United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MARY M. ROWLAND, Magistrate Judge.
Plaintiff Alexandra Lauren Chilton filed this action seeking reversal of the final decision of the Commissioner of Social Security denying her application for Disability Insurance Benefits under Title II of the Social Security Act (Act). 42 U.S.C. §§ 405(g), 423 et seq. The parties have consented to the jurisdiction of the United States Magistrate Judge, pursuant to 28 U.S.C. § 636(c), and Plaintiff has filed a request to reverse the ALJ's decision and remand for additional proceedings. For the reasons stated below, the Commissioner's decision is affirmed.
I. THE SEQUENTIAL EVALUATION PROCESS
To recover Disability Insurance Benefits (DIB), a claimant must establish that he or she is disabled within the meaning of the Act. York v. Massanari, 155 F.Supp.2d 973, 977 (N.D. Ill. 2001). A person is disabled if he or she is unable to perform "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." 20 C.F.R. § 404.1505(a). In determining whether a claimant suffers from a disability, the Commissioner conducts a standard five-step inquiry:
1. Is the claimant presently unemployed?
2. Does the claimant have a severe medically determinable physical or mental impairment that interferes with basic work-related activities and is expected to last at least 12 months?
3. Does the impairment meet or equal one of a list of specific impairments enumerated in the regulations?
4. Is the claimant unable to perform his or her former occupation?
5. Is the claimant unable to perform any other work?
20 C.F.R. §§ 404.1509, 404.1520; see Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). "An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled. A negative answer at any point, other than Step 3, ends the inquiry and leads to a determination that a claimant is not disabled." Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985). "The burden of proof is on the claimant through step four; only at step five does the burden shift to the Commissioner." Clifford, 227 F.3d at 868.
II. PROCEDURAL HISTORY
Plaintiff applied for DIB on May 12, 2009, alleging that she became disabled on August 21, 2002, because of epilepsy. (R. at 23, 192, 196). The application was denied initially and on reconsideration, after which Plaintiff filed a timely request for a hearing. ( Id. at 23, 94, 95, 109-10). On February 28, 2011, Plaintiff, represented by counsel, testified at a hearing before an Administrative Law Judge (ALJ). (R. at 23, 38-93). The ALJ also heard testimony from Ashok G. Jilhewar, M.D., a medical expert (ME), and Jill K. Radke, a vocational expert (VE). ( Id. ). At the hearing, Plaintiff amended her alleged onset date to November 1, 2008. ( Id. at 41). The ALJ denied Plaintiff's request for benefits on April 19, 2011. (R. at 23-30). Applying the five-step sequential evaluation process, the ALJ found, at step one, that Plaintiff had not engaged in substantial gainful activity from her alleged onset date through June 30, 2010, her date last insured. ( Id. at 25). At step two, the ALJ found that Plaintiff's seizure disorder is a severe impairment. ( Id. at 25-26). At step three, the ALJ determined that Plaintiff does not have an impairment or combination of impairments that meet or medically equal the severity of any of the listings enumerated in the regulations. ( Id. at 26).
The ALJ then assessed Plaintiff's residual functional capacity ("RFC") and determined that she has the RFC to "perform light work as defined in 20 C.F.R. § 404.1567(b) except she should not be exposed to hazards like dangerous moving machinery or unprotected heights." (R. at 26). At step four, based on Plaintiff's RFC and the VE's testimony, the ALJ determined that Plaintiff was capable of performing past relevant work as a bank teller. ( Id. at 29). Accordingly, the ALJ concluded that Plaintiff was not suffering from a disability as defined by the Act. ( Id. ). The Appeals Council denied Plaintiff's request for review on June 23, 2012. (R. at 1-5). Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner. Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).
III. STANDARD OF REVIEW
Judicial review of the Commissioner's final decision is authorized by § 405(g) of the Act. In reviewing this decision, the Court may not engage in its own analysis of whether the plaintiff is severely impaired as defined by the Social Security Regulations. Young v. Barnhart, 362 F.3d 995, 1001 (7th Cir. 2004). Nor may it "reweigh evidence, resolve conflicts in the record, decide questions of credibility, or, in general, substitute [its] own judgment for that of the Commissioner." Id. The Court's task is "limited to determining whether the ALJ's factual findings are supported by substantial evidence." Id. (citing § 405(g)). Evidence is considered substantial "if a reasonable person would accept it as adequate to support a conclusion." Indoranto v. Barnhart, 374 F.3d 470, 473 (7th Cir. 2004). "Substantial evidence must be more than a scintilla but may be less than a preponderance." Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). "In addition to relying on substantial evidence, the ALJ must also explain his analysis of the evidence with enough detail and clarity to permit meaningful appellate review." Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005).
Although this Court accords great deference to the ALJ's determination, it "must do more than merely rubber stamp the ALJ's decision." Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (citation omitted). The Court must critically review the ALJ's decision to ensure that the ALJ has built an "accurate and logical bridge from the evidence to his conclusion." Young, 362 F.3d at 1002. Where the Commissioner's decision "lacks evidentiary support or is so poorly articulated as to prevent meaningful review, the case must be remanded." Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).
IV. MEDICAL EVIDENCE
Plaintiff has a history of epilepsy since age 14. (R. at 434). She began treating with Thomas H. Burnstine, M.D., a neurologist, in April 2004, when she was 16 years old. ( Id. at 68, 144, 296). On April 16, 2004, Plaintiff reported six seizures over the prior 18 months, one of which occurred during a period of noncompliance with her medications. ( Id. at 296). At the time, Plaintiff was taking Trileptal 300mg twice daily to control her seizures. ( Id. ). Plaintiff also reported a history of anxiety/panic attacks. ( Id. ). Her physical examination was unremarkable. ( Id. ). Dr. Burnstine diagnosed a generalized seizure disorder, along with panic attacks and anxiety. ( Id. ). He increased her Trileptal dosage to 450mg, twice daily. ( Id. at 297).
On April 30 through May 3, 2004, a 72-hour Ambulatory/Computer Monitored EEG Recording with Video was performed. (R. at 298-99). Dr. Burnstine found the results "moderately abnormal" "due to the presence of electrographic, clinically correlated seizure activity consistent with a primary generalized seizure disorder." ( Id. at 299).
On May 13, 2004, Plaintiff reported no side effects from her seizure medication and fewer events. (R. at 291-92). Dr. Burnstine increased her Trileptal dosage to 600mg, twice daily. ( Id. ). On July 23, 2004, Plaintiff reported no seizures with the increased Trileptal dosage. ( Id. at 289-90). She still had some early morning myoclonus,  occurring once every two weeks, where she had fallen and dropped glass-ware. ( Id. ). Dr. Burnstine added Topamax 25mg at bedtime to control the myoclonus. ( Id. ). On September 24, 2004, he increased the Topamax dosage to 50mg. ( Id. at 288). On December 14, 2005, and November 1, 2006, Plaintiff reported being seizure free since June 25, 2005. ( Id. at 286-87). Dr. Burnstine continued her medications. ( Id. at 286).
On October 14 and November 2, 2006, Plaintiff went to the emergency room complaining of chronic seizures. (R. at 353, 358). A physical examination was unremarkable. ( Id. at 359).
On December 11, 2008, Plaintiff presented to the emergency room complaining of shakiness. (R. at 437). After taking her seizure medications, the feeling of shakiness disappeared. ( Id. ). She denied having a seizure or losing consciousness. ( Id. ). She reported only one seizure in the last several years, in April 2008. ( Id. ). A physical examination was unremarkable. ( Id. ).
On July 3, 2009, Plaintiff went to the emergency room, complaining of chest pain. (R. at 330-33). She felt shaky, like she was going to have a seizure. ( Id. at 330). No symptoms were noted by the ER physicians. ( Id. ). A physical examination was unremarkable. ( Id. at 331). Plaintiff was diagnosed with atypical chest pain and seizure and discharged. ( Id. at 332).
On July 15, 2009, Dr. Burnstine informed the Commissioner that he had not seen Plaintiff in over a year and she had not been refilling her medications. (R. at 320). The Commissioner ordered tests to check Plaintiff's topiramate and oxcarbazepine levels. ( Id. ). Thereafter, blood tests indicated that her medications were within normal range. ( Id. at 308; see id. at 314).
On August 15, 2009, Peter Biale, M.D., completed an internal medicine consultative examination on behalf of the Commissioner. (R. at 304-07). Plaintiff reported having grand mal type seizures weekly: five in July and one so far in August. ( Id. at 304). The seizures lasted five minutes and were accompanied by postictal symptoms. ( Id. ). Plaintiff stated that she takes Trileptal and Topamax to control her seizures. ( Id. ). A physical examination was unremarkable. ( Id. at 305). Plaintiff's immediate and remote memory were intact, and her recent memory good. ( Id. at 306). Dr. Biale diagnosed seizure disorder, noting that Plaintiff was Romberg positive and she had reported a history of falling due to seizures. ( Id. at 307).
On August 20, 2009, Plaintiff had a seizure while driving and was taken to the emergency room. (R. at 365). She admitted drinking in excess the prior night and may have missed her night dosage. ( Id. ). She stated that her seizures occur every few weeks. ( Id. ). A physical examination was unremarkable. ( Id. at 366). Plaintiff refused to have diagnostic laboratory tests performed. ( Id. ). The attending physician diagnosed grand mal status epilepticus seizures. ( Id. ).
On August 24, 2009, Francis Vincent, M.D., a DDS consultant, prepared a physical RFC assessment. (R. at 310-17). He opined that Plaintiff should never climb ladders, ropes, or scaffolds, and should avoid machinery and heights because of her seizure disorder. ( Id. at 312, 314). Dr. Vincent found Plaintiff's statements regarding epilepsy only partially credible because she was not currently being treated and had not seen Dr. Burnstine in over a year. ( Id. at 315, 317). On June 3, 2010, Barry Free, M.D, a DDS consultant, affirmed Dr. Vincent's opinion. ( Id. at 301-03).
On September 21, 2009, Plaintiff went to the emergency room, complaining that she felt like she was going to have a seizure. (R. at 371). Symptoms disappeared and a physical examination was unremarkable. ( Id. at 371-72). Plaintiff asserted that she was compliant with her medications. ( Id. ...