In the five-step sequential
evaluation of disability, at step 3, Social Security considers whether a
claimant “meets or equals” a medical condition set out in the rules.
The claimant’s medical evidence
included a December, 2009, MRI which “showed a herniated disc at L4-5 with
compromise of the exiting nerve root.” In
an office visit in February, 2010, the doctor reported that the claimant “had a
normal gait and was able to toe walk, heel walk, squat and arise, hop and get
on and off the examining table with no difficulty. . . . She had some limitation of the range of
motion of her lumbar spine. Straight leg raising was negative in both the
sitting and supine positions.”
In its confirmation of the ALJ decision, the court quoted
the most relevant listing for the claimant’s back pain, Listing 1.04. [See, 20 C.F.R. 404, Appendix 1 to Subpart P
of Part 404—Listing of Impairments. 1.00 Musculoskeletal System.] The court stated
that: “the evidence falls far short of establishing that plaintiff met all of
the requirements of Listing 1.04A. There was no evidence of a neuro-anatomic
distribution of pain. Listing 1.04A specifically requires evidence of positive
straight-leg raising test in both the sitting and supine positions,
which is absent here. Further, there is no evidence of motor loss, muscle
atrophy, sensory loss or reflex loss.”
The court did not discuss whether the impairments equaled a
listing. For the ALJ to find that the
claimant equaled a listing, a medical expert testifying at the hearing would have
had to say as much. [See 20 C.F.R. 404.1526;
Social Security Ruling 96-6p.]
COMMENT
Doctor’s notes will include observations on how a person
entered an examination room and whether the person had any difficulty getting
on and off an examining table.
The court noted that the claimant submitted additional
medical records to the Appeals Council, but it could not use them as a basis
for finding that the ALJ (who had not seen the records) had committed
reversible error.
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