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Casanova v. Colvin

United States District Court, N.D. Illinois, Eastern Division

July 30, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, [1] Defendant.


SIDNEY I. SCHENKIER, Magistrate Judge.

Plaintiff Alicia Casanova seeks reversal and remand of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") (doc. # 22). The Commissioner opposes the motion and seeks affirmance of the decision denying benefits (doc. # 23). For the following reasons, we deny Ms. Casanova's motion and affirm the Commissioner's decision.


We begin with the procedural history of the case. On January 13, 2010, Ms. Casanova filed a Title II application for DIB, alleging disability beginning December 1, 2004. The claim was denied on July 27, 2010 and again upon reconsideration on October 7, 2010. Sections 216(i) and 223 of the Social Security Act require a claimant to establish disability on or before the date through which she was last insured. The relevant period for this case begins with the alleged onset date, December 1, 2004, and continues through Ms. Casanova's date last insured ("DLI"), which was December 31, 2008. Thus, it was incumbent upon Ms. Casanova to prove her disability on or before that date (R. 31). Ms. Casanova requested, and was granted, a hearing before an administrative law judge ("ALJ"). Ms. Casanova appeared and testified along with a vocational expert before ALJ Victoria A. Ferrer on November 4, 2011 (R. 46-91). The ALJ issued an opinion denying DIB on November 22, 2011 (R. 31-39). The Appeals Council then denied Ms. Casanova's request for review, making the ALJ's ruling the final decision of the Commissioner (R. 1-5). See Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012).


We next provide a summary of the administrative record. Part A sets forth Ms. Casanova's background. Part B provides a review of her medical history during the relevant period (December 1, 2004 - December 31, 2008), followed in Part C by a discussion of Ms. Casanova's testimony during the hearing in front of the ALJ. Part D follows with a brief explanation of the Vocational Expert's testimony. Finally, Part E summarizes the ALJ's opinion.


Ms. Casanova was born on June 15, 1952 (R. 159). She is not married and lived with her sister in a two-story home during the relevant period (R. 60-62). She has an eleventh grade education (R. 192). She attended classes for six months toward her GED during the relevant period, but did not complete the program (R. 70). Ms. Casanova worked as a production supervisor for a chemical company until she was laid off in September 2004 when the company downsized its workforce (R. 49-54). After she was laid-off, Ms. Casanova continued to search for work, but was unsuccessful in finding comparable employment (R. 55-56). She worked for a short while as a Spanish language interpreter at a school ( Id. ). She is currently unemployed, although she receives SSI benefits (R. 74-76).[3] She rarely drives, but is able to do so when necessary (R. 60).


The relevant medical record begins in August 2004, when Ms. Casanova visited Susan Kim, M.D., with a complaint of knee pain (R. 294). Dr. Kim examined Ms. Casanova and ordered X-rays which revealed "minor arthritic changes in the right knee" (R. 313). Dr. Kim referred Ms. Casanova to Kevin Walsh, M.D., an orthopedic specialist, who saw her on September 13, 2004 (R. 330). Dr. Walsh ordered a set of standing X-rays of both knees and diagnosed Ms. Casanova with "moderately severe osteoarthritis" in both knees, but opined that arthroscopic intervention would not be helpful ( Id. ). Instead, Dr. Walsh injected both knees with a corticosteroid and recommended that Ms. Casanova continue to use ice and Vioxx to control the pain ( Id. ). Dr. Walsh instructed Ms. Casanova to return after one month if she continued to be symptomatic ( Id. ). The record does not indicate that Ms. Casanova returned to see Dr. Walsh for any follow up visits.[4]

In November 2004, Ms. Casanova was involved in a car accident where she reported that she was standing behind a parked car when it was struck by another car, causing her to fall to the ground (R. 282). Consequently, she returned to Dr. Kim complaining of back pain ( Id. ). After examining Ms. Casanova, Dr. Kim referred her to physical therapy, which she attended five times between December 2004 and January 2005 (R. 280). The physical therapist, Sue Miller, noted a subjective improvement of 50 percent over the course of treatment and a "fair" prognosis, provided Ms. Casanova complied with her home exercise program ("HEP") ( Id. ). The therapist further noted that Ms. Casanova reported a 0/10 pain rating when standing upright, but that her pain increased to 9/10 when bending to lift an object from the floor ( Id. ). The therapist opined that if Ms. Casanova continued the HEP, she would see continued improvement (R. 285). However, the therapist also commented that Ms. Casanova's compliance with her HEP was "poor" ( Id. ).

Ms. Casanova returned to Dr. Kim in September 2005 complaining again of back pain (R. 274). Dr. Kim completed an examination, ordered an MRI, and again referred Ms. Casanova to an orthopedic specialist (R. 273). The MRI indicated mild central canal stenosis, mild degenerative disc disease, and mild to moderate neural foraminal stenosis (R. 310). Nicholas Mataragas, M.D., the orthopedic specialist, saw Ms. Casanova on November 30 2005; he recommended a series of epidural steroid injections to alleviate her pain, but did not recommend surgery (R. 319-29). Dr. Mataragas instructed Ms. Casanova to return after the injection therapy was complete if she continued to have pain (R. 329). In the patient intake survey for Dr. Mataragas, Ms. Casanova reported that she did have some neck, shoulder, and right hand pain; however, she stated that the pain was "not bad" (R. 325). The record does not indicate that Ms. Casanova ever returned to see Dr. Mataragas.

In October 2005, Ms. Casanova visited Heidee Kalmar, D.P.M., complaining of pain after she stubbed her toe (R. 318). Ms. Casanova informed Dr. Kalmar that she was diabetic, and the doctor explained the importance of proper foot care in light of this condition ( Id. ). Dr. Kalmar concluded that Ms. Casanova's risk for diabetic complications affecting the feet was "very low" ( Id. ).

The record does not contain any additional medical records reflecting treatment received between October 2005 and her DLI, December 31, 2008.[5] The next medical consultation that appears in the record took place in February 2010, when Ms. Casanova reported that she began to experience back pain after falling in the shower in October 2009 (R. 447-49). Cary R. Templin, M.D., an orthopedic specialist, noted that Ms. Casanova reported that her back injury that had preceded the more recent fall had healed ( Id. ).[6] Ms. Casanova provided Dr. Templin with X-rays and an MRI taken in Mexico in October 2009 ( Id. ; R. 456). On her "New Patient Questionnaire" for Dr. Templin, Ms. Casanova indicated that she lives alone and that she is "retired" (R. 452). Ms. Casanova has since seen Paul A. Sauer, M.D., Jason T. Franklin, D.O., and Eugene C. Kuo, M.D., with complaints of back and leg pain; however, their records do not refer to Ms. Casanova's conditions during the period before the DLI of December 31, 2008 (R. 356-66; R. 427-31).

In July 2010, Francis Vincent, M.D., evaluated Ms. Casanova's current medical condition based on all of her medical records (R. 403-13). Dr. Vincent completed an Illinois Request for Medical Advice and a Physical Residual Functional Capacity ("RFC") Assessment ( Id. ). In his evaluation, Dr. Vincent concluded that there was insufficient evidence by which to evaluate whether Ms. Casanova was eligible for DIB prior to the DLI (R. 405). Dr. Vincent noted the absence of Medical Source Statements in the record describing limitations, and commented that Ms. Casanova's statements regarding the extent of her limitations were not consistent with the objective medical evidence for the period prior to December 31, 2008 (R. 413). Following Dr. Vincent's evaluation, Ms. Casanova submitted additional medical records, which ...

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