TAMBRA LESTER v. DEPARTMENT OF SOCIAL SERVICES, FAMILY SUPPORT DIVISION, Respondent-Respondent. , 2014 Mo. App. LEXIS 40 ( 2014 )


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  • TAMBRA LESTER,                 )
    )
    Petitioner-Appellant,     )
    )
    v.                             )                   No. SD32457
    )                   Filed: 1-16-14
    DEPARTMENT OF SOCIAL SERVICES, )
    FAMILY SUPPORT DIVISION,       )
    )
    Respondent-Respondent.    )
    APPEAL FROM THE CIRCUIT COURT OF IRON COUNTY
    Honorable Kelly W. Parker, Circuit Judge
    AFFIRMED
    Tambra Lester (Claimant) appeals from a judgment entered by the Circuit Court
    of Iron County affirming a decision and order from the Director of the Missouri
    Department of Social Services, Family Support Division (the Director). The Director’s
    decision affirmed the denial of Claimant’s application for MO HealthNet for the Aged,
    Blind and Disabled (MHABD) benefits, based on a determination that Claimant was not
    permanently and totally disabled.
    On appeal, Claimant contends the trial court erred in affirming the Director’s
    denial of benefits because: (1) that decision was not based in law, in that the Director
    failed to properly apply certain federal regulations; and (2) that decision was not
    supported by substantial evidence and was arbitrary, capricious and unreasonable, in that
    the Director failed to accord proper weight to medical opinion evidence. Finding no
    merit in either contention, we affirm.
    Standard of Review
    “On appeal, we review the decision of the administrative agency, not the
    judgment of the circuit court.” Cruz v. MO. Dept. of Social Services, 
    386 S.W.3d 899
    ,
    902 (Mo. App. 2012). Section 536.140.2 limits our review to determining whether the
    administrative agency’s decision:
    (1) Is in violation of constitutional provisions;
    (2) Is in excess of the statutory authority or jurisdiction of the agency;
    (3) Is unsupported by competent and substantial evidence upon the whole
    record;
    (4) Is, for any other reason, unauthorized by law;
    (5) Is made upon unlawful procedure or without a fair trial;
    (6) Is arbitrary, capricious or unreasonable;
    (7) Involves an abuse of discretion.
    Id.1 This Court examines the whole record to determine whether there is sufficient
    evidence to support the decision. Dambach v. Department of Social Services, Family
    Support Div., 
    313 S.W.3d 188
    , 191 (Mo. App. 2010). “We must examine the record in
    the light most favorable to the Division’s decision and disregard evidence that might
    support findings different from those of the Division.”           
    Id. In addition,
    “[t]he
    1
    All references to statutes are to RSMo Cum. Supp. (2010) unless otherwise
    specified.
    2
    determination of the credibility of witnesses is within the province of the director.”
    Chrismer v. Missouri State Div. of Family Services, 
    816 S.W.2d 696
    , 700 (Mo. App.
    1991); Rader v. Missouri State Div. of Family Services, 
    810 S.W.2d 346
    , 348 (Mo. App.
    1991). We will not substitute our judgment for that of the Director on factual matters, but
    questions of law are matters for the independent judgment of this Court. 
    Cruz, 386 S.W.3d at 902
    ; see 
    Dambach, 313 S.W.3d at 191
    .             “If the Division’s decision is
    supported by substantial and competent evidence found in the record, then the Division’s
    decision should be affirmed.” Garrett v. Missouri Dept. of Social Services, 
    57 S.W.3d 916
    , 919 (Mo. App. 2001). We have summarized the relevant facts in accordance with
    the foregoing principles.
    Factual and Procedural Background
    In March 2010, Claimant was 51 years of age. She injured her ankle while
    working as a housekeeper at a motel. Dr. Craig Ruble diagnosed Claimant’s injury as a
    distal fibular fracture and treated Claimant for several months. Her treatment included
    frequent ice and elevation, anti-inflammatory medication and physical therapy. The
    doctor noted continued improvement and progress throughout Claimant’s treatment.
    In April 2010, while recovering from the ankle injury, Claimant complained to
    Dr. Ruble of mid-to-low back pain. Claimant reported the pain as on-and-off aching that
    was occasionally sharp and severe.        Dr. Ruble diagnosed a lumbar strain after
    examination and x-rays revealed no abnormalities, fractures, dislocations or significant
    degeneration of the lumbar spine. The doctor recommended Claimant apply ice and/or
    heat frequently to her back and continue anti-inflammatory medication. He also ordered
    one physical therapy visit to set up a home exercise program for Claimant’s back.
    3
    In May 2010, Claimant followed up with her chiropractor, Dr. Steven McAdams.
    He diagnosed Claimant as having a sprain or strain of the lumbar spine with associated
    subluxations and muscle spasms.
    On May 10, 2010, after completion of Claimant’s prescribed physical therapy
    sessions for her ankle and continued improvement, Dr. Ruble released Claimant to work
    an eight-hour day with the assistance of a boot, with weight bearing as tolerated.
    Although instances of ankle swelling or soreness were noted in follow-up appointments
    in May and June, Claimant’s range of motion, strength, stability and pain levels
    continued to improve. Dr. Ruble prescribed at-home daily exercises, ice and elevation,
    compression hosiery and anti-inflammatory medication. Throughout these follow-up
    appointments, Dr. Ruble consistently reaffirmed that Claimant was able to work full duty
    with the assistance of a boot or ankle brace.
    Thereafter, Claimant returned to work, but only for a short time. In June 2010,
    Claimant stopped working. According to her, she was not able to work because the
    demands of the job caused her right ankle and calf to swell.
    On July 19, 2010, at Claimant’s final appointment with Dr. Ruble, the doctor
    noted good range of motion of her ankle, no tenderness, and good strength and stability.
    Although he mentioned in his notes that Claimant was no longer employed, he
    maintained his recommendation that “[a]s far as work, she is obviously still full duty.”
    He went on to state that Claimant is “at maximum medical improvement” and released
    Claimant to her own care.
    In January 2011, Claimant applied for MHABD benefits, claiming that she was
    permanently and totally disabled. Claimant listed her disabling physical symptoms and
    4
    problems as “pain & stiffness in back, neck & ankle, headaches, limited mobility[.]” She
    reported “depression” as her mental health symptom and problem. Claimant submitted
    her application and medical information on her complaints to the Medical Review Team
    (the Team). On March 30, 2011, the Team determined that Claimant was ineligible for
    MHABD benefits because she was not permanently and totally disabled. Claimant then
    requested an administrative hearing.
    On June 1, 2011, a hearing officer held a telephone hearing, at which several
    medical records were introduced into evidence. These records included a one-page report
    from Claimant’s chiropractor, Dr. McAdams; and Dr. Ruble’s records, which contained
    detailed examination summaries, imaging reports and physical therapy notes.           The
    medical evidence also included records from Claimant’s primary care physician, Dr.
    Stephanie Moniz, who had treated Claimant for low back pain on September 14, 2010
    and February 8, 2011.
    On the latter date, Dr. Moniz also completed residual functional capacity (RFC)
    questionnaires concerning Claimant’s physical and mental capabilities.       Based upon
    Claimant’s responses to the questions, Dr. Moniz concluded that: (1) Claimant could
    only sit or stand less than two hours in an eight-hour work day; (2) she would be
    restricted in bending, twisting or stooping; and (3) she could only occasionally lift less
    than 10 pounds. The doctor also opined that Claimant would be frequently limited in her
    ability to focus on and handle stress related to her work tasks. Dr. Moniz characterized
    Claimant’s ability to return to work as “poor.”
    During the hearing, Claimant testified about her physical and mental conditions
    and how they restricted her daily activities. In addition to low-back and ankle pain,
    5
    Claimant testified that she suffers from wrist pain and weakness, headaches and
    depression. When questioned about her ability to return to any of her prior jobs in
    housekeeping, cashiering or waitressing, Claimant stated that she could no longer
    perform those jobs. Claimant admitted, however, that she is able to: (1) do light
    gardening; (2) walk daily up to a quarter of a mile; (3) perform most of her own
    housekeeping, including laundry in her basement; (4) prepare her own meals; and (5)
    drive. Claimant testified that her highest level of education is one year of college. She
    also testified that she applied for Social Security, but was denied on the basis that she was
    not disabled.
    Thereafter, the Director issued a decision affirming the Team’s denial of MHABD
    benefits. The Director found that Claimant had not met her burden of proving that she
    was permanently and totally disabled. Although the Director found that Claimant was
    not gainfully employed and that her condition was “severe,” Claimant’s medical
    conditions did not meet or equal Social Security disability listings “as set forth in 20
    C.F.R., Ch. III, Part 404, Subpart P, Appendix 1 ....”           Specifically, the Director
    considered disability listings for Claimant’s “spinal condition,” her “leg and ankle injury”
    and “depression.” The Director further found that Claimant was able to do past relevant
    work because:
    Dr. Ruble returned claimant to full duty in May 2010. Dr. Ruble’s and Dr.
    McAdams’ X-Ray reports do not demonstrate Claimant suffers from a
    severe spinal condition. Dr. Moniz’s report is simply not enough to
    overcome the other medical evidence.
    Lastly, the Director found that Claimant is able to do other work because:
    Claimant testified that she is able to walk a quarter of a mile. Claimant
    testified she is able to do laundry in the basement of her home. She is able
    to do light gardening such as watering the flowers and pulling weeds.
    6
    Claimant has experience as a cashier and experience in the food service
    industry. Claimant has one year of college education. There is no medical
    evidence that Claimant could not do other work. There is nothing in the
    record to support that Claimant is not capable of performing other work.
    Considering Claimant’s [RFC], educational level, and prior work
    experience, there is no evidence she will not be able to adjust to other
    types of work within the next 12 months and thereby engage in substantial
    gainful activity.
    The Director therefore concluded that “Claimant is not permanently and totally disabled
    and [is] medically ineligible to receive MHABD benefits.” This appeal followed.
    Discussion and Decision
    Point I
    Claimant’s first point contends the Director’s decision to deny her application for
    MHABD benefits was “not based in law” in that the Director “failed to properly apply
    certain applicable Social Security regulations as required.”2 To properly analyze this
    point, an overview of the statutes and regulations governing eligibility for MHABD
    benefits is necessary.
    Missouri administers Medicaid, which is a federal-state program providing
    medical assistance to needy persons pursuant to Title XIX of the Social Security Act, in a
    program known as “MO HealthNet.” § 208.001.2; § 208.151.1; J.P. v. Missouri State
    Family Support Div., 
    318 S.W.3d 140
    , 144-45 (Mo. App. 2010).                    Generally,
    2
    We note Claimant’s point is defective because it fails, inter alia, to reference
    the applicable regulations and specify the legal reasons to support the claim of reversible
    error, in violation of Rule 84.04(d)(2). See Dep’t of Soc. Servs. v. Peace of Mind Adult
    Day Care Ctr., 
    377 S.W.3d 631
    , 638 (Mo. App. 2012). Further, Claimant raised
    additional claims of error in her brief and at oral argument that were not included in her
    point relied on, in violation of Rule 84.04(e). See 
    id. at 642
    n.14. Because these
    deficiencies do not impede our disposition on the merits, however, we exercise our
    discretion to review the issues raised by Claimant’s point, as best we understand them, ex
    gratia. See Bank of New York v. Yonts, 
    388 S.W.3d 560
    , 561 n.2 (Mo. App. 2012).
    7
    participation in Medicaid requires a state to develop a plan that complies with the basic
    federal guidelines. Plumb v. Missouri Dept. of Social Services, Family Support Div.,
    
    246 S.W.3d 475
    , 479 (Mo. App. 2007).            “The methodology utilized to determine
    eligibility for services by the state cannot be more restrictive than the methodology
    utilized by the federal government.       The state is permitted, however, to employ
    methodologies which are less restrictive than those utilized by the federal government.”
    
    Id. (citation omitted).
    MO HealthNet provides medical assistance for permanently and totally disabled
    persons. § 208.151.1(24)(c). “Persons who are eligible for [medical assistance] must
    meet the eligibility requirements, other than income, for ... Permanent and Total
    Disability ....” 13 C.S.R. 40-2.200(7).3 To be eligible to receive such medical assistance,
    also known as MHABD benefits, for “permanent and total disability” means that “the
    individual has some physical or mental impairment, disease or loss from which recovery
    or substantial improvement cannot be expected and which substantially precludes him/her
    from engaging in any occupation within his/her competence, such as holding a job or
    homemaking.” 13 C.S.R. 40-2.100(1). In addition, the individual also must meet the
    definition of “disability,” as defined by the Social Security Administration to receive
    Social Security Disability and Supplemental Security Income (SSI), which is “the
    individual’s inability to be gainfully and substantially employed for one year or longer
    due to a physical or mental incapacity.” § 1060.000.00, Department of Social Services,
    Family Support Division, Income Maintenance Manual; Chrismer v. Missouri State Div.
    3
    All references to the Code of State Regulations are to versions in current use,
    namely: 13 C.S.R. 40-2.200(7) dated 12/31/05; 13 C.S.R. 40-2.100(1) dated 3/31/06.
    All references to the Code of Federal Regulations are to the 2010 edition.
    8
    of Family Services, 
    816 S.W.2d 696
    , 700 (Mo. App. 1991); see 20 C.F.R. § 404.1505(a)
    (disability benefits); 20 C.F.R. § 416.905(a) (SSI benefits). Claimant bears the burden of
    proving that she is permanently and totally disabled and, therefore, medically eligible to
    receive MHABD benefits. See Garrett v. Missouri Dept. of Social Services, 
    57 S.W.3d 916
    , 919 (Mo. App. 2001); 
    Chrismer, 816 S.W.2d at 700
    .
    Pursuant to 20 C.F.R. § 404.1520, a five-step analysis is used to determine
    disability. These five sequential steps are, in relevant part, as follows:
    [Step 1] (b) If you are working. If you are working and the work that you
    are doing is substantial gainful activity, we will find you are not disabled
    regardless of your medical condition or your age, education, and work
    experience.
    [Step 2] (c) You must have a severe impairment. If you do not have any
    impairment or combination of impairments which significantly limits your
    physical or mental ability to do basic work activities, we will find that you
    do not have a severe impairment and are, therefore, not disabled ....
    [Step 3] (d) When your impairment(s) meets or equals a listed impairment
    in appendix 1. If you have an impairment(s) which meets the duration
    requirement and is listed in appendix 1 or is equal to a listed
    impairment(s), we will find you disabled without considering your age,
    education, and work experience. (e) When your impairment(s) does not
    meet or equal a listed impairment. If your impairment(s) does not meet or
    equal a listed impairment, we will assess and make a finding about your
    residual functional capacity based on all the relevant medical and other
    evidence in your case record .... We use our residual functional capacity
    assessment at the fourth step of the sequential evaluation process to
    determine if you can do your past relevant work (paragraph (f) of this
    section) and at the fifth step of the sequential evaluation process (if the
    evaluation proceeds to this step) to determine if you can adjust to other
    work (paragraph (g) of this section).
    [Step 4] (f) Your impairment(s) must prevent you from doing your past
    relevant work. If we cannot make a determination or decision at the first
    three steps of the sequential evaluation process, we will compare our
    residual functional capacity assessment, which we made under paragraph
    (e) of this section, with the physical and mental demands of your past
    relevant work .... If you can still do this kind of work, we will find you are
    not disabled.
    9
    [Step 5] (g) Your impairments must prevent you from making an
    adjustment to any other work. (1) If we find that you cannot do your past
    relevant work because you have severe impairment(s) (or you do not have
    any past relevant work), we will consider the same residual functional
    capacity assessment we made under paragraph (e) of this section, together
    with your vocational factors (your age, education, and work experience) to
    determine if you can make an adjustment to other work. ... If you can
    make an adjustment to other work, we will find you not disabled. If you
    cannot, we will find you disabled.
    See 20 C.F.R. § 404.1520(b)-(g) (internal references omitted); see also 20 C.F.R.
    § 416.920(b)-(g). Claimant argues that the Director erred in applying steps 3 and 4 of
    this analysis.
    With respect to step 3, Claimant argues the Director initially erred “by not
    considering all of [Claimant’s] impairments in combination as required by the Social
    Security regulations.” This argument is based upon 20 C.F.R. § 404.1523, which states:
    In determining whether your physical or mental impairment or
    impairments are of a sufficient medical severity that such impairment or
    impairments could be the basis of eligibility under the law, we will
    consider the combined effect of all of your impairments without regard to
    whether any such impairment, if considered separately, would be of
    sufficient severity. If we do find a medically severe combination of
    impairments, the combined impact of the impairments will be considered
    throughout the disability determination process. If we do not find that you
    have a medically severe combination of impairments, we will determine
    that you are not disabled (see § 404.1520).
    Id.; see also 20 C.F.R. § 416.923.       Claimant’s argument fails because 20 C.F.R.
    § 404.1523 does not apply to step 3. Instead, it is utilized in step 2 to determine “whether
    your physical or mental impairment or impairments are of a sufficient medical severity
    10
    ....” 
    Id. (italics added).
    In the analysis for step 2 here, the Director ruled in Claimant’s
    favor by finding that her condition was “severe.”4
    With respect to step 4, Claimant argues the Director erred by failing to make
    specific findings assessing Claimant’s RFC and comparing her “[RFC] to the physical
    and mental demands of [her] past relevant work” to determine whether she is capable of
    performing those tasks.5 For the following reasons, this argument also fails.
    The applicable regulation is 20 C.F.R. § 404.1520(f). There are federal cases
    which require the fact-finder to make specific factual findings in applying the regulation.
    See, e.g., Groeper v. Sullivan, 
    932 F.2d 1234
    , 1238-39 (8th Cir. 1991). Claimant does not
    cite any federal statute or regulation, however, which requires a state fact-finder to make
    the same specific findings. In Missouri, the standards for a written decision in MO
    HealthNet proceedings are discussed in §§ 208.080 and 536.090 RSMo (2000). With
    respect to findings, § 536.090 provides, in relevant part:
    Every decision and order in a contested case shall be in writing, and,
    except in default cases or cases disposed of by stipulation, consent order
    or agreed settlement, the decision, including orders refusing licenses, shall
    include or be accompanied by findings of fact and conclusions of law.
    The findings of fact shall be stated separately from the conclusions of law
    4
    In step 3, the Director found that Claimant’s impairments did not meet or equal
    any Social Security listing for disability. Claimant does not argue the Director erred in
    determining her impairments – her spinal condition, leg and ankle injury, and depression
    – did not qualify as a disability. Because only conditions substantiated by medical
    evidence can be considered in a disability determination, the Director properly
    disregarded Claimant’s additional complaints that were not supported by medical
    evidence. See 20 C.F.R. § 404.1508 (“[a] physical or mental impairment must be
    established by medical evidence consisting of signs, symptoms, and laboratory findings,
    not only by your statement of symptoms”); see also 20 C.F.R. § 416.908.
    5
    RFC, residual functional capacity, is defined as the most a person can do
    despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). It is assessed using all
    relevant evidence in the record. 
    Id. 11 and
    shall include a concise statement of the findings on which the agency
    bases its order.
    
    Id. (emphasis added).6
    Whether or not an agency “made adequate findings of fact is an
    issue of law for our independent judgment.” State ex rel. Public Counsel v. Pub. Serv.
    Comm’n, 
    274 S.W.3d 569
    , 576-77 (Mo. App. 2009). In Public Counsel, the western
    district of this Court explained:
    We use a flexible standard: The findings of fact must be sufficiently
    definite and certain or specific under the circumstances of the particular
    case to enable the court to review the decision intelligently and ascertain if
    the facts afford a reasonable basis for the order without resorting to the
    evidence. Findings are inadequate if they cause us to speculate as to
    which part of the evidence the commission believed.
    
    Id. at 577
    (internal citations and quotation marks omitted); State ex rel. Aquila, Inc. v.
    Public Service Comm’n of State, 
    326 S.W.3d 20
    , 28-29 (Mo. App. 2010).
    We have no difficulty understanding the basis for the Director’s decision that
    Claimant is able to perform past relevant work. The Director relied on Dr. Ruble’s May
    2010 release of Claimant to work an eight-hour day with the assistance of a boot, with
    weight bearing as tolerated. Although Claimant testified that she could no longer work
    due to swelling of her ankle and calf, the Director found Dr. Ruble’s medical opinion and
    treatment records more persuasive. See Chrismer v. Missouri State Div. of Family
    Services, 
    816 S.W.2d 696
    , 700 (Mo. App. 1991) (“[t]he Division Director, as the
    determiner of facts, is not required to accept as true each and every statement of
    appellant”); see, e.g., Rader v. Missouri State Div. of Family Services, 
    810 S.W.2d 346
    ,
    6
    Section 208.080 specifically provides that “[t]he director shall clearly state the
    reasons for his decision and shall include a statement of findings of fact and conclusions
    of law pertinent to the questions in issue.” § 208.080.7 RSMo (2000). Similarly,
    Missouri regulations require “a statement of Findings of Fact and Conclusions of Law”
    that must be based on the Missouri rules of evidence as applied to civil cases. 13 C.S.R.
    § 40-2.160(5)(G) dated 6/30/04.
    12
    348 (Mo. App. 1991) (“[t]he Director balanced appellant’s evidence against the medical
    evidence and discounted appellant’s complaints accordingly”). In addition, it was up to
    the Director to resolve conflicts in the evidence between Dr. Ruble’s medical evidence
    and Dr. Moniz’s medical evidence, including the RFC questionnaires.               See, e.g.,
    
    Rader, 810 S.W.2d at 348
    ; see also 20 C.F.R. § 404.1527(d)(2) (while medical source
    opinions are considered in assessing RFC, the final determination of RFC is left to the
    Commissioner). Thus, contrary to Claimant’s argument, the Director did not fail to
    properly apply the applicable Social Security regulations.7 Point I is denied.8
    Point II
    Claimant’s second point contends the Director’s decision to deny her application
    for MHABD benefits was “not supported by substantial evidence on the record as a
    7
    Claimant also argues that the Director failed to make explicit findings with
    respect to step 5; that argument fails for the same reasons stated above. Additionally, any
    alleged error is immaterial because the Director was not required to reach step 5. That
    step of the analysis is only required “[i]f we find that you cannot do your past relevant
    work ....” 20 C.F.R. § 404.1520(g) (underlining added). Because the Director found
    Claimant could perform her past relevant work, the Director properly concluded Claimant
    was not disabled under 20 C.F.R. § 404.1520(f) and could have ended the analysis there.
    8
    The gist of all of Claimant’s arguments is that the Director must make
    eligibility determinations in strict compliance with Social Security regulations. However,
    Claimant has not directed this Court’s attention to any portion of the Medicaid statute that
    requires states to make the same factual findings required by federal decisions like
    
    Groeper, supra
    . Missouri’s methodology to determine eligibility for services simply
    cannot be more restrictive than that utilized by the federal government. Plumb v.
    Missouri Dept. of Social Services, Family Support Div., 
    246 S.W.3d 475
    , 479 (Mo.
    App. 2007); see J.P. v. Missouri State Family Support Div., 
    318 S.W.3d 140
    , 145 (Mo.
    App. 2010); see also Wis. Dep’t of Health & Family Servs. v. Blumer, 
    534 U.S. 473
    ,
    479 (2002) (each participating state develops its own plan containing reasonable
    standards for determining eligibility for and the extent of medical assistance within
    boundaries set by the Medicaid statute and the Secretary of Health and Human Services);
    Vaughn v. Missouri Dept. of Social Services, 
    323 S.W.3d 44
    , 47 (Mo. App. 2010); see
    generally 42 U.S.C. § 1396a (2010). The Director in this case properly evaluated all of
    the evidence in accordance with the five-step analysis as required under 20 C.F.R.
    § 404.1520.
    13
    whole [and was] arbitrary, capricious and unreasonable in that the Division Director
    failed to accord proper weight to medical opinion evidence.” We disagree.
    In support of her argument, Claimant relies on the general principle that “[a]
    treating physician’s opinion is due controlling weight if that opinion is well-supported by
    medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent
    with the other substantial evidence in the record.” Ellis v. Barnhart, 
    392 F.3d 988
    ,
    995 (8th Cir. 2005) (citation and internal quotation marks omitted). Here, however, the
    opinion of Claimant’s physician, Dr. Moniz, was inconsistent with other medical
    evidence. With respect to Claimant’s ability to perform past work, the Director noted
    that Dr. Ruble returned Claimant to full duty in May 2010 and specifically found that
    “Dr. Ruble’s and Dr. McAdams’ X-Ray reports do not demonstrate Claimant suffers
    from a severe spinal condition.” The Director explained that “Dr. Moniz’s report is
    simply not enough to overcome the other medical evidence.” Although Claimant argues
    that the Director should have given controlling weight to her physician, Dr. Moniz, the
    Director acted well within the authority to resolve conflicts in the evidence and determine
    credibility. See 
    Chrismer, 816 S.W.2d at 700
    ; 
    Rader, 810 S.W.2d at 348
    ; see also Cruz
    v. MO. Dept. of Social Services, 
    386 S.W.3d 899
    , 902 (Mo. App. 2012) (this Court
    defers to the Director on factual matters). By relying primarily on Dr. Ruble’s medical
    evidence, which contained detailed examination summaries, imaging reports and physical
    therapy notes involving Claimant’s treatment over several months, the Director’s
    decision to deny benefits was not arbitrary, capricious or unreasonable.
    Moreover, the Director’s decision is supported by substantial and competent
    evidence on the record as a whole. After determining that Claimant was not gainfully
    14
    employed and had a severe condition, the Director evaluated each of Claimant’s
    medically determinable impairments and found none of her impairments met the Social
    Security disability listings. See 20 C.F.R. § 404.1520(b)-(d). The determination that
    Claimant could perform past relevant work was supported, in large part, by the medical
    records of Dr. Ruble and Dr. McAdams, which demonstrated that Claimant’s ankle
    exhibited good strength, stability and range of motion, that her back pain was likely the
    result of a lumbar strain and that her depression did not interfere with her ability to work.
    See 20 C.F.R. § 404.1520(e)-(f). Because the Director’s decision that Claimant failed to
    prove she was permanently and totally disabled was supported by substantial and
    competent evidence on the record as a whole, Point II is denied.
    The Director’s decision and order is affirmed.
    JEFFREY W. BATES, P.J. – OPINION AUTHOR
    GARY W. LYNCH, J. – CONCUR
    MARY W. SHEFFIELD, J. – CONCUR
    15