United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
Plaintiff Katara Marks seeks reversal and remand of the final determination of the Commissioner of Social Security ("Commissioner"), denying her application for Supplemental Security Income ("SSI") (doc #17). The Commissioner has responded, seeking affirmance of the decision denying benefits (doc. #32). For the following reasons, the Court grants Ms. Marks's motion to remand and denies the Commissioner's motion.
On July 12, 2010, Ms. Marks applied for SSI, alleging a disability onset date of March 1, 2010 (R. 128). To qualify for SSI, Ms. Marks must show that she was both disabled and financially eligible at any time after the filing of her July 12, 2010 application and prior to the October 13, 2011 Administrative Law Judge ("ALJ") decision. See 20 C.F.R. §§ 416.200, 416.202, 416.203, 416.305, 416.335.
At the administrative level, Ms. Marks claimed an inability to work due to lupus, depression, numbness in her right side, arthritis in her lower back, weakness, headaches, muscle pains, and swelling (R. 141, 169). Ms. Marks's claims were denied initially, and again upon reconsideration (R. 75-79, 81-84). She requested a hearing before an ALJ, which was granted and held on August 26, 2011 (R. 27-70, 85-86, 98). In a written opinion issued on October 13, 2011, the ALJ concluded that Ms. Marks is not disabled (R. 12-20). Ms. Marks filed an appeal with the Appeals Council, and also submitted additional medical records for review (R. 7, 186-92, 677-1069). The Appeals Council denied Ms. Marks's request for review of the ALJ's decision (R. 1-6), making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.981; Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012).
We begin with a summary of the administrative record. We review Ms. Marks's general background in Part A; her medical records in Part B; the hearing testimony in Part C; the ALJ's written opinion in Part D; and the Appeals Council's denial of review and additional medical evidence submitted to the Appeals Council in Part E.
Ms. Marks was born on May 11, 1992, and was 19 years old at the time of the hearing (R. 27, 128, 178). She began seeking treatment for lupus in 2008 (R. 145). At the time of the hearing, Ms. Marks had just graduated from high school (R. 178), and was to begin studying at Robert Morris University that coming fall, in September of 2011 (R. 30). She currently lives in an apartment with her mother and grandmother and does not contribute to rent (R. 129). Ms. Marks only has part-time work experience as an assistant in a senior assisted living facility during the summers of 2008 through 2011 (R. 133, 178). She has no other work experience ( Id. ).
Kathy Marks, Ms. Marks's mother, completed a function report for her daughter (R. 150-157). She reported that her daughter goes to and from school and church on a regular basis and goes outside "every day" (R. 151, 153, 154). She does not drive, but she uses car rides and public transportation (R. 153). She is able to go to the store and shop for clothes and shoes ( Id. ). Ms. Marks needs to be reminded to take her medicine, does not prepare her own meals, but is able to do laundry, ironing, and cleaning every other month, though her mother observes that it takes her "hours to do [them]" (R. 152). Ms. Marks does not pay the bills, but she can handle money (R. 153). She watches television and socializes with others over the phone and on the computer (R. 154), though her mother notes that Ms. Marks prefers "to be by herself" (R. 155).
Kathy Marks opined that her daughter's conditions affect her ability to lift, squat, bend, stand, sit, kneel, climb stairs, see, complete tasks, memorize, understand, follow instructions, and get along with others (R. 155). Kathy Marks also explained that her daughter only can walk for 15 to 20 minutes before needing to rest for 30 minutes; can only pay attention for 10 to 15 minutes; does not finish what she starts; has trouble following written and spoken instructions; can get along with authority figures; does not handle stress and changes in routine "very well"; and wears glasses since May 12, 2010 (R. 155, 156). Her mother also wrote that Ms. Marks has never "been fired or laid off from a job because of problems getting along with other people" (R. 156).
Ms. Marks also made available records from her high school (R. 665-76). The records show that Ms. Marks was granted numerous educational accommodations under a "504 Plan" (R. 666). The school records also indicate that during the 2010-2011 school year, Ms. Marks had seven excused and eighteen unexcused absences and one tardy by January 25, 2011 (R. 667).
The original medical record contains treatment records from May 12, 2010 through May 19, 2011 (R. 193-664), indicating initial diagnoses of lupus nephritis in April of 2008, headache and depression in May of 2008, and radiculopathy in April of 2010, among other lesser diagnoses (R. 221, 222, 237). Treatment records also indicate that Ms. Marks was taking seventeen different medications for her condition as of June 21, 2010.
The medical record begins with an eye examination conducted by Eric Conley, O.D., on May 12, 2010 (R. 199-205). Ms. Marks complained of headaches, eye irritation, blurry vision, eye strain, tinnitus (ringing in ears), vertigo, and nausea (R. 199, 201). On June 21, 2010, Ms. Marks returned complaining of flashes and floaters in her vision and arm discomfort (R. 197). Dr. Conley diagnosed her with proliferative retinopathy secondary to systemic lupus erythematosus ("SLE") (R. 198).
Ms. Marks was treated by rheumatologist Marisa S. Klein-Gitelman, M.D., on June 17, 2010 at Children's Memorial Hospital ("CMH") (R. 206-09, 216-32, 251-58, 339-42). Dr. Klein-Gitelman assessed Ms. Marks with stable SLE, and began tapering her medication (R. 208, 342). On June 29, 2010, Ms. Marks was seen by gastroenterologist Maria T. Greene, M.D., for abdominal pain (R. 210-15, 233-50). Dr. Greene reported that Ms. Marks's symptoms had improved with medication, and that her abdominal pain did not restrict her from performing daily activities ( Id. ).
On August 16, 2010, Ms. Marks was assessed by nephrologist Jerome C. Lane, M.D., at the CMH Division of Kidney Diseases (R. 351-54). Ms. Marks complained of occasional headaches, chest palpitations, worsening lymph node swelling in her neck, and rashes on her face (R. 352). Dr. Lane noted normal kidney function, no hematuria (blood in urine), and no proteinuria (high levels of protein in urine) ( Id. ). He diagnosed her with SLE and "Class III/V lupus nephritis with good symptomatic control" and made no changes to her treatment plan ( Id. ). Ms. Marks followed up with Dr. Klein-Gitelman on September 2, 2010, complaining of chest pain (R. 259-67, 360-64). Dr. Klein-Gitelman noted that Ms. Marks was "[d]oing well" (R. 362), and began tapering her Prednisone (R. 364).
On September 22, 2010, consulting psychologist Robert Neufeld, Ph.D., completed a psychological report on Ms. Marks (R. 268-71). Mr. Neufeld observed that Ms. Marks was "generally somewhat flat and submissive emotionally... [self-describing] her mood as irritated'" (R. 268-69). He concluded Ms. Marks was "a pleasant eighteen-year old female who presents with mild flat/dysphoric affect, " and diagnosed her with "dysthymic disorder" (R. 270). On October 18, 2010, state agency consulting psychiatrist Elizabeth Kuester, M.D., examined Ms. Marks (R. 272-85). Dr. Kuester opined that Ms. Marks's dysthymic disorder did not affect her activities of daily living but mildly affected her ability to "maintain social functioning" and "concentration, persistence, or pace" (R. 275, 282).
On October 21, 2010, state agency consulting physician Marion Panepinto, M.D., reviewed Ms. Marks's medical records and assessed her residual functional capacity ("RFC") (R. 286-93). Dr. Panepinto opined that Ms. Marks could lift twenty pounds occasionally and ten pounds frequently, could stand/walk about six hours and sit about six hours in an eight-hour work day, and had no limitations on her ability to push or pull (R. 287). Dr. Panepinto also wrote that Ms. Marks had no postural, manipulative, visual, communicative, or environmental limitations (R. 288-90). She noted that Ms. Marks was "partially credible" as there were objective medical findings compatible with her alleged problems (R. 293). Dr. Panepinto's RFC was affirmed by state agency consulting psychologist Ronald Havens, Ph.D., on December 30, 2010, and by state agency consulting physician Towfig Arjmand, M.D., on January 3, 2011 (R. 294-96).
On December 2, 2010, Ms. Marks returned to Dr. Klein-Gitelman complaining of cold symptoms and a headache (R. 355-59, 608-17). Dr. Klein-Gitelman noted Ms. Marks had "tender and painful" lymph nodes, but no "mouth sores, nose sores, rashes, chest or abdominal pain, or fatigue" (R. 356-57). Dr. Klein-Gitelman was concerned Ms. Marks might have a "lupus flare" (R. 357). After reviewing the results of laboratory tests, Dr. Klein-Gitelman opined that "[l]upus serology [was] better than expected" and began tapering steroid medications (R. 359).
From December 15 through December 20, 2010, Ms. Marks was admitted to CMH for inpatient treatment following complaints of frequent urination, back and abdominal pain, and bloody urine (R. 343-50, 366-410). She was diagnosed with pyelonephritis and discharged after five days (R. 369). On January 12, 2011, Ms. Marks was seen again at the CMH emergency room, complaining of intermittent headaches and abdominal pain (R. 414-23). The doctors noted neutropenia in otherwise ...