United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION and ORDER
YOUNG B. KIM, Magistrate Judge.
David Mason claims that he is unable to work because he suffers from a number of health problems, including depression, relentless fatigue, and a spinal disorder known as Scheuermann's disease. In July 2010, not long after Mason turned 19, he applied for supplemental security income ("SSI"). See 42 U.S.C. §§ 416(i), 1382(c). The Appeals Council declined to review an administrative law judge's ("ALJ") decision denying that application, so Mason brought this suit seeking judicial review. 42 U.S.C. § 405(g). Before the court are the parties' cross motions for summary judgment. For the following reasons Mason's motion is granted, the government's is denied, and the case is remanded for further proceedings consistent with this opinion:
Mason applied for SSI benefits in July 2010, claiming a disability onset date of December 27, 2002. (Administrative Record ("A.R.") 117.) His application was denied initially and upon reconsideration, (id. at 64-70, 73-76), so Mason requested and was granted a hearing before an ALJ. Following the hearing the ALJ issued a decision finding that Mason is not disabled. (Id. at 19-31.) The Appeals Council declined review, (id. at 8-10), making the ALJ's decision the final decision of the Commissioner, see Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). Mason filed his federal complaint on January 9, 2013, (R. 1); see 42 U.S.C. § 405(g), and the parties consented to this court's jurisdiction, (R. 7); see 28 U.S.C. § 636(c).
Mason's health problems emerged in his early teenage years when he began experiencing back pain, dizziness, and chronic sleepiness. His back pain was attributed to Scheuermann's disease, a condition also known as "adolescent round back" that causes a curvature of the thoracic spine. See Stedman's Medical Dictionary 563 (28th ed. 2006). Through the years, Mason's other major symptoms, which are light-headedness and fatigue, have been attributed by various doctors to a range of conditions, including anxiety, depression, dysthymic disorder, circadian rhythm sleep disorder, chronic pain syndrome, organic sleep apnea, idiopathic hypersomnolence, chronic fatigue syndrome, and delayed sleep phase syndrome. At his hearing before the ALJ, Mason presented voluminous medical records as well as his own testimony in support of his claim that those conditions and symptoms render him disabled.
A. Medical Evidence
The medical records Mason submitted at the hearing include over eight years of treatment records from a wide array of specialists, all seeking answers to Mason's persistent symptoms. The summary that follows is organized by symptom, rather than by chronology, to help chart the course that his various doctors took in their attempts to help provide Mason relief from his complaints of pain, fatigue, dizziness, and depression.
1. Scheuermann's Disease
After he was diagnosed with Scheuermann's disease in 2002, Mason began physical therapy and was fitted with a back brace to treat his spinal curvature and strengthen his back. (A.R. 321-23, 330, 357.) He reported to his physical therapist in 2004 that his back felt weak when he did not wear his brace. (Id. at 321.) Mason underwent an MRI of his back in 2004 and the radiologist described his condition as "mild thoracolumbar scoliosis, " noting that his curvature had increased slightly in the previous 11 months. (Id. at 319.) Apparently Mason's spinal condition stabilized in the years that followed, because he did not receive active, on-going treatment or physical therapy for his Scheuermann's disease after 2008.
2. Light-Headedness and Fatigue
In March 2007 Mason underwent a sleep study aimed at finding the answer to his persistent fatigue. (Id. at 470-71.) That study revealed that Mason had increased upper airway resistance and restless legs syndrome. (Id.) He was referred to Dr. Sheldon, a sleep specialist at Children's Memorial Hospital. Mason reported to Dr. Sheldon that he never felt refreshed despite sleeping excessively. (Id. at 413.) He reported sleeping for five to six hours after school each day, waking up between 9:00 p.m. and 10:00 p.m. to have dinner, and then sleeping again until 6:30 a.m. (Id. at 414.) Dr. Sheldon diagnosed Mason with idiopathic hypersomnia, counseled him on good "sleep hygiene, " and recommended that he shorten his naps. (Id. at 416.) Two months later Dr. Sheldon examined Mason and diagnosed him with circadian rhythm sleep disorder, delayed sleep phase type, and organic sleep apnea, unspecified. (Id. at 421.) Dr. Sheldon prescribed Citalopram and Melatonin and instructed Mason to stop watching television before bed. (Id. at 421-22.)
In December 2007 Mason had a follow-up visit with Dr. Sheldon, who noted that his review of Mason's physical systems was unremarkable. (Id. at 439.) Because Mason reported that he was still sleeping excessively, Dr. Sheldon reiterated his diagnosis of idiopathic hypersomnolence and recommended him for a trial of a drug called Modafinil. (Id. at 440.) A year later Dr. Sheldon described Mason as "delightful and engaging" but still suffering from idiopathic hypersomnia. (Id. at 451.) He recommended Mason continue taking Provigil, a reduced dose of Melatonin, and Nasalcort. (Id. at 443, 451.)
Mason followed up with Dr. Sheldon three times between April 2009 and November 2010. After the April 2009 examination Dr. Sheldon decided that Mason's idiopathic hypersomnolence was not responsive to Provigil, so he started Mason on Neurontin. (Id. at 456.) Eleven months later Mason returned to Dr. Sheldon reporting continued fatigue and a delayed sleep cycle in which he was falling asleep between 10:00 p.m. and 2:00 a.m. and sleeping until 11:30 a.m. or 12:00 p.m. the following day. (Id. at 384.) He reported sleeping again for two to three hours after school. (Id.) In November 2010 Mason told Dr. Sheldon that he was no longer taking Concerta because his insurance would not cover it, but was taking Ritalin, Armodafinil, and Melatonin. (Id. at 657.) He was sleeping from midnight until late the next morning and napping for two hours in the evenings. (Id.) Dr. Sheldon noted that Mason looked well, was in no apparent distress, and was making all A's in school. (Id. at 657-58.) Dr. Sheldon's final diagnosis was idiopathic hypersomnia and possible circadian rhythm abnormality. (Id. at 658.)
In February 2011 Mason saw a neurologist named Dr. Phyllis Zee for help with his chronic sleepiness and dizziness. (Id. at 709, 711.) Dr. Zee diagnosed him with chronic fatigue syndrome. (Id. at 709.) She referred him for a cardiac tilt table test to confirm the diagnosis. (Id. at 711.) Mason completed the test in September 2011. The results were negative ...