United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION and ORDER
YOUNG B. KIM, Magistrate Judge.
Marcus Love seeks Supplemental Security Income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. § 1381, et seq., based on his claim that he is unable to work because of borderline intellectual functioning, a history of seizures, polyuria, low blood pressure, and a hypothalamic mass. After his application was denied in a final decision by the Commissioner of the Social Security Administration, Love filed this suit seeking judicial review. See 42 U.S.C. § 405(g). Before the court is Love's motion for summary judgment seeking reversal of the Commissioner's decision and the Commissioner's cross-motion for summary judgment seeking to affirm the Commissioner's decision. For the following reasons, Love's motion for summary judgment is denied and the Commissioner's cross-motion is granted:
Love applied for SSI on October 14, 2009, alleging disability beginning on July 22, 1973. (Administrative Record ("A.R.") 107.) After his claims were denied initially and upon reconsideration, (id. at 50-55, 60-63), Love sought and was granted a hearing before an administrative law judge ("ALJ"), (id. at 73-74, 80-85). The ALJ held a hearing on February 15, 2011, at which Love and a vocational expert provided testimony. (Id. at 26-49.) On May 26, 2011, the ALJ issued a decision finding that Love is not disabled within the meaning of the Social Security Act and denying his SSI claim. (Id. at 11-21.) Love submitted additional evidence to the Appeals Council dating from April 2011 to October 2011. (Id. at 337-50.) When the Appeals Council denied Love's request for review in July 2012, (id. at 1-6), the ALJ's denial of benefits became the final decision of the Commissioner, see O'Connor-Spinner v. Astrue, 627 F.3d 614, 618 (7th Cir. 2010). On September 6, 2012, Love filed the current suit seeking judicial review of the Commissioner's decision. See 42 U.S.C. § 405(g). The parties have consented to the jurisdiction of this court. See 28 U.S.C. § 636(c).
Love suffers from numerous ailments including a remote history of seizure disorder, a hypothalamic mass, a long history of urinary urgency, and borderline intellectual functioning. (A.R. 13.) At the February 2011 hearing before the ALJ, Love presented both documentary and testimonial evidence in support of his claim.
A. Medical Evidence
At the request of the state disability agency, John Brauer, Psy.D., a clinical psychologist, performed a consultative evaluation of Love in December 2009. (A.R. 204-07.) Love related to Dr. Brauer that he took five years of special education courses in high school before graduating, that he worked as a dishwasher for approximately nine years, and that he spent ten years in jail. (Id. at 205.) Love also told Dr. Brauer that he had never been hospitalized or medicated for mental illness. (Id.)
Dr. Brauer administered a mental status examination and the WAIS-4 intelligence test. (Id. at 206-07.) His impression was that Love exercised his best effort and that the scores appeared to be a valid representation of Love's capacities. (Id. at 206.) Love's full scale I.Q. score was 70, with scores in the component areas ranging from 70 to 81. (Id. at 207.) Dr. Brauer explained that Love's scores placed him in the low average range of intellectual functioning in regard to perceptual reasoning and in the borderline range in all other areas. (Id.)
Dr. Brauer's report informed the opinion of Jerrold Heinrich, Ph.D., a state agency consultant who reviewed Love's file and provided a mental functional capacity assessment. (Id. at 216-233.) He noted that Love had received benefits as of January 1, 1991, because of a diagnosis of mental retardation. (Id. at 228.) In a report dated December 16, 2009, Dr. Heinrich characterized Love's medically determinable impairment as borderline intellectual functioning. (Id. at 217.) He evaluated Love under Category 12.02, entitled "Organic Mental Disorders." (Id. at 216.) Regarding the 12.02(B) factors, Dr. Heinrich opined that Love exhibited mild restrictions in activities of daily living, mild difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and had not presented evidence of any episodes of decompensation. (Id. at 226.) He further opined that the evidence did not establish the presence of the "C" criteria under category 12.02. (Id. at 227.) But Dr. Heinrich concluded that Love "retains the mental and behavioral capacity" to perform only simple tasks "within an organized setting, " and to make adjustments to "routine changes in his environment as long as they are not too frequent." (Id. at 232.)
The state disability agency also requested that Love submit to an internal medicine consultative examination. (Id. at 208-211.) On December 26, 2009, Dr. Stanley Simon reviewed Love's file and conducted a consultative examination. (Id.) Dr. Simon noted Love's chief complaints of a learning disability, a seizure disorder, and birth defects. (Id. at 208.) Love told Dr. Simon that he has difficulties with reading and needs extra time to calculate change when shopping. (Id.) He also told Dr. Simon that he was diagnosed with seizures secondary to a birth defect, that he took medication for his seizures, that his last seizure episode occurred in 1980, and that he stopped taking his medication in 1995. (Id.) Dr. Simon noted normal range of motion in all of Love's major joints and in the cervical and lumbar spines. (Id. at 210.) After summarizing Love's recitation of his medical history and the results of the examination, Dr. Simon noted the following impressions: a learning disability, a history of seizure disorder, and a history of birth defect. (Id. at 211.) There is no mention of Love's urinary urgency in the report.
Seven months after Love visited Dr. Simon and Dr. Brauer for their evaluations, Love sought care at a free clinic in July 2010. (Id. at 240.) A doctor at the clinic, Dr. Cerniak, ordered numerous tests and referred Love to a foot doctor and to a urologist. (Id.) Love complained to Dr. Jones, the urologist, of urinary frequency and incontinence. (Id. at 283.) Love said that he voids six or seven times during the night. (Id.) He also told Dr. Jones that he had suffered a seizure on July 9, 2010. (Id.) As a result of the seizure, Love underwent an electroencephalogram ("EEG") on July 21, 2010. (Id. at 268-69.) Dr. Peter Analytis reported that the EEG was normal and showed no evidence of seizure activity. (Id. at 268, 317.) Dr. Cerniak prescribed Dilantin following the EEG. (Id. at 245.) The record contains no other evidence of seizure activity.
In July 2010, an MRI of Love's lumbar spine showed mild degenerative changes in the lower lumbar spine and a mild diffuse disk bulge at L4-5 with minimal impression on the anterior thecal sac. (Id. at 266.) In August 2010, Love was given an order for a CT scan of his abdomen and pelvis because of diagnoses of anemia and hyperlipidemia. (Id. at 316.) The CT scan revealed an "[a]pparent incisional hernia... with no loops of bowel within it." (Id.) On September 14, 2010, an MRI of Love's brain showed a "lesion within the hypothalamus that appears to involve the pituitary stalk." (Id. at 264.) The MRI report states that "the lesion surrounds portions of the third ventricle resulting in moderate to severe hydrocephalus." (Id.)
On September 22, 2010, Love visited Dr. Thomas Hurley for an evaluation of the abnormal MRI scan. (Id. at 262.) Dr. Hurley noted that Love had developed a seizure disorder as a child as a result of bacterial meningitis. (Id.) Dr. Hurley also noted Love's cognitive impairments and history of urinary urgency dating from childhood. (Id.) Dr. Hurley suspected that Love's lesion was a hypothalamic glioma. (Id. at 263.) He recommended a short interval study to confirm that the mass was not growing rapidly. (Id.) He also ordered blood work to assess the hypothalamic-pituitary axis. (Id.) A second MRI taken on October 15, 2010, showed a "persistent abnormality involving the hypothalamus and pituitary stalk that is grossly unchanged" with "[s]table appearing hydrocephalus." (Id. at 258.) Dr. Hurley reviewed the second MRI with Love on October 19, 2010. (Id. at 257.) He concluded that the MRI showed no change in the lesion "which suggests the likely diagnosis of a low grade glioma." (Id.) He commented that "[s]urgical resection is impossible and biopsy does have risk... recommendation is to observe and treat (radiation therapy) only if the tumor increases in size." (Id.) Dr. Hurley also reviewed Love's blood work and noted that the endocrine studies showed "some dysfunction of the hypothalamic-pituitary axis." (Id.)
Love was referred to a nephrologist for treatment of his polyuria. (Id. at 326.) At a visit on September 27, 2010, Love complained of waking 10 times a night because of polyuria. (Id. at 327.) Records from the following month show that Love started desmopressin and that his polyuria was "resolved." (Id. at 326.) Records from November 2010 and January 2011 show that Love's urine output had decreased and that he was doing well. (Id. at 324-25.)
Another medical record from September 2010 includes Love's complaint of bone aches in his feet, legs, and back upon waking. (Id. at 278.) He said that he feels okay after he walks around. (Id.) He reiterated complaints regarding frequency of urination and incontinence. (Id.) On October 20, 2010, Love visited a podiatrist. (Id. at 274.) The podiatrist diagnosed him with plantar fasciitis, and encouraged him to stretch and to use arch supports. (Id. at 255, 274.)
At the close of the administrative hearing on February 15, 2011, the ALJ agreed to hold open the record for 30 days. (Id. at 48.) Sometime after the ALJ issued an unfavorable decision in May 2011, Love submitted an evaluation from Dr. Hurley dated April 21, 2011. (Id. at 338.) The Appeals Council noted the inclusion of this evaluation in its list of exhibits. (Id. at 5.) In that evaluation, Dr. Hurley opined that "as long as there is no change in the hypothalamic mass I believe it is best just to observe." (Id. at 338.) He gave Love a referral to see an endocrinologist. (Id.) He also offered the following opinion: "Due to his arrested hydrocephalus due to his infantile meningitis which has affected his cognitive abilities and now with ...