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Williams v. Colvin

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

October 25, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          MARY M. ROWLAND, United States Magistrate Judge.

         Plaintiff Dorlene Williams filed this action seeking reversal of the final decision of the Commissioner of Social Security denying her application for Disability Insurance Benefits under Title II of the Social Security Act (Act). 42 U.S.C. §§ 405(g), 423 et seq. The parties have consented to the jurisdiction of the United States Magistrate Judge, pursuant to 28 U.S.C. § 636(c), and Plaintiff has filed a motion for summary judgment. For the reasons stated below, the case is remanded for further proceedings consistent with this Opinion.


         To recover Disability Insurance Benefits (DIB), a claimant must establish that he or she is disabled within the meaning of the Act.[1] York v. Massanari, 155 F.Supp.2d 973, 977 (N.D. Ill. 2001). A person is disabled if he or she is unable to perform “any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. § 404.1505(a). In determining whether a claimant suffers from a disability, the Commissioner conducts a standard five-step inquiry:

1. Is the claimant presently unemployed?
2. Does the claimant have a severe medically determinable physical or mental impairment that interferes with basic work- related activities that is expected to last at least 12 months?
3. Does the impairment meet or equal one of a list of specific impairments enumerated in the regulations?
4. Is the claimant unable to perform his or her former occupation?
5. Is the claimant unable to perform any other work?

20 C.F.R. §§ 404.1509, 404.1520; see Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). “An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled. A negative answer at any point, other than Step 3, ends the inquiry and leads to a determination that a claimant is not disabled.” Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985). “The burden of proof is on the claimant through step four; only at step five does the burden shift to the Commissioner.” Clifford, 227 F.3d at 868.


         Plaintiff applied for DIB on February 11, 2013, alleging that she became disabled on February 1, 2013. (R. at 40, 198-204). Plaintiff claimed that she suffered from 14 disorders, including pulmonary hypertension, memory problems, fatigue, dyspnea (shortness of breath), asthma, syncope (a temporary loss of consciousness), lack of concentration, cardiac arrhythmia, Raynaud's disease (numbness or coldness in the extremities), a heart murmur, a heart valve disorder, a herniated disc, and bursitis of the hips. (Id. at 133). The application was denied initially and upon reconsideration, after which Plaintiff filed a timely request for a hearing. (Id. at 134- 37, 144-67, 148-49). On December 19, 2014, Plaintiff, who was represented by counsel, testified at a hearing before an Administrative Law Judge (ALJ). (Id. at 58-98). The ALJ also heard testimony from vocational expert (VE) Ronald Malik. (Id.).

         The ALJ denied Plaintiff's request for benefits in a January 7, 2015 written decision. (R. at 40-51). Applying the five-step sequential evaluation process, the ALJ found at step one that Plaintiff had not engaged in substantial gainful activity since her alleged onset date of February 1, 2013. (Id. at 42). At step two, the ALJ found that Plaintiff's severe impairments included a lumbar spine disorder, degenerative disc disease, bursitis, asthma, and Raynaud's disease. The ALJ also concluded that Plaintiff suffered from several nonsevere impairments. These included a right toe bunion, visual impairments, arterial and pulmonary hypertension, premature ventricular contractions, bipolar disorder, obesity, dyslipidemia, depression, and post- traumatic stress disorder (PTSD). (Id.). At step three, none of these impairments met or medically equaled, either singly or in combination, the severity of the listings enumerated in the regulations. (Id. at 43-44). The ALJ then assessed Plaintiff's Residual Functional Capacity (RFC)[2] and determined that Plaintiff has the RFC to perform sedentary work

except that she can occasionally push or pull with the upper extremities, climb ramps or stairs and stoop. She should never climb ladders, ropes or scaffolds, balance, crouch, kneel or crawl. [Plaintiff] is limited to frequent reaching (including overhead), handling and fingering. She should avoid concentrated exposure to environmental irritants such a fumes, odors, dusts, and gases, poorly ventilated areas and chemicals.

(Id. at 46). Based on this RFC and the VE's testimony, the ALJ determined at step four that Plaintiff was able to perform her past relevant work as an office manager. (Id. at 50). Accordingly, the ALJ did not proceed to step five and concluded that Plaintiff was not under a disability from the alleged onset date through the date of his decision. (Id. at 50-51).

         Plaintiff filed a timely request for review of the ALJ's decision. (R. at 24). As part of that request, Plaintiff submitted evidence that she claimed was new and material. (Id. at 19-36). The Appeals Council denied her request on June 24, 2015. (Id. at 1-6). Plaintiff now seeks judicial review of the ALJ's decision, which stands as the Commissioner's final decision. Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).


         Judicial review of the Commissioner's final decision is authorized by § 405(g) of the SSA. In reviewing this decision, the Court may not engage in its own analysis of whether the plaintiff is severely impaired as defined by the Social Security Regulations. Young v. Barnhart, 362 F.3d 995, 1001 (7th Cir. 2004). Nor may it “reweigh evidence, resolve conflicts in the record, decide questions of credibility, or, in general, substitute [its] own judgment for that of the Commissioner.” Id. The Court's task is “limited to determining whether the ALJ's factual findings are supported by substantial evidence.” Id. (citing § 405(g)). Evidence is considered substantial “if a reasonable person would accept it as adequate to support a conclusion.” Indoranto v. Barnhart, 374 F.3d 470, 473 (7th Cir. 2004); see Moore v. Colvin, 743 F.3d 1118, 1120-21 (7th Cir. 2014) (“We will uphold the ALJ's decision if it is supported by substantial evidence, that is, such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”) (internal quotes and citation omitted). “Substantial evidence must be more than a scintilla but may be less than a preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). “In addition to relying on substantial evidence, the ALJ must also explain his analysis of the evidence with enough detail and clarity to permit meaningful appellate review.” Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005).

         Although this Court accords great deference to the ALJ's determination, it “must do more than merely rubber stamp the ALJ's decision.” Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (internal quotes and citation omitted). “This deferential standard of review is weighted in favor of upholding the ALJ's decision, but it does not mean that we scour the record for supportive evidence or rack our brains for reasons to uphold the ALJ's decision. Rather, the ALJ must identify the relevant evidence and build a ‘logical bridge' between that evidence and the ultimate determination.” Moon v. Colvin, 763 F.3d 718, 721 (7th Cir. 2014). Where the Commissioner's decision “lacks evidentiary support or is so poorly articulated as to prevent meaningful review, the case must be remanded.” Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).


         Plaintiff stopped working in January 2013 after being employed for 18 years as an office manager in a medical clinic. (R. at 63). She stated at the hearing that she was unable to continue working because the pain that she experienced in her back and hips made it difficult for her to concentrate on what she was doing or to remember what she was reading. (Id. at 64-65).

         Plaintiff had sought medical treatment for these conditions long before her last employment date. Some records suggest that she received epidural steroid injections in her lower back as early as 1994. (R. at 799). A November 2004 MRI of Plaintiff's lumbar spine revealed a left-sided disc herniation and degenerative disc bulging at ¶ 5-S1. (Id. at 412). A CT scan performed the same month suggested moderate central canal stenosis and moderate to severe bilateral foraminal stenosis. (Id. at 788). An epidural steroid injection was administered to lessen Plaintiff's discomfort on November 23, 2004. (Id. at 463). Although Plaintiff complained of back pain during treatment sessions for other conditions, the next treatment note concerning her back pain was given on October 27, 2014. A recent MRI showed that she had degenerative disc disease, a disc bulge at ¶ 5-S1, and a small diffuse bulge at ¶ 4-L5. (Id. at 788). Orthopedist Dr. Anis Mekhail diagnosed her with lumbar radiculopathy and gave her an epidural injection. (Id. at 794, 797). He then referred Plaintiff to pain specialist Dr. Neema Bayran. (Id. at 799). Dr. Bayran noted full lower-extremity extension but also found that Plaintiff had no deep tendon reflexes. She recommended that Plaintiff receive additional injections at the L4-L5 and L5-S1 levels. (Id. at 801).

         Records submitted for the first time to the Appeals Council show that Plaintiff received those injections at some unspecified date. (R. at 32). The relief they gave lasted less than one week. (Id.). Dr. Mekhail noted on January 26, 2015, that Plaintiff was experiencing numbness and tingling in her feet and diagnosed her with diabetic peripheral neuropathy.[3] (Id. at 33). A subsequent EMG study confirmed that diagnosis. (Id. at 28, 31). On February 20, 2015, she also received a lumbar medial branch nerve block at ¶ 3, L4, and L5 on the right side. (Id. at 21-22). Dr. Bayran noted three days later that Plaintiff experienced relief for four to five hours after the procedure but it gradually returned to its baseline level. (Id. at 20). Dr. Bayran thought that Plaintiff should receive only conservative care. (Id. at 23, 28). She therefore administered a radiofrequency ablation of the lumbar medial branches that gave Plaintiff significant pain relief for the first two weeks. (Id. at 8). The pain then returned in full on the left side, with radiating symptoms through the left hip and calf. Dr. Bayran recommended further epidural injections. (Id.).

         Plaintiff also experienced ongoing pain in her hips. A May 2004 MRI was administered to evaluate her complaints, but it revealed a normal left hip. (R. at 413). A June 2007 x-ray showed a cyst in the femoral neck of the left hip, with mild degenerative changes and space narrowing. (Id. at 409). A follow-up MRI for Plaintiff's hip was performed in December 2012 by Dr. Bruce Dolitsky. It revealed bilateral trochanteric bursitis, which was treated with a steroid injection. (Id. at 558). Dr. Dolitsky gave Plaintiff another injection in her hips in February 2013. (Id. at 556, 562). An exam in June of that year showed that Plaintiff had mild pain with a normal range of motion and a normal walking posture. (Id. at 640). She had an additional x-ray study of the hip done in February 2014 that showed normal hips with no degenerative changes. (Id. at 746). Nabumetone and tramadol were both administered to relieve her pain. (Id. at 772).

         Although Plaintiff's orthopedic complaints were largely limited to the hips and back, she also experienced pain in her fingers. Treating physician Dr. Hajat noted in March 2011 that Plaintiff had been experiencing numbness in her left hand and the two medial fingers for the past two months. She diagnosed a possible case of carpal tunnel syndrome. (R. at 580). Plaintiff then saw neurologist Dr. Anthony Stephens. He noted that an EMG study had shown evidence of ulnar neuropathy at the elbow but found that it did not require further treatment other than therapy. (Id. at 325). Nevertheless, Plaintiff's pain continued, and she received a steroid injection in her left middle finger at some unspecified point by July 2013. (Id. at 609). Records concerning her other medical consultations record ongoing complaints of finger pain throughout 2013. (Id. at 638, 679).

         Plaintiff claimed in a written April 2013 Function Report that her joint pain, particularly her back discomfort, affects almost all of her functional abilities except hearing and getting along with others. (R. at 248). She is unable to lift more than ten pounds or to walk more than five to ten minutes at a time. Even then, she must rest for five to ten minutes before resuming her activities. (Id.). Plaintiff further claimed at the administrative hearing that her back pain had become worse over time. (Id. at 67-68). She now experiences back and hip pain on a daily basis. (Id. at 86). In addition, her legs became painful and her right foot began to go numb four months prior to the August 2014 hearing. (Id. at 86-87). The pain is so great that she must lie down in a reclining chair for four or five hours during the day and nap for up to an hour-and-a-half daily. (Id. at 88-89). Plaintiff explained to the ALJ that she would be unable to carry out her former work because she could no longer sit for the required time. (Id. at 88). The pain in her fingers, which Plaintiff attributed to Raynaud's disease, would also prevent her from typing or writing for the five hours she used to carry out those tasks at her prior job. (Id. at 76, 89). Plaintiff expressed particular concern over ability to handle small objects. (Id. at 76). Repetitive move- ments like writing for more than 20 minutes or even stirring something while cooking can bring on serious pain. (Id. at 76-77).

         Plaintiff also claimed at the hearing that her multiple joint problems significantly limited her ability to carry out many activities of daily living (ADLs). She described her day as limited to walking to the end of the block and back, watching television, napping, and doing light dusting and housekeeping. (R. at 82). She only uses paper plates and utensils. Her boyfriend prepares most meals and walks the dog. (Id. at 81-82). An October 2013 Function Report states that Plaintiff can only do light laundry once a week. (Id. at 278). She goes outside twice a week, mostly to visit her mother, to keep a doctor's appointment, or to go to the grocery store for 15 to 20 minutes. (Id. at 279).

         In addition to pain in her back and joints, Plaintiff also claims that she is impaired by episodes of dizziness and syncope. She was treated for dizzy spells as early as August 1999, when Dr. Arvind Kumar found that an MRI of Plaintiff's brain was normal. (R. at 304, 310-11). A tilt-table test, which assesses the causes of a fainting episode, itself triggered an episode of syncope in July 1999. (Id. at 315, 520). Dr. Kumar suggested that Plaintiff's light headedness might be due to orthos-tatic hypotension but noted that medication helped to relieve her symptoms. (Id. at 310-11). Neurologist Dr. Anthony Stephens was also unable to identify a specific cause for the syncope. (Id. at 326). Two years later, Plaintiff appeared at South Suburban Hospital in June 2001 with complaints of light headedness, which the ...

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