Basic Facts
My client was a married 37-year-old female with three children. Her past relevant work was as a receiving coordinator and a sales associate at a retail store, and fast-food manager/working supervisor.
Disabling Condition
She left her last job due to severe fatigue, dizziness, nausea, headaches, and weakness. The claimant had two spinal/brain surgeries (2005 and 2008) and has not been back to work since the second surgery. The claimant was diagnosed with Arnold-Chiari malformation and syringomyelia as early as 2004, and underwent decompression surgery in 2005. Her symptoms abated somewhat but began to worsen again in 2007-2008, including neck and arm pain and severe headache, all attributed to the continuing malformation evident on repeat abnormal MRIs. As a result, the claimant was forced to quit her job. The claimant underwent a second spinal/brain surgery on December 2, 2008 for “syringomyelia extending throughout the cervical and upper thoracic spine,” with C4-5-6 laminectomy, microsurgery, and placement of the syringe-subarachnoid shunt. A follow-up MRI in February of 2009 showed extensive postoperative changes in the cervical spine, including continued extensive syrinx.
Procedural Facts and Initial Denial
The claimant filed for Social Security Disability around August 2009, with an alleged onset date (AOD) of September 2008. Despite a well-developed longitudinal medical history fully supported by objective medical tests, the Louisiana Social Security Disability Determination Service sent her for a consultative examination. Her initial claim for SSDI benefits was denied.
Dr. C.D. examined the claimant at the request of the DDS in December 2009. That physician concluded that the claimant suffered from Arnold-Chiari malformation, dizziness, impaired mobility, nausea, pain in neck, head and back, and loss of feeling in the left arm, feelings of severe fatigue, and nerve damage in both hands. He noted that the claimant was unable to walk on her heels or toes or squat, and had functional limitation and residual weakness on the right side. Further, he noted, there is no additional medical option for treatment of her condition.
Despite her medical records and a supporting CE opinion, in a Physical Residual Functional Assessment dated January 2010, the DDS found the claimant capable, in essence, of work at the light exertional level, only with limitations in gross manipulation and a few postural limitations, and no explanation other than the claimant “should be able to perform all [routine] self-care chores, cook, shop and house work.” [sic]. Her SSDI claim was denied based on this Residual Functional Capacity (RFC).
Attorney Involvement & Case Development
Shortly after receiving her denial, the claimant engaged me to represent her in trying to obtain her social security disability benefits. My first task was to obtain the exhibits and medical records used by the Louisiana Social Security Disability Determination Service (DDS) in its determination that the claimant was not disabled. I also had to make the claimant aware of and understand the need to continue to seek medical treatment during the pendency of her SSDI claim.
I began to develop a theme for my client’s case. Here we had a younger female who had significant medical issues that were adequately documented in the medical records, but whose medical condition did not meet any listing. After reviewing the records, I was confident that this case would be a Step 5 case – that is, I would have to significantly erode the available occupational base such that an insufficient number of occupations would be available that my client could compete in.
To do this, I had to obtain additional medical records available that were not present in the social security file, as well as obtain the updated medical records from the claimant’s treating physician. I then reviewed all of the medical records, the DDS exhibits, and made specific note of consistency between my client’s symptoms and the objective evidence. I also made specific note of inconsistencies between the medical records and the CE’s and ME’s reports.
My client also had a very supportive doctor who had treated her for several years and still treats her for her disability. She had been and continued to, seek ongoing medical care for her disability. I requested that her doctor complete a Medical Source Statement explaining in detail the limitations and residual functional capacity my client maintained with her disability.
Her doctor complied with my request and provided in clear and unambiguous terms the symptomology and etiology of her disability, the specific objective medical tests/results that confirmed the client’s diagnosis and prognosis as well as her symptoms. The Medical Source Statement also clearly explained the client’s less than sedentary residual functional capacity.
With the Medical Source Statement in hand, we prepared a prehearing brief and submitted the Medical Source Statement as an exhibit along with all of the additional medical records.
Client Preparation and Hearing
A few days before the hearing, I met with my client and went over the timeline of her diagnosis, inability to work, and ongoing treatment. We discussed the impact the disability had on her activities of daily living and her overall life. I stressed to her the importance of explaining the full details of her disability without exaggerating or going overboard.
On the day of the hearing, my client and I were well prepared. I gave a brief opening statement, highlighting a few things from the prehearing brief, and especially pointing out the inconsistency between Louisiana’s DDS determination and the medical records. The Administrative Law Judge then asked my client about all of the things we discussed in our preparation, including her current medical treatment and prognosis. When I had an opportunity to question the client, I asked only about the severe impacts the disability had on her life and got her to share a few concrete examples of how her disability affected her.
The Vocational Expert was then asked one hypothetical that mirrored all of the limitations placed on the client by her own doctor and reported in the Medical Source Statement. The VE testified that the claimant could not, in his opinion, work at any competitive occupation with those limitations.
At that point, the ALJ said she was granting a fully favorable decision. A few weeks later, we received the decision and my client received the disability benefits she desperately needed. The ALJ specifically pointed out the inconsistencies with the ME’s opinion and RFC, and noted how my client’s self-reported limitations and difficulties at the hearing were consistent with the medical records and how credible her testimony was as a result.
What Did This Case Teach Us?
First, even with fully developed and supporting medical records, your disability claim can be denied by DDS.
Second, review the medical opinions and reports of the CE and ME because they may conflict with each other and the claimant’s medical records.
Third, a Medical Source Statement is important. A Medical Source Statement supported by medical records and ongoing treatment is very important.
Fourth, credibility is always a factor, even where the medical evidence is in your favor.
Fifth, I still get very excited when I am able to get a deserving client the SSDI benefits they desperately need.
