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Scaravilli v. Astrue

United States District Court, Seventh Circuit

July 3, 2013

MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.


JOE BILLY McDADE, Senior District Judge.

This matter is before the Court on Plaintiff's Motion for Summary Judgment (Doc. 11) and Defendant's Motion for Summary Affirmance (Doc. 15). Plaintiff seeks judicial review of a decision of the Commissioner of Social Security denying disability benefits to Plaintiff. (Doc. 1 at 1). For the reasons stated below, Plaintiff's Motion for Summary Judgment is DENIED, and Defendant's Motion for Summary Affirmance is GRANTED.


Plaintiff filed for Disability Insurance Benefits and Supplemental Security Income under Titles II and XVI of the Social Security Act on August 20, 2007. (R. at 154-164). Plaintiff claims she has been disabled with lower back problems since December 18, 2004. (R. at 154, 157, 202). Plaintiff's claim for disability benefits was initially denied on November 20, 2007. (R. at 94). Plaintiff then filed a request for reconsideration on January 31, 2008, (R. at 103), and was denied on May 22, 2008. (R. at 106, 111). On June 16, 2008, Plaintiff filed a request for a hearing before an Administrative Law Judge ("ALJ"), which took place on March 29, 2010. (R. at 116, 64-93). In a written decision issued on April 15, 2010, Shreese M. Wilson, the presiding ALJ, determined that Plaintiff had a severe back impairment, but was not disabled under the Act. (R. at 45-58). Plaintiff filed a request for appeal, but the Appeals Council denied Plaintiff's request on August 5, 2011, thus making the ALJ's decision the final decision of the Commissioner of Social Security. (R. at 39, 28). Plaintiff then filed the present action on May 21, 2012, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (Doc. 1). Plaintiff further filed a Motion for Summary Judgment in the instant case (Doc. 11), and a Memorandum in support of the Motion (Doc. 12). Defendant filed a Motion for Summary Affirmance (Doc. 15), and a Memorandum in support of that Motion (Doc. 16).


I. Disability Standard

To qualify for disability benefits under the Social Security Act, a claimant must prove that she is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment." 42 U.S.C. § 423(d)(1)(a). The impairment must either "be expected to result in death, " or must have lasted or "be expected to last for a continuous period of not less than 12 months." Id. The Commissioner must consider the evidence in a claimant's case record and make factual determinations to establish whether the claimant is entitled to any benefits. See 42 U.S.C. § 405(b)(1).

The Commissioner applies a five-step sequential analysis to determine whether a claimant is disabled and thus entitled to benefits. 20 C.F.R. § 404.1520;[1] see also Maggard v. Apfel, 167 F.3d 376, 378 (7th Cir. 1999). The claimant bears the burden of proving the existence of her disability through the first four steps of the analysis by demonstrating she has "an impairment of sufficient severity" to preclude her from engaging in past work. McNeil v. Califano, 614 F.2d 142, 145 (7th Cir. 1980). The claimant must provide objective medical evidence of "the existence of a medical impairment that results from anatomical, physiological, or psychological abnormalities which could reasonably be expected to produce the pain or other symptoms alleged." 42 U.S.C. § 423(d)(5)(A). A claimant's statements as to pain or other symptoms alone will not be conclusive evidence of a disability. 42 U.S.C. § 423(d)(5)(A). If a claimant meets her burden, the burden then shifts to the Commissioner to prove that the claimant is able to perform "some other kind of substantial gainful employment." McNeil, 614 F.2d at 145 (internal quotation marks omitted).

The five-step analysis more specifically breaks down in the following sequence:

1) The Commissioner determines whether the claimant is currently involved in any substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If the claimant engages in substantial gainful activity, she is not disabled. Id. If she does not, the Commissioner proceeds to step two. 20 C.F.R. § 404.1520(a)(4).

2) The Commissioner determines whether the claimant has a severe medically determinable physical or mental impairment that meets the durational requirement. 20 C.F.R. § 404.1520(a)(4)(ii). A severe impairment is one that significantly inhibits the claimant's ability to do basic work activities. 20 C.F.R. § 404.1520(c). If the claimant's impairments or combination of impairments is not severe, she is not disabled. 20 C.F.R. § 404.1520(a)(4)(ii). If the impairment or combination of impairments is severe, the Commissioner proceeds to the next step.

3) The Commissioner determines whether the claimant's impairment meets or medically equals the criteria of a listed impairment. 20 C.F.R. § 404.1520(a)(4)(iii); 20 C.F.R. Part 404, Subpart P, Appendix 1. If the claimant's impairment meets or medically equals a listed impairment, the claimant is disabled. 20 C.F.R. § 404.1520(d). If not, the Commissioner moves to step four.

4) The Commissioner reviews the evidence to consider the claimant's residual functional capacity ("RFC") and her past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant is still able to meet the physical and mental demands of her past relevant work, she is not disabled. 20 C.F.R. § 404.1520(a)(4)(iv); 20 C.F.R. § 404.1520(f).

5) At the final step, the Commissioner determines whether the claimant can adjust to other work by considering the claimant's RFC, age, education, and past work experience. 20 C.F.R. § 404.1520(a)(4)(v). If the claimant cannot adjust to other work, she is disabled. 20 C.F.R. § 404.1520(g). Otherwise, she is not. Id.

II. Standard of Review

When a claimant seeks judicial review of the ALJ's decision to deny benefits, the Court must "determine whether it was supported by substantial evidence or is the result of an error of law." Rice v. Barnhart, 384 F.3d 363, 369 (7th Cir. 2004). "The 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 defined as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971) (internal quotation marks omitted).

To determine whether the ALJ's decision is supported by substantial evidence, the Court will review the entire administrative record. Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). The Court will not, however, "reweigh the evidence, resolve conflicts, decide questions of credibility or substitute [its] own judgment for that of the Commissioner." Id. In particular, credibility determinations by the ALJ are not upset "so long as they find some support in the record and are not patently wrong." Herron v. Shalala, 19 F.3d 329, 335 (7th Cir. 1994). Moreover, the court must ensure that the ALJ "build[s] an accurate and logical bridge from the evidence to [her] conclusion, " though she need not address every piece of evidence. Clifford, 227 F.3d at 872; see McKinzey v. Astrue, 641 F.3d 884, 891 (7th Cir. 2011) ("[A]n ALJ's adequate discussion' of the issues need not contain a complete written evaluation of every piece of evidence'") (quoting Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2004). The Court will remand the case only where the Commissioner's decision "lacks evidentiary support or is so poorly articulated as to prevent meaningful review." Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).


Plaintiff was 39 years old at the time of her alleged disability onset date of December 18, 2004. (R. at 154). She has no health insurance, nor a state medical card. (R. at 74).

I. Relevant Medical History

Plaintiff has seen her primary care physician Dr. Shawn Bailey, M.D., consistently for many years. (R. at 76, 78). Plaintiff's first recorded visit with Dr. Bailey was on May 5, 2004. (R. at 440). Dr. Bailey assessed Plaintiff with chronic back pain and leg pain, and prescribed Vicodin[2] and Flexeril.[3] (R. at 440). At a follow-up visit with Dr. Bailey on July 23, 2004, he noted that Plaintiff showed signs of sciatica, [4] "but with normal imaging." (R. at 439). Dr. Bailey found that Plaintiff was limping and having cramp-like sensations in her leg in October and November of 2004. (R. at 371, 372). Additionally, Plaintiff was treated for irritable bowel syndrome. (R. at 370-72).

Plaintiff saw Dr. Bailey again in April 2005, and was prescribed Vicodin and Quinine.[5] (R. at 368). Despite Plaintiff's continued back pain, Dr. Bailey wrote a note in May 2005 stating that Plaintiff was able to care for her grandchildren. (R. at 367).

On June 27, 2005, Plaintiff again saw Dr. Bailey, who found Plaintiff had trochanteric bursitis, [6] and noted that Plaintiff was in pain after running out of Vicodin. (R. at 364). Dr. Bailey ordered additional testing, asking Plaintiff to get an "EMG/nerve conduction study, "[7] though the testing was not performed. (R. at 364, 363). Dr. Bailey examined Plaintiff again on July 8, 2005, and noted that Plaintiff had left sacroiliitis[8] and continuing problems in her lower back. (R. at 363). Dr. Bailey noticed tenderness in Plaintiff's knee, heel, and left trochanter, [9] and noted that Plaintiff had a dysfunctional knee upon examination on September 13, 2005. (R. at 361).

On September 25, 2005, Plaintiff went to the emergency room complaining of lower back pain. (R. at 297). Dr. Alejandro Bernal examined Plaintiff, finding tenderness in Plaintiff's lumbar region, and the straight leg raise test was negative. (R. at 297). Additionally, Dr. Bernal diagnosed Plaintiff with degenerative disc disease. (R. at 297). Dr. Bernal prescribed Medrol Dosepak, [10] Skelaxin, [11] and Vicodin. (R. at 329). Two days later, Dr. Bailey's examination revealed tenderness in Plaintiff's lower back and sacroiliac joints. (R. at 360). Dr. Bailey injected Decadron[12] with Xylocaine[13] into each of Plaintiff's sacroiliac joints, and Dr. Bailey prescribed Valium[14] to help relax Plaintiff's muscles. (R. at 360). Three days later, Dr. Bailey found that Plaintiff had some tenderness, noting bilateral sacroiliitis, but the examination was otherwise unremarkable. (R. at 359). Plaintiff was released back to work after her October 7, 2005 visit. (R. at 357).

Plaintiff experienced shoulder pain in February 2006, and Dr. Bailey injected Decadron with Xylocaine into Plaintiff's right subacromial spot[15] with "excellent results." (R. at 355). Dr. Bailey renewed Plaintiff's Vicodin prescription on April 12, 2006, noting that Plaintiff continues to have back pain and "takes chronic Vicodin" for it. (R. at 354). In July and August of 2006, Plaintiff told Dr. Bailey that Vicodin was not helping her pain, and Dr. Bailey noted that Plaintiff's left leg pain was worsening. (R. at 349-50).

Dr. Steven Lukancic, M.D., a radiologist, found mild disc desiccation[16] at the T12-L1, L1-2, and L5-S1[17] levels in Plaintiff's MRI of September 1, 2006. (R. at 305). Further, Plaintiff's MRI revealed slight hypertrophic change[18] in the facet joints[19] at L4-5 and L5-S1, and a slight posterior disc protrusion at the L5-S1 level. (R. at 305). Dr. Lukancic found no evidence of significant disc herniation, spinal stenosis, [20] or neural foraminal stenosis.[21] (R. at 305). A lumbar x-ray taken the same day showed mild degenerative changes in the lumbar spine and right sacroiliac joint. (R. at 304).

On September 14, 2006, Plaintiff saw Dr. Deofil Orteza, M.D., a pain specialist, for evaluation and management of her lower back pain, as recommended by Dr. Bailey. (R. at 341-43). Dr. Orteza reported that Plaintiff had a limp and that her back pain was due to degenerative disc disease, and recommended a bilateral L3-4, L4-5, and L5-S1 facet joint injection. (R. at 342-43).

Plaintiff saw Dr. Bailey again on January 5, 2007, and noted that Plaintiff had not yet gotten the joint injections recommended by Dr. Orteza. (R. at 348). Plaintiff also told Dr. Bailey that she had stopped taking her prescribed Vicodin because it was not helping. (R. at 348). Plaintiff was prescribed Celexa, [22] Sinemet, [23] and Flexeril. (R. at 348). On February 21, 2007, Plaintiff was having some discomfort, tenderness in her back, and was unable to bend over to touch her toes. (R. at 347).

Plaintiff continued seeing Dr. Bailey, and on August 15, 2007, Dr. Bailey prescribed Cymbalta[24] to help with Plaintiff's chronic and worsening depression. (R. at 410). Two months later, Dr. Bailey noted that Plaintiff did not "tolerate" Cymbalta. (R. at 410).

Plaintiff was prescribed Feldene[25] in November 2007, and again saw Dr. Bailey in January and February of 2008, at which time Dr. Bailey noted that Plaintiff had continued back pain and some muscle tenderness in her leg. (R. at 406, 407).

Plaintiff had seen a chiropractor, Dr. Patrick Westefer, in October of 2007 in an attempt to alleviate her back pain, but in response to the state Social Security Office's request for information in March 2008, Dr. Westefer remarked he had not treated Plaintiff regularly enough to "adequately assess her condition or her ability to respond to care." (R. at 458). Further, as he had only seen Plaintiff four times, Dr. Westefer stated he "simply [does] not have enough solid information on which to base [his] opinion." (R. at 459).

Plaintiff was examined by Dr. Phillip S. Budzenski on October 17, 2007. (R. at 376). Dr. Budzenski noted that Plaintiff ambulates with a left antalgia, [26] but that her gait is steady and predictable. (R. at 377).

On April 4, 2008, Plaintiff was examined by Dr. Mark B. Langgut, a clinical psychologist, who noted that Plaintiff complained of depression over the past two years, but that she had never sought treatment. (R. at 460). In his psychological assessment report, Dr. Langgut diagnosed Plaintiff with dysthymic disorder.[27] (R. at 463). He also found that ...

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