                  United States Court of Appeals
                             For the Eighth Circuit
                         ___________________________

                                 No. 14-2780
                         ___________________________

                                  Tammy Hesseltine

                        lllllllllllllllllllll Plaintiff - Appellant

                                            v.

           Carolyn W. Colvin, Acting Commissioner of Social Security

                        lllllllllllllllllllll Defendant - Appellee
                                       ____________

                     Appeal from United States District Court
                   for the Southern District of Iowa - Davenport
                                  ____________

                              Submitted: April 17, 2015
                               Filed: August 26, 2015
                                   ____________

Before MURPHY, COLLOTON, and KELLY, Circuit Judges.
                         ____________

KELLY, Circuit Judge.

      Tammy Hesseltine applied for disability insurance benefits under Title II of the
Social Security Act. An administrative law judge (ALJ) found Hesseltine was not
disabled because the combination of her mental and physical impairments did not
meet the listed impairment under 20 C.F.R. § 404, Subp. P. App. 1, § 12.05C. The
Social Security Appeals Council denied Hesseltine’s request for review, and the
district court affirmed. On appeal, Hesseltine argues the ALJ failed to sufficiently
address whether her impairments medically equal Listing 12.05C. We agree, and
remand the case for further proceedings.

                                   I. Background

      In 1993, when Hesseltine was eight years old, she was given IQ testing by a
school psychologist.1 Under the Wechsler Intelligence Scale for Children, she
obtained a full scale IQ score of 70, a 72 in processing, and a 73 in verbal. The
psychologist noted that Hesseltine was “within the Borderline range of mental
functioning.” The psychologist also found that Hesseltine’s “adaptive behavior
composite score” was a 71, which placed her in the third percentile of her peers.
When Hesseltine graduated from high school in 2003, she read at a sixth grade level.

       Hesseltine underwent several surgeries as a child to treat an impairment in her
left leg caused by Perthes disease, a disorder that cuts off blood flow to the hip. In
2004, when Hesseltine was age 18, David Speigel, M.D., noted that there had been
no changes in her hip since 2001 and that her Perthes disease was asymptomatic. Her
left leg was 1.5 centimeters shorter than her right leg, and her mobility was limited
by the condition.

       In 2005, Roger Mraz, Ph.D., a licensed psychologist, administered a Wechsler
Adult Intelligence Scale and determined that Hesseltine had a full scale IQ score of
71, a processing score of 73, and a verbal score of 74. Dr. Mraz noted that “[o]verall,
the results of the intellectual assessment suggests [sic] that Tammy is functioning
near the lower end of the Borderline Range, at the 3rd percentile.” Dr. Mraz
additionally assessed Hesseltine’s adaptive behavior, based on consultations with her


      1
       School psychologists are “acceptable medical sources” under 20 C.F.R.
§ 404.1513(a)(2).

                                         -2-
aunt. Her daily living skills were low-average, in the 25th percentile, but her
communication skills were “below the 0.1 percentile” due to her “low academic
skills” and “borderline adaptive functioning.” The assessment concluded that
“Tammy should have no difficulty following simple instructions, and would probably
do better on repetitive type tasks.”

      From 2004 to 2005, Hesseltine worked irregularly as a cook’s helper in a
school cafeteria. From 2005 to 2007, Hesseltine worked part-time at a laundry
business with the help of a job coach. Her supervisor at the laundry indicated that
Hesseltine “works better than most in the same position,” that she required little
supervision and sometimes had “ a lot of independence,” and that he “would hire her
again.” In 2009, Hesseltine worked briefly as a housekeeper in a casino.

      In 2006, Hesseltine was diagnosed with polycystic ovarian syndrome, but after
several months her symptoms resolved and she was able to manage her syndrome
with medication. In 2007, C.W. Huang, M.D., gave Hesseltine a physical
examination and observed limitation in flexion of her left hip and knee, “probably due
to obesity.” He noted that left hip pain would occur if she stood for more than one
hour.

       Hesseltine twisted her hip while at work in July 2009. She sought treatment,
and an X-ray revealed “extensive changes consistent with Perthes disease.” Her
treating physician, Gregory Bell, M.D., diagnosed “acute exacerbation of left hip
pain” but indicated that no MRIs or other follow up was necessary and that Hesseltine
“can go back to work in a week like she is planning to do.”

       Hesseltine completed a function report form in 2007, and again in 2012. She
indicated that she lived with her husband, that she “prepare[d] food all the time
daily,” as well as “small amounts of cleaning, laundry, [and] mowing” with breaks.
She reported that she went shopping for household items and food, but that she had

                                         -3-
trouble counting change and got confused. She stated that she followed cooking
recipes “Ok.” She also reported that she could not walk more than a block without
needing to rest and could lift a gallon of milk at a maximum.

       Hesseltine’s insured status expired on September 30, 2009. She applied for
disability insurance benefits on July 28, 2010. At the request of the ALJ and
Hesseltine’s attorney, on January 31, 2012, Dr. Mraz met Hesseltine for a second IQ
evaluation. This time her results included: a full scale IQ of 72, a processing score
of 79, and a verbal score of 76. Dr. Mraz noted that “the results of the intellectual
assessment indicate that Tammy is functioning near the lower end of the Borderline
range.” Her Global Assessment of Functioning (GAF) was assessed at 65.

       Following an administrative hearing, the ALJ denied Hesseltine’s claim for
insurance benefits in February 2012. In reaching her decision the ALJ engaged in the
familiar five step analysis outlined in 20 C.F.R. § 416.920(a)(4). At the first step she
found that Hesseltine had not engaged in substantial gainful activity after January 1,
2007, the alleged onset date. Next, she found that Hesseltine suffered from the
following severe impairments: borderline intellectual functioning, Perthes disease of
the left hip, polycystic ovarian syndrome, and obesity. Third, she found that this
combination of impairments did not meet or medically equal one of the listed
impairments in 20 C.F.R. § 404, Subp. P. App. 1, including Listing 12.05C.

        The ALJ then evaluated Hesseltine’s residual functional capacity and
concluded that through the last insured date Hesseltine could lift and carry twenty
pounds occasionally and ten pounds frequently; could push and pull within the same
weight restrictions; could stand or walk for two hours in an eight hour workday;
could sit for six hours in an eight hour workday; could occasionally climb ramps and
stairs, but never ladders, ropes, or scaffolds; could occasionally balance and stoop,
but never kneel; could occasionally crouch, but never crawl; should avoid
concentrated exposure to hazards such as heights and machinery; and could perform

                                          -4-
only simple, routine tasks with a specific vocational preparation level of one or two.
At the hearing a vocational expert testified that a hypothetical person with these
limitations could perform work as an ampoule sealer, lens gauger, or final assembler.
The ALJ therefore concluded that there were jobs in the national economy that
Hesseltine could perform and denied her application for disability benefits.

       The Appeals Council denied review of the ALJ’s decision and the district court
affirmed. On appeal, Hesseltine argues that her impairments “medically equal”
Listing 12.05C. She maintains that the ALJ failed to provide a reviewable decision
as to her equivalence findings.

                                    II. Discussion

      “We review de novo a district court’s denial of social security benefits.”
Halverson v. Astrue, 600 F.3d 922, 929 (8th Cir. 2010). We must “determine whether
the ALJ’s decision complies with the relevant legal requirements and is supported by
substantial evidence in the record as a whole.” Id. (quotation omitted). We have
defined substantial evidence as “such relevant evidence that a reasonable mind might
accept as adequate to support a conclusion.” Id. (citing Heino v. Astrue, 578 F.3d
873, 878 (8th Cir. 2009)).

       Hesseltine argues that the ALJ erred in step three of the sequential evaluation
by finding that her impairments did not satisfy the requirements of Listing 12.05C.
Hesseltine was required to establish: “(1) a valid verbal, performance, or full scale IQ
score of 60 through 70, (2) an onset of the impairment before age 22, and (3) a
physical or other mental impairment imposing an additional and significant work-
related limitation of function.” Phillips v. Colvin, 721 F.3d 623, 625 (8th Cir. 2013)
(quoting McNamara v. Astrue, 590 F.3d 607, 610–11 (8th Cir. 2010)); see also 20
C.F.R. § 404, Subp. P, App. 1, § 12.05C. Because Hesseltine had received IQ scores



                                          -5-
of 71 and 72, above the range of 60–70, the ALJ determined that she failed to meet
the first element of Listing 12.05C.2

       However, a finding that a claimant does not meet a given listing “does not end
the inquiry.” Shontos v. Barnhart, 328 F.3d 418, 424 (8th Cir. 2003). “The
regulations provide that if a claimant has more than one impairment, the combined
effect of the impairments will be considered.” Id. The medical equivalence
regulation provides:

      If you have a combination of impairments, no one of which meets a
      listing . . . , we will compare your findings with those for closely
      analogous listed impairments. If the findings related to your
      impairments are at least of equal medical significance to those of a listed
      impairment, we will find that your combination of impairments is
      medically equivalent to that listing.

20 C.F.R. § 404.1526(b)(3).

      Instructions for determining whether a person’s combination of impairments
is medically equal to a given listing are outlined in the Program Operations Manual
System (POMS). “Although POMS guidelines do not have legal force, and do not
bind the Commissioner, this court has instructed that an ALJ should consider the
POMS guidelines.” Shontos, 328 F.3d at 424. The applicable POMS guideline for
Listing 12.05C provides:



      2
       When Hesseltine was eight years old she received a full scale IQ score of 70,
which would place her within the limits of Listing 12.05C. Under SSA regulations,
however, this score is outdated and her more recent scores must be used for
determining her IQ (which ranged from 71 to 79 from 2005 to 2012). See 20 C.F.R.
§ 404, Subp. P, App. 1, § 112.00(D)(1) (“IQ test results obtained between ages 7 and
16 should be considered current . . . for 2 years when the IQ is 40 or above.”)
Hesseltine does not contest this regulation.

                                         -6-
      D. Determining Medical Equivalence in Particular Situations

      1. MEDICAL EQUIVALENCE AND MENTAL RETARDATION
      Listing 12.05C, Mental Retardation and Autism, applies primarily to
      adults with significantly subaverage intellectual functioning and deficits
      in adaptive behavior that were initially manifested in the individual’s
      developmental period (before age 22). As with other mental impairment
      categories, the focus of Listing 12.05 is on the individual’s inability to
      perform and sustain critical mental activities of work.

            ***

      c. 12.05 C

      Listing 12.05 C is based on a combination of an IQ score with an
      additional and significant mental or physical impairment. The criteria
      for this paragraph are such that a medical equivalence determination
      would very rarely be required. However, slightly higher IQ’s (e.g.,
      70–75) in the presence of other physical or mental disorders that
      impose additional and significant work-related limitation of function
      may support an equivalence determination. It should be noted that
      generally the higher the IQ, the less likely medical equivalence in
      combination with another physical or mental impairment(s) can be
      found.

      POMS § DI 24515.056 (emphasis added).

      Hesseltine achieved IQ scores of 71 in 2005, and 72 in 2012—both within the
70–75 range that would render her eligible for an equivalency finding under the
POMS guidelines for Listing 12.05C. In addition to her borderline intellectual
functioning, the ALJ found that Hesseltine suffered from three other “severe
impairments:” Perthes disease of the left hip, polycystic ovarian syndrome, and
obesity. Hesseltine urges that she is especially suited for an equivalence finding
because of her deficits in adaptive functioning. Dr. Mraz found that Hesseltine’s
“overall adaptive behavior skills were generally commensurate with her intellectual


                                         -7-
functioning, placing her at the 1st percentile.” He described her communication skills
as “below the 0.1 percentile.”

       In the portion of the ALJ’s decision addressing whether Hesseltine meets a
listed impairment, the ALJ stated:

      At the hearing the claimant’s representative argued that the claimant met
      Listing 12.05C. The severity of the claimant’s mental impairment does
      not meet or medically equal the criteria of Listing 12.05. . . . To satisfy
      the “paragraph C” criteria, the claimant must have a valid verbal,
      performance, or full scale IQ of 60 through 70 and a physical or other
      mental impairment imposing an additional and significant work-related
      limitation of function.

The decision does not further discuss Listing 12.05C, nor does it address whether
Hesseltine’s impairments are medically equal to this listing. In Shontos, this court
determined that the ALJ had erred when there was “no evidence that the ALJ
considered the POMS guidelines” despite evidence that Shontos suffered from
“marked disabilities that would interfere with her ability to work.” Shontos, 328 F.3d
at 425, 427. Shontos had a full scale IQ score of 72, placing her outside the range
required by Listing 12.05C. Id. at 424. Nevertheless, she suffered from anxiety and
depression to the extent that her treating medical professionals determined that her
ability to perform work was severely limited. Id. at 422.

       Similarly, the ALJ’s decision in this case does not mention the POMS guideline
for determining medical equivalence, let alone explain why Hesseltine fails to meet
it. We have ruled that “a remand is appropriate where the ALJ’s factual findings,
considered in light of the record as a whole, are insufficient to permit this Court to
conclude that substantial evidence supports the Commission’s decision.” Scott ex rel.
Scott v. Astrue, 529 F.3d 818, 822 (8th Cir. 2008). Hesseltine has (1) “a valid verbal,
performance, or full scale IQ score” that hovers slightly above the 60–70 range, (2)
“an onset of the impairment before age 22,” and (3) several other physical

                                         -8-
impairments that impose additional work-related limitations: Perthes disease of the
left hip, polycystic ovarian syndrome, and obesity. See 20 C.F.R. § 404, Subp. P,
App. 1, § 12.05C. The ALJ summarily concluded that Hesseltine’s combination of
impairments did not medically equal the criteria of Listing 12.05C, but she did not
provide the reasons for her conclusion. Without further explanation, we cannot say
whether there was sufficient evidence to support her decision. See Chunn v.
Barnhart, 397 F.3d 667, 672 (8th Cir. 2005) (remanding to the ALJ for further
proceedings because it was “not clear from his decision that he even considered
whether [claimant] met the requirements for listing 12.05C”); cf. Phillips v. Colvin,
721 F.3d 623, 629 (8th Cir. 2013) (affirming ALJ’s rejection of medical equivalence
because Phillips did not have any “physical or mental disorders that impose additional
and significant work-related limitation of function”).

                                   III. Conclusion

       We reverse the district court’s judgment and remand with instructions to return
the case to the Commissioner for proceedings consistent with this opinion.

COLLOTON, Circuit Judge, dissenting.

       To establish eligibility for social security disability benefits, Tammy Hesseltine
was required to show that she met or equaled a listed impairment for intellectual
disability in the governing regulations. See 20 C.F.R. § 404, Subp. P App. 1. The
“required level of severity” for intellectual disability is met when a claimant has a
“valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other
mental impairment imposing an additional and significant work-related limitation of
function.” Id. § 12.05C.

      Unlike the administrative law judge in Chunn v. Barnhart, 397 F.3d 667, 671
(8th Cir. 2005), who did not even mention listing 12.05C, or the ALJ in Scott ex rel.


                                          -9-
Scott v. Astrue, 529 F.3d 818, 822 (8th Cir. 2008), who did not cite or reference any
listing, the ALJ in this case expressly found that Hesseltine did not meet or equal
listing 12.05C: “The severity of the claimant’s medical impairment does not meet or
medically equal the criteria of listing 12.05. In making this finding, the undersigned
has considered whether the ‘paragraph A, B, C, or D’ criteria are satisfied.” R. 19.

       Hesseltine complains that the ALJ did not adequately explain her finding, but
even the failure to address a specific listing, much less the non-binding POMS
guidelines, “is not reversible error if the record supports the overall conclusion.”
Pepper ex rel. Gardner v. Barnhart, 342 F.3d 853, 855 (8th Cir. 2003); see Moore ex
rel. Moore v. Barnhart, 413 F.3d 718, 721 n.3 (8th Cir. 2005). That an ALJ does not
elaborate on her finding that a claimant’s impairments do not equal a listing does not
require reversal if the record supports the ALJ’s overall conclusion. Karlix v.
Barnhart, 457 F.3d 742, 746 (8th Cir. 2006). “[A] deficiency in opinion-writing is
not a sufficient reason for setting aside an administrative finding where the deficiency
had no practical effect on the outcome of the case.” Senne v. Apfel, 198 F.3d 1065,
1067 (8th Cir. 1999).

       The ALJ’s decision must be supported by substantial evidence on the record
as a whole—that is, less than a preponderance, but “enough that a reasonable mind
would find it adequate to support the Commissioner’s conclusion.” McKinney v.
Apfel, 228 F.3d 860, 863 (8th Cir. 2000). As the district court observed, the ALJ’s
finding is “supported by a solid credibility analysis” that included reference to
evidence of Hesseltine’s capacity to work.

       Hesseltine’s full-scale IQ scores—71 and 72 in 2005 and 2012,
respectively—are above the listing’s IQ range of 60 through 70. To “equal” the IQ
requirement, Hesseltine must present medical findings equal in severity to that lower
IQ range. Sullivan v. Zebley, 493 U.S. 521, 531 (1990). Hesseltine argues that her
deficits in adaptive functioning and low scores on the Vineland Adaptive Behavior

                                         -10-
Scales support a finding of equivalence. But according to a consultative examination
performed by Dr. Roger Mraz in 2005, Hesseltine’s “overall adaptive behavior skills
were generally commensurate with her intellectual functioning.” At another
consultative examination with Dr. Mraz in 2012, Hesseltine “presented no evidence
of a thought disorder or perceptual abnormalities,” and denied experiencing anxiety
or depression. Cf. Shontos v. Barnhart, 328 F.3d 418, 424 (8th Cir. 2003) (relying
on evidence from treating providers that claimant suffered from anxiety and
depression).

       Dr. Mraz concluded that Hesseltine had “a history of being a responsible
worker,” and that she “should have no difficulty following simple instructions,” as
long as she had “an employer who [understood] her cognitive and academic
limitations.” Hesseltine’s former work supervisor at a laundry reported that she
worked “better than most in the same position,” required “less supervision,” and
demonstrated “some to a lot of independence.” The supervisor also rated as “good”
Hesseltine’s ability to “understand and carry out simple (1 and 2 step) instructions
and procedures” and to “concentrate and remain on task.” In a function report,
Hesseltine stated that she was able to “prepare food all the time daily,” shop for food,
and perform “small amounts” of cleaning, laundry, and mowing.

      A reasonable mind could find the record evidence adequate to buttress the
ALJ’s determination that Hesseltine’s impairments do not medically equal listing
12.05C. Substantial evidence on the record as a whole supports a finding that
Hesseltine does not suffer from other mental disorders that temporarily lowered her
IQ or rendered her equal to a person with an IQ between 60 and 70. The POMS
guidelines notwithstanding, physical disorders cannot support a finding of
equivalence to the IQ requirement of listing 12.05C. See Zebley, 493 U.S. at 530 n.8,
531; Kennedy v. Colvin, 738 F.3d 1172, 1177 (9th Cir. 2013). I would therefore
affirm the judgment.
                       ______________________________

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