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Roeder v. Colvin

United States District Court, Seventh Circuit

July 2, 2013

CAROLYN COLVIN, Commissioner of Social Security, Defendant.


DANIEL G. MARTIN, Magistrate Judge.

Plaintiff Rebecca Roeder ("Plaintiff" or "Roeder") seeks judicial review of a final decision of Defendant Carolyn Colvin, the Commissioner of Social Security ("Commissioner"). The Commissioner denied Plaintiff's application for Supplemental Security Income benefits ("SSI") and disability insurance benefits. Roeder filed a Motion for Summary Judgment that seeks to reverse the Commissioner's decision. The Commissioner subsequently filed a cross motion. The parties have consented to have this Court conduct all proceedings in this case, including an entry of final judgment. 28 U.S.C. § 636(e); N.D.Ill. R. 73.1(c). For the reasons stated below, Plaintiff's motion is granted. The Commissioner's motion is denied.

I. Legal Standard

A. The Social Security Administration Standard

In order to qualify for disability benefits, a claimant must demonstrate that he is disabled. An individual does so by showing that he cannot "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 4243(d)(1)(A). Gainful activity is defined as "the kind of work usually done for pay or profit, whether or not a profit is realized." 20 C.F.R. § 404.1572(b).

The Social Security Administration ("SSA") applies a five-step analysis to disability claims. See 20 C.F.R. § 404.1520. The SSA first considers whether the claimant has engaged in substantial gainful activity during the claimed period of disability. 20 C.F.R. § 404.1520(a)(4)(I). It then determines at Step 2 whether the claimant's physical or mental impairment is severe and meets the twelve-month durational requirement noted above. 20 C.F.R. § 404.1520(a)(4)(ii). At Step 3, the SSA compares the impairment (or combination of impairments) found at Step 2 to a list of impairments identified in the regulations ("the Listings"). The specific criteria that must be met to satisfy a Listing are described in Appendix 1 of the regulations. See 20 C.F.R. Pt. 404, Subpt. P, App. 1. If the claimant's impairments meet or "medically equal" a Listing, the individual is considered to be disabled, and the analysis concludes; if a Listing is not met, the analysis proceeds to Step 4. 20 C.F.R. § 404.1520(a)(4)(iii).

Before addressing the fourth step, the SSA must assess a claimant's residual functional capacity ("RFC"), which defines his exertional and non-exertional capacity to work. The SSA then determines at the fourth step whether the claimant is able to engage in any of his past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant can do so, he is not disabled. Id. If the claimant cannot undertake past work, the SSA proceeds to Step 5 to determine whether a substantial number of jobs exist that the claimant can perform in light of his RFC, age, education, and work experience. An individual is not disabled if he can do work that is available under this standard. 20 C.F.R. § 404.1520(a)(4)(v).

B. Standard of Review

A claimant who is found to be "not disabled" may challenge the Commissioner's final decision in federal court. Judicial review of an ALJ's decision is governed by 42 U.S.C. § 405(g), which provides that "[t]he findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). Substantial evidence is "such evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). A court reviews the entire record, but it does not displace the ALJ's judgment by reweighing the facts or by making independent credibility determinations. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). Instead, the court looks at whether the ALJ articulated an "accurate and logical bridge" from the evidence to her conclusions. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). This requirement is designed to allow a reviewing court to "assess the validity of the agency's ultimate findings and afford a claimant meaningful judicial review." Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002). Thus, even if reasonable minds could differ as to whether the claimant is disabled, courts will affirm a decision if the ALJ's opinion is adequately explained and supported by substantial evidence. Elder, 529 F.3d at 413 (citation omitted).

II. Background Facts

A. Medical History

In January 2006, Roeder was sitting in her car when another vehicle traveling at 40 miles per hour hit her from behind. (R. 312). The driver responsible for the accident was not significantly injured, though he later died in a separate automobile accident. Roeder was taken to the emergency room at North Shore Medical Center, where an x-ray showed normal alignment of the spine with some signs of spasm. (R. 199). She was released after being prescribed Motrin and Vicodin for pain relief.

Roeder followed up one month later with neurologist Dr. Hien Dang. Her complaints were largely consistent with those made at the hearing - head pain from the neck up, poor sleep, neck and back pain, and problems with concentration. (R. 201). Dr. Dang noted lumbar and cervical sprains, as well as post-traumatic headaches. (R. 202). He prescribed more Vicodin, as well as the muscle relaxant methocarbanol. Dr. Dang also ordered a brain MRI for Roeder. The MRI showed only small "patchy" areas in the cerebellum that were consistent with vascular-pattern headaches. (R. 212). An MRI of the lumbar spine was also unremarkable except for a mild curvature. (R. 211). An EEG study ordered by Dr. Dang revealed a left lumbar radiculopathy at the L5 level. (R. 205).

Despite these unremarkable studies, Roeder continued to experience pain and to seek relief from it. She began treatment with chiropractor Christopher Szpila shortly after her accident. Roeder also consulted pain specialist Dr. John O'Hara, who injected her with nerve blocks and prescribed two medications that are not legible from the record. (R. 215). The record is unclear, but Roeder appears to have seen Dr. O'Hara at least through July 2007 for her pain. (R. 214). In September 2007, she consulted with neurologist Dr. Neil Allen. Dr. Allen agreed with the earlier diagnosis of cervical and lumbar strains, but he also believed that Roeder had myofascial pain syndrome. Dr. Allen recommended that she start on Lyrica, which is used to treat fibromyalgia, and a low dose of the antidepressant Elavil for sleep. (R. 273). A formal diagnosis of fibromyalgia was made in November 2007 by a physician whose name is illegible. (R. 277).

Roeder began physical therapy at Lake County Physical Therapy LLC shortly after this diagnosis was made. (R. 278-79). The record does not indicate what treatment she may have received in 2008. In January 2009, however, Roeder consulted rheumatologist Dr. David Mael. Dr. Mael confirmed that she had tenderness at all 18 of the test points used to diagnose fibromyalgia, as well as significant signs of depression. He urged Roeder to take Cymbalta to decrease her pain. When she refused, Dr. Mael increased her dosage of Lyrica and added the pain reliever Tramadol three times a day. (R. 312-14). Three months later, Dr. Mael added Vicodin to her medication regime. (R. 363). Roeder attempted to deal with her depression by seeking counseling with Certified Mental Health Professional Elaine Beisito. The treatment sessions ended in August 2009, when Roeder claimed that she had no money and was in too much pain to continue with counselling. (R. 418).

B. Examining and State Agency Physician Reports

Seven reports by examining and state agency physicians were submitted to the ALJ in this case. Dr. Scott Kale provided a report to the state disability office concerning his February 12, 2009 examination of Roeder. Dr. Kale diagnosed her with posttraumatic fibromyalgia, fatigue, non-restorative sleep, and a "markedly" weak cervical spine that suggested a possible cervical myelopathy. (R. 317). Dr. Darrell Snyder issued a Psychiatric Review Technique ("PRT") for the SSA later the same month. Dr. Snyder found that Roeder suffered from a non-severe form of depression. (R. 319, 322). He found no ...

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