United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JAMES F. HOLDERMAN, District Judge.
Plaintiff Alisa Spraggins ("Spraggins") seeks review of the Social Security Administration's ("SSA") decision to deny her application for Disability Insurance Benefits and Supplemental Security Income. After a hearing, the assigned Administrative Law Judge ("ALJ"), ALJ Kraybill, determined that even though Spraggins suffers from two severe impairments - degenerative disc disease of the cervical and lumbar spine and obesity - Spraggins is not disabled because she still has the Residual Functional Capacity ("RFC") to perform light work. On April 2, 2014, the Appeals Council denied review, rendering the ALJ's decision the final and reviewable administrative decision of defendant Carolyn W. Colvin, the Acting Commissioner of the SSA ("Commissioner"). In challenging the denial of benefits, Spraggins argues that the ALJ erred in determining Spraggins' RFC by (1) improperly analyzing the medical opinion evidence in the record, (2) failing to address Spraggins' treating physician's opinion that she cannot perform full-time work, (3) failing to address testimony by the vocational expert, and (4) improperly relying on boilerplate language in his assessment of Spraggins' credibility. The court agrees with Spraggins' first two contentions. Accordingly, the court denies the Commissioner's motion for summary judgment (Dkt. No. 23) and remands the case to the Commissioner for further review consistent with this opinion.
Spraggins, born on March 17, 1969, was 41 years old at the alleged onset of her disability. (Certified Copy of Admin. Record (Dkt. No. 11), hereinafter "R., " 19, 136.) Her last full-time job was as a forklift operator in a warehouse, where she worked most recently from March 2009 until September 2010, and sporadically before that from 2002 through 2008. (R. at 266.)
On May 8, 2011, Spraggins filed an application for Disability Insurance Benefits and Supplemental Security Income. (R. at 19.) In her application, Spraggins alleged that she became disabled at work on September 9, 2010, when a package she was lifting by forklift slipped from the forks, fell through the protective grating on the roof of the forklift, and struck her on the right side of head. ( Id. at 19, 22.) The agency denied Spraggins' application on August 11, 2011, and again, after reconsideration, on October 18, 2011. (R. at 19.) Each time, the agency concluded that while the medical evidence did show "some restrictions in [Spraggins'] ability to function, " and prevented her from doing her past work as a forklift operator, she remained capable of performing "other types of work which are less demanding." (R. at 78, 90.) Spraggins then filed a written Request for Hearing, which was held on January 15, 2013 before ALJ John Kraybill. (R. at 19.) The ALJ issued his written decision on January 22, 2013, likewise concluding that although the medical evidence revealed some functional restrictions, Spraggins retained "the residual functional capacity to perform light work, " (R. at 25), including her "past relevant work as a bill collector." (R. at 28.) As stated earlier in this opinion, on April 2, 2014, the Appeals Council denied review, rendering the ALJ's decision the final and reviewable. (R. at 1.) Spraggins filed this action seeking review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). (Dkt. No. 1.)
At the hearing before ALJ Kraybill, Spraggins presented her medical records from her treating physicians and her own testimony. (R. at 1.) ALJ Kraybill also heard from Dr. Ashok Dr. Jilhewar, an independent medical expert, and Cheryl Hoiseth, an independent vocational expert. ( Id. ) The court reviews each category of evidence below.
I. Spraggins' Medical Records
A. Dr. Sunavo Dasgupta
On September 16, 2010, roughly one week after Spraggins was struck by a 25 pound package while operating a forklift, Spraggins visited Dr. Sunavo Dasgupta, a doctor at the Chicago Pain and Orthopedic Institute. (R. at 414.) Spraggins told Dr. Dasgupta that she noticed some right-sided neck pain immediately after the forklift incident but did not have a headache right away. ( Id. ) The next morning, however, Spraggins woke up with an excruciating headache affecting the front, back, and right side of her head. ( Id. ) By the time she visited Dr. Dasgupta, the majority of Spraggins' pain was confined to her occipital lobe (the back of her head) and the right side of her neck. ( Id. ) She also reported a shooting pain in her right arm above her elbow and noted a tingling and numbness in her hands and fingers. ( Id. ) Dr. Dasgupta ordered an MRI, physical therapy, and a series of steroid injections. ( Id. at 417-18.) Based on the MRI and additional examinations, Dr. Dasgupta concluded that Spraggins suffered from cervical radiculitis, cervical herniated nucleus pulposus, and cervical spondylosis. He ordered her to continue her physical therapy, medications, and steroid injections. ( Id. at 424-25.) After Spraggins' radiculopathy in her upper extremities did not respond well to the steroid injections, Dr. Dasgupta sent her to a neurosurgeon for further examination. ( Id. at 436.)
On November 2, 2010, Spraggins saw Dr. Gregory Thurston, a neurologist, for an examination and an electromyography/nerve conduction velocity ("EMG/NCV") study. (R. at 376.) Spraggins again reported pain, numbness, and tingling, but the pain had moved predominantly to the left side of her body, rather than the right. ( Id. ) Dr. Thurston's clinical exam and the EMG/NCV study found evidence of bilateral neuropathy in three spinal segments and radiculopathy with left proximal and distal axonal denervation. ( Id. at 379.)
B. Dr. Theodore Fisher
On November 11, 2010, Spraggins saw Dr. Theodore Dr. Fisher, an orthopedic and spine surgery specialist. (R. at 507.) Dr. Fisher conducted a physical exam, reviewed Spraggins' earlier MRI, and reviewed four radiographs taken at his office on the day of his exam. ( Id. at 507-508.) He concluded that Spraggins suffered from "C4-5 and C6-7 herniated nucleus pulposus with bilateral upper extremities radiculopathy, left greater than right, " and a "C-spine strain." ( Id. at 508.) Dr. Fisher advised Spraggins to continue with her nonsteroidal anti-inflammatory medications and to "increase her activity and physical therapy to be more of an active exercise program." ( Id. )
On December 8, 2010, Spraggins returned to see Dr. Fisher and reported that although her condition had improved with physical therapy, she still had trouble using her left arm. ( Id. at 372.) Dr. Fisher diagnosed the same conditions he identified in his November 11, 2010 examination as well as a "left shoulder impingement." ( Id. at 373.) He administered an epidural steroid injection and recommended additional physical therapy, a daily home exercise routine, and potentially a second MRI scan if Spraggins' condition failed to improve. ( Id. ) Dr. Fisher ultimately ordered the second MRI on January 17, 2011, ( id. at 369), and reviewed the results with Spraggins on March 7, 2011 and again on April 7, 2011 ( id. at 478, 528-29.) The MRI revealed "minimal degenerative changes, " but indicated that Spraggins suffered from circumferential bulging of the disc and mild canal stenosis in several spine segments. ( Id. at 369.) Although Spraggins desired to pursue surgical options, Dr. Fisher did not "believe the pathology on the MRI scan was severe enough to be causing her symptoms and require[e] surgical intervention." ( Id. at 478.) On April 7, 2011, because Spraggins had failed to improve with physical therapy, epidural steroid injections, medications, and time, Dr. Fisher referred her for a functional capacity evaluation to "determine her abilities and the validity of her complaints." ( Id. )
1. Mitch Kaminsky's KEY Functional Assessment
On May 13, 2011, Spraggins visited Mick Kaminsky, a certified KEY specialist,  to undergo the KEY Functional Assessment ("Key Assessment") ordered by Dr. Fisher. (R. at 463.) Kaminsky determined that Spraggins was capable of occasionally lifting 12.6 pounds and frequently lifting 8.2 pounds, sustaining a 3 to 4 hour work day, sitting for 4 to 5 hours, standing for 1 to 2 hours, and walking for 3 to 4 hours. ( Id. at 463-64.) According to KEY's capacity scale, Spraggins' capabilities qualified her to perform work at the light physical demand level. ( Id. )
On June 6, 2011, Spraggins returned to Dr. Fisher for another examination, where she again complained of neck pain, back pain, and left upper extremity radiculopathy. ( Id. at 479.) Dr. Fisher also observed decreased sensation in the tips of the second through fifth fingers of Spraggins' left hand. ( Id. ) Following his review of Kaminsky's KEY Assessment and his re-review of Spraggins' medical history, Dr. Fisher concluded that Spraggins had achieved "maximum medical improvement, " and released her to perform "light physical demand duty" work consistent with Kaminsky's KEY Assessment (Spraggins had been off of work since the September 9, 2010 accident). ( Id. at 479-80.)
C. Dr. Madala's RFC Assessment
On June 24, 2011, roughly six weeks after Spraggins filed her application for Disability Insurance Benefits and Supplemental Security Income and slightly more than one month after Kaminsky performed a KEY Assessment, Dr. Vidya Madala, M.D., performed an RFC assessment at the request of the Bureau of Disability Determination Services ("DDS"). (R. at 541.) Dr. Madala found that Spraggins could occasionally lift 20 pounds; frequently lift 10 pounds; stand or walk with a normal gait, with normal breaks, for about 6 hours in an 8-hour workday; sit for about 6 hours in an 8-hour workday; and push or pull with limitations in her left upper extremity. ( Id. at 542, 548.) Dr. Madala also found that Spraggins could climb stairs, balance, stoop, kneel, crouch, and crawl occasionally, but that she could never climb a ladder, rope or scaffolding. ( Id. at 543.) Finally, Dr. Madala found that Spraggins was unlimited in her handling, fingering, and feeling, but that she could only reach her left arm over her head occasionally on account of her left shoulder impingement. ( Id. at 544, 548.)
D. Provena Mercy Medical Center Emergency Room
On December 19, 2011, Spraggins visited the emergency room at Provena Mercy Medical Center, where she complained of pain in her middle and lower back and received an examination and x-ray. (R. at 579-87.) The x-ray revealed mild levoscoliosis and degenerative change of the lumbar spine, as well as reversal of the normal cervical lordosis, but no acute osseous injury involving the cervical or lumbar spine. ( Id. at 596.) On January 11, 2012, Spraggins again visited the Provena emergency room with complaints of lower back pain radiating down through her legs. ( Id. at 611.) Dr. Thomas McGivney, Provena's attending ER physician at the time, referred Spraggins for an MRI of her lumbar spine. ( Id. 621-22.) The MRI revealed no acute abnormality, no significant central spinal stenosis, and no neural foraminal narrowing. ( Id. at 625.) It did, however, show bilateral facet hypertrophy in two spinal segments. ( Id. )
E. Dr. Andrew Chenelle
On November 12, 2012, Spraggins met with a neurosurgeon named Andrew G. Chenelle, M.D., to whom she was referred by a friend who was also patient of Dr. Chenelle. (R. at 642.) Spraggins told Dr. Chenelle that she had been experiencing pain since September 9, 2010, when a box weighing 125 pounds fell on her head from 5 levels up. ( Id. ) She reported 8 out of 10 pain in her neck without movement, 10 out of 10 pain radiating into her spine and throughout her legs with movement, and an ...