Sciatica, Arthritis in the Lower Back, and Pinched Nerve in the Back with Steady Pain and Radiating Pain down the Left Leg/Calf and the Right Leg.

The medical evidence included the claimant’s treating orthopedic doctor’s opinion that “a facet arthropathy . . . on the right. . . may well be producing these symptoms” in the claimant’s right lower back and leg

The court agreed with the claimant’s that the Administrative Law Judge “did not mention the treating physician’s medical opinion, let alone give it ‘considerable weight.’ Likewise, the ALJ did not discuss pertinent elements of the examining physician’s medical opinion, and the ALJ’s conclusions suggest that those elements were not considered. It is possible that the ALJ considered and rejected these two medical opinions, but without clearly articulated grounds for such a rejection, we cannot determine whether the ALJ’s conclusions were rational and supported by substantial evidence.”

The court stated that the ALJ “must make his findings clear.”  In this case, the ALJ’s residual functional capacity assessment was deficient in that it did not first identify the claimant’s functional limitations or restrictions on a function-by-function basis as required by the regulations.  Social Security Ruling 96-8p.

Additionally the court found that the ALJ’s reliance on the Medical-Vocational Rules was not appropriate where the claimant suffered from non-exertional limitations, such as pain.  See, 20 C FR Part 404, Subpart P, Appendix 2, § 200.00(e).

ANALYSIS

While it is true that your doctor’s opinion that you are disabled is not sufficient for Social Security to award you disability, Social Security rules and regulations require the adjudicator to consider and evaluate medical evidence and opinions.  This is the treating physician rule.

Because your medical records and the opinions that may be included are the heart of your case, the disabled applicant (and his personal advocate and representative) must make sure that his case file includes all his medical evidence.

HOW TO GET SOCIAL SECURITY DISABILITY & SSI DISABILITY provides templates for keeping journals of medical visits and prescriptions.

Mieles v. Commissioner of Social Security, Case No. 6:13-cv-91-Orl-DAB (D. M.D. Fla., Orlando Div., Jan. 10, 2014).

http://scholar.google.com/scholar_case?case=2896090530026119360&q=social+security&hl=en&as_sdt=40000003&as_ylo=2014