatment with various medical providers for this condition, including Dr. Allen, Beata Majewski, M.D., and Jennifer Long, APN, and these providers continue to prescribe pain medication-including toradol, hydrocodone, and tramadol-for "severe pain" due to her rheumatoid arthritis. X-rays showed severe degenerative changes in both of Combs' knees, narrowing of the joint space in her wrists and in the fingers of both hands. Treatment notes from Dr. Allen, Dr. Majewski, and APN Long reported swelling, warmth, and tenderness in Combs' hands, wrists, knees, and ankles, as well as painful range of motion, but "no acute distress" and "normal movement of all extremities." None of these medical treatment providers offered an opinion about Combs' ability to function in the workplace.

          The only medical opinions regarding Combs' residual functional capacity (RFC)[4] that the ALJ considered were from two state-agency medical consultants: Robert Redd, M.D., who conducted an initial review of Combs' medical records, and Sharon Keith, M.D., who reviewed Combs' records at the reconsideration level. Neither doctor examined Combs. Dr. Redd opined that Combs was able to lift ten pounds occasionally and less than ten pounds frequently and was therefore limited to sedentary work. In Dr. Keith's opinion, Combs was capable of work at the light exertional level and could lift twenty pounds occasionally and ten pounds frequently.[5]

         Following the hearing, the ALJ issued a decision on July 18, 2014, analyzing Combs' disability following the five-step sequential evaluation process outlined in 20 C.F.R. § 420.1520(a)-(f). At the first and second steps, the ALJ determined that Combs had not engaged in substantial gainful activity since her alleged disability onset date, and had the following severe impairments: rheumatoid arthritis, fibromyalgia, and obesity. At step three, the ALJ determined that Combs did not have an impairment or combination of impairments listed in or medically equal to one listed in Appendix 1, Subpart P, Regulation No. 4.

         The ALJ next considered Combs' RFC. The ALJ found Combs' subjective complaints of pain not entirely credible in large part based on her treating physicians' notations that she was in "no acute distress" and "had normal movement of all extremities." The ALJ gave "some weight" to Dr. Redd's opinion but concluded that Dr. Keith's opinion was more consistent with the record as a whole, and with the notations in the treatment notes specifically. Relying on Combs' medical records and Dr. Keith's opinion, as well as the VE's testimony, the ALJ determined Combs had the RFC to perform light work as defined in 20 C.F.R. § 404.1567(b) with the following limitations: she can only frequently use her hands to finger and grasp; only occasionally climb ladders, ropes, scaffolds, ramps, or stairs; and only occasionally balance, stoop, kneel, crouch, and crawl. Because Combs' past work as a hotel housekeeper did not require her to perform any work-related activities precluded by her RFC, the ALJ concluded ...

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