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Heeman v. Astrue

August 16, 2010


The opinion of the court was delivered by: Charles H. Evans United States Magistrate Judge


CHARLES H. EVANS, U.S. Magistrate Judge

Plaintiff Lonald W. Heeman appeals from a final decision of the Social Security Administration (SSA) denying his application for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416, 423, and 1381a. Plaintiff brings this appeal pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). The parties have consented to a determination of this case by the United States Magistrate Judge, under 28 U.S.C. § 636. Consent to Proceed Before a United States Magistrate (d/e 7). Pursuant to Local Rule 8.1(D), Plainitff has filed a Brief in Support of Complaint (d/e 11), which the Court construes as a motion for summary judgment. The Commissioner has filed a Motion for Summary Affirmance (d/e 13) and Commissioner's Memorandum in Support of Motion for Summary Affirmance (d/e 14).

For the reasons set forth below, the Court determines that the SSA's decision is supported by the law and the evidence. Plaintiff's motion for summary judgment is DENIED. The Commissioner's Motion for Summary Affirmance is GRANTED, and the decision of the Commissioner is AFFIRMED.


Judicial review of the Commissioner's final determination of disability is limited, and the Commissioner's findings of fact are treated as conclusive as long as they are supported by substantial evidence. 42 U.S.C. § 405(g); Halbrook v. Chater, 925 F. Supp. 563, 571 (N.D. Ill. 1996). "Substantial evidence" means evidence that "a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971); Powers v. Apfel, 207 F.3d 431, 434 (7th Cir. 2000). On review, courts may not reevaluate evidence, make new factual determinations, or substitute their judgment for that of the Commissioner. Powers, 207 F.3d at 434-35.

Nonetheless, the Court must look to the record as a whole to determine if there is "substantial evidence" supporting the ALJ's decision. Stephens v. Heckler, 766 F.2d 284, 287 (7th Cir. 1985). An ALJ's opinion need not evaluate "every piece of testimony and evidence submitted." Zalewski v. Heckler, 760 F.2d 160, 166 (7th Cir. 1985). All that is required is that the ALJ "considered the important evidence" in the opinion, thus allowing the Court to "trace the path of the ALJ's reasoning." Stephens, 766 F.2d at 287.

In determining whether an individual is disabled for Social Security purposes, the ALJ must use the five-step sequence outlined in 20 C.F.R. § 404.1520(a). Each step must be satisfied before moving on to the next step. First, the ALJ determines if the claimant engages in "substantial gainful activity," (SGA) defined as work that involves significant physical or mental activities, usually done for pay or profit. 20 C.F.R. § 416.920(b). If the claimant is not involved in SGA, step two requires the ALJ to decide whether the claimant has a medically determinable impairment that is "severe," or a combination of impairments that, taken together, are "severe."

20 C.F.R. § 416.920(c). Severity is measured by whether an impairment significantly limits an individual's ability to perform basic work activities.

20 C.F.R. § 416.921; SSRs 85-28, 96-3p, 96-4p. If such an impairment is found, the ALJ proceeds to step three.

In step three, the ALJ evaluates whether the claimant's impairment meets criteria listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the Listings). If the ALJ decides in the affirmative, the claimant is disabled. If the claimant's condition is not equivalent to a Listing, the ALJ moves on to step four. Step four requires the ALJ to determine the claimant's residual functional capacity (RFC). The ALJ considers all impairments, not just those found to be severe under step two. 20 C.F.R. § 416.945. The ALJ then determines whether the claimant has the RFC to perform past relevant work.

If the claimant is not able to perform past relevant work, the ALJ moves to step five, where he evaluates whether the claimant is capable of performing other work. 20 C.F.R. § 416.920(g). The ALJ takes into consideration the claimant's RFC, age, education, and work experience. At this juncture, the SSA is responsible for producing evidence that demonstrates that there is work suitable for the claimant in the national economy. 20 C.F.R. §§ 416.912(g), 416.960(c). If the ALJ determines that there is other work available to the claimant, the claimant is not disabled for purposes of SSI or DIB.



At the time of the administrative hearing, Plaintiff was a forty-three- year-old male who lived in Meredosia, Illinois, with his wife and fifteen-year-old daughter. Answer (d/e 9), Exs. 1-14, Social Security Transcript (Tr.), 673-74. In July 2001, Plaintiff was hospitalized after he hurt his back and neck while stepping off of a pallet at work. Tr. at 176. The treating physician noted that Plaintiff had a history of back pain, and prescribed him medication and ordered work restrictions until Plaintiff could follow up with his regular physician. Tr. at 176. Plaintiff received some physical therapy for his injuries, but as of September 25, 2001, still experienced back pain. Tr. at 166. On October 2, 2001, Plaintiff went back to the hospital with back pain. The treating physician ordered more medication and ordered Plaintiff to see a neurologist. Tr. at 173-74.

Plaintiff continued to have back pain throughout the fall of 2001. In late October, Plaintiff had an epidural injection to help manage his pain. Tr. at 329. He followed up with Dr. Marshall Robert on November 7, 2001, seeking different methods of pain management and another round of physical therapy. Tr. at 328. Dr. Robert indicated that Plaintiff had a herniated nucleus pulposis and spondylolisthesis. Tr. at 328. On November 21, 2001, Plaintiff again saw Dr. Robert. Dr. Robert indicated that Oxycontin was helping Plaintiff with his pain, but Plaintiff complained that his employer was not adhering to the functional restrictions imposed by Plaintiff's physicians. Tr. at 327. On November 26, 2001, Dr. Robert confirmed that he would issue a written work-restriction order, limiting Plaintiff to carrying no more than ten pounds. Tr. at 327. Dr. Robert received a more comprehensive list of restrictions from a Dr. Holt*fn1 on December 7, 2001, limiting Plaintiff to carrying no more than ten pounds, sitting at least fifty percent of the time, infrequent bending, and ordering time off for physical therapy sessions. Tr. at 326.

On December 28, 2001, Dr. Barry Samson examined Plaintiff and diagnosed him with degenerative disc disease and spondylolisthesis. Tr. at 363. Dr. Samson believed that Plaintiff's injury in July 2001 had exacerbated pre-existing conditions, and noted that Plaintiff's options were to attend physical therapy sessions, undergo further testing, or live with the pain. Tr. at 363. In February 2002, Plaintiff began seeing Cathy Wilson, a physical therapist. Tr. at 298-300. Plaintiff attended several therapy sessions during February 2002, but complained that his back pain was severe. Tr. at 299.

Plaintiff also continued to see Dr. Robert throughout 2002. In August 2002, Dr. Robert indicated that Plaintiff had obtained a job washing dishes at a restaurant, but that the work made Plaintiff's extremities go numb and caused his neck pain to flare up. Tr. at 318. Dr. Robert noted that Plaintiff was still having pain, despite his physical therapy and medications. Tr. at 315. On December 3, 2002, an MRI revealed that Plaintiff had two herniated discs. Tr. at 315. In January 2003, Plaintiff told Dr. Robert that the Vicodin was not alleviating his pain, and that his job washing dishes was making his back pain worse. Tr. at 314. Legal troubles made it difficult for Plaintiff to afford his medication. Tr. at 313.

In February 2003, Dr. Robert again ordered physical therapy for Plaintiff. Tr. at 313. The Vicodin was still not alleviating Plaintiff's pain, but on April 4, 2003, Dr. Robert noted that he had referred Plaintiff to Dr. Claude Fortin for further treatment. Tr. at 312. Dr. Fortin performed a neurological evaluation on Plaintiff in April 2003, and prescribed medication to help with Plaintiffs recurring lower back pain. However, Dr. Fortin noted a "paucity of objective findings . . . other than lumbar paraspinal muscle spasms." Tr. at 188. In June and July 2003, Dr. Fortin performed a nerve root block and gave Plaintiff steroid injections. Tr. at 192-95. Dr. Fortin did another steroid injection in August. Tr. at 190-91. Dr. Fortin indicated that Plaintiff's lower back pain had "significantly improved" after the injections. Tr. at 184. A September 2003 progress note from Dr. Robert indicated that Plaintiff's steroid injection treatments had been largely successful, and that Plaintiff was more functional, although not pain free. Tr. at 310. Dr. Robert indicated that Plaintiff was anxious about his legal situation. Tr. at 310.

On November 5, 2003, Dr. Robert wrote a letter stating that Plaintiff had been "medically disabled and in chronic pain from a back injury at work" for nearly two years, and noting that various treatments for pain had been unsuccessful. Tr. at 558. Dr. Robert wrote that specialists indicated that Plaintiff would always be in pain and would "have some stringent physical restrictions that will affect his employability." Tr. at 558. Dr. Robert did not indicate what those restrictions would be. Plaintiff continued to see Dr. Robert throughout 2003 and into 2004, but his pain only worsened. Plaintiff visited the emergency room with back pain in December 2003 and March 2004. Tr. at 232-41.

Plaintiff once again began physical therapy in March 2004, but continued to complain of lower back pain. Tr. at 164. He received another steroid injection in March 2004, and expressed some pain relief afterwards. Tr. at 232-35. An MRI from April 2004 indicated some degenerative disc disease, but no spinal stenosis, enhancing pathology, or frank disc herniation. Tr. at 172. An examining physician indicated on May 6, 2004, that Plaintiff engaged in "somewhat exaggerated pain behaviors with moaning and groaning upon arising from a chair." Tr. at 179.

On June 9, 2004, Dr. Koteswara Narla performed a neurological evaluation on Plaintiff. Tr. at 213-15. Dr. Narla diagnosed Plaintiff with failed back syndrome "with an MRI scan showing very little pathology with the lumbar pain and right-sided radiculopathic symptomatology." Tr. at 214. Dr. Narla wanted Plaintiff to continue on Methadone, and suggested a spinal stimulator as a potential treatment. Tr. at 214. In October 2004, Dr. Narla indicated that medication treatment had been unsuccessful, and that the only thing left to try was a spinal stimulator. Dr. Narla also suggested that Plaintiff see a psychiatrist to help with his depression. Tr. at 337-38. A progress note from December 11, 2004, indicated that the trial with the spinal stimulator was unsuccessful, and the device was removed. Tr. at 207-10.

On May 24, 2005, Plaintiff saw Dr. Richard Kujoth, a clinical psychologist, for a psychological evaluation. Tr. at 367-74. Plaintiff expressed suicidal thoughts. Dr. Kujoth noted that Plaintiff could perform one- or two-step tasks, but that he would have difficulty concentrating because of his back pain. Tr. at 373. Dr. Kujoth diagnosed Plaintiff with pain disorder and depressive disorder. Tr. at 373.

In June 2005, Dr. Marion Panepinto performed a physical RFC assessment on Plaintiff on behalf of the state agency. Tr. at 383-90. Dr. Panepinto found that Plaintiff could occasionally lift twenty pounds, frequently lift ten pounds, and stand or walk for six hours during an eight-hour work day. Tr. at 384. He also noted that Plaintiff could sit for six hours during an eight-hour work day, and that his ability to push and pull was unlimited. Tr. at 384. Plaintiff could occasionally climb stairs, stoop, kneel, crouch, and crawl, but could never climb ladders, ropes, or scaffolds. He could frequently balance, though. Tr. at 385. Plaintiff had no environmental or manipulative limitations.

Also in June 2005, Dr. Lionel Hudspeth performed a psychiatric review technique on Plaintiff. Tr. at 391. Dr. Hudspeth found that there were indications of an affective disorder under Listing 12.04 because of Plaintiff's symptoms of depression. Tr. at 394. However, Plaintiff did not satisfy any of the Paragraph B criteria because he only had mild restrictions in activities of daily living and difficulties maintaining social functioning. Tr. at 401. While his ...

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