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Ray v. Berryhill

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

April 19, 2017

LARRY RAY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.

          MEMORANDUM OPINION AND ORDER

          Young B. Kim United States Magistrate Judge

         Larry Ray seeks disability insurance benefits (“DIB”) and supplemental security income (“SSI”) based on his claim that he is disabled by chronic pain stemming from a work-related back injury and by symptoms related to his peripheral artery disease. After an Administrative Law Judge (“ALJ”) denied his applications for DIB and SSI and the Appeals Council declined review, Ray brought this lawsuit seeking judicial review of the denial. See 42 U.S.C. § 405(g). Before the court are the parties' cross-motions for summary judgment. For the following reasons, Ray's motion is denied and the government's is granted:

         Procedural History

         Ray filed his DIB and SSI applications in October 2012 claiming a disability onset date of August 11, 2011. (Administrative Record (“A.R.”) 200-13.) After his claims were denied initially and upon reconsideration, (id. at 90-91, 114-15), Ray sought and was granted a hearing before an ALJ. That hearing took place on August 7, 2014. (Id. at 30-71.) On September 26, 2014, the ALJ issued a decision concluding that Ray is not disabled and therefore not entitled to DIB or SSI. (Id. at 24.) When the Appeals Council declined review, (id. at 1-7), the ALJ's decision became the final decision of the Commissioner, see Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). Ray filed this lawsuit seeking judicial review of the Commissioner's final decision, see 42 U.S.C. § 405(g), and the parties consented to this court's jurisdiction, see 28 U.S.C. § 636(c); (R. 10).

         Facts

         Ray's disability onset date corresponds with the date of an on-the-job back injury he suffered in August 2011. Ray was working as a housekeeper when he bent over to lift a heavy blower from the floor and felt a sharp pain in his lower back. He asserts that despite time and treatment his back pain persists to an extent that prevents him from working in any capacity. At his August 2014 hearing before the ALJ, Ray submitted both documentary and testimonial evidence in support of his claims.

         A. Medical Evidence

         In the immediate wake of his on-the-job injury, Ray underwent a lumbar-spine MRI that revealed moderate disc degeneration with broad-based disc protrusion and neural foraminal narrowing at ¶ 5-S1 and mild disc bulging at ¶ 3-4 and L4-5. (A.R. 346.) In the five months following his injury, Ray received treatment from Dr. Mark Gerber, who prescribed anti-inflammatory and analgesic medications. (Id. 738-43.) Dr. Gerber noted in December 2011 that Ray had moderate end-range pain and restrictions in lumbar extension and that there was evident spasm and inflammation in his lower back. (Id. at 738-39.) Dr. Gerber's goals for Ray were to increase his range of motion and strength, decrease his pain, and restore him to normal function. (Id. at 739.) In furtherance of those goals, Dr. Gerber directed Ray to temporarily refrain from working and prescribed epidural steroid injections and 20 sessions of physical therapy. (Id.) By early January 2012, Dr. Gerber found that “Ray has improved sufficiently that he can be released from care to return to work light duty as of 01/11/12.” (Id. at 743.)

         Starting before his injury and throughout the period relevant to the current claims, Ray's primary physician was Dr. R. Medavaram, who treated him for a range of medical issues from a cold to big-toe pain. (Id. at 362-63.) The bulk of Dr. Medavaram's handwritten notes are illegible, but those that can be parsed show that in January 2012 Dr. Medavaram noted that Ray was a smoker who needed a cardiac evaluation and referred him in April 2012 to a cardiologist. (Id. at 357-58.) Dr. Medavaram noted in May 2012 that Ray reported that his back pain had improved but then had increased and that his medications were not helping. (Id. at 378.) In response, Dr. Medavaram prescribed him Vicodin. (Id.) That same month a myocardial perfusion imaging test showed normal results with “no scintigraphic evidence of fixed or reversible defects.” (Id. at 344.) In July 2012 Dr. Medavaram described Ray as having stable coronary artery disease and low back pain. (Id. at 355.)

         In September 2012 Dr. Medavaram filled out a medical report regarding Ray's employability. (Id. at 380-81.) Dr. Medavaram opined that Ray was disabled by coronary artery disease and low-back pain, resulting in his having only a “partial capacity” to walk, stand, sit, bend, stoop, turn, reach, or engage in finger dexterity, and as having “no capacity” to run, climb, push, or travel. (Id. at 380.) Dr. Medavaram endorsed the view that Ray was “totally permanently disabled from all forms of employment.” (Id. at 381.)

         The following month, in October 2012, Ray was admitted to a hospital for five days after he reported to the emergency room with complaints of chest pain and shortness of breath. (Id. at 390.) The emergency room notes reflect that Ray had normal range of motion and strength in his musculoskeletal system, and reflect diagnoses of chest pain, diabetes mellitus, and hypertension. (Id. at 392, 395.) An EKG test performed during his hospital stay reflected that he has “normal exercise tolerance” and had reached “adequate workload.” (Id. at 387.) A month after his discharge, Ray underwent an outpatient cardiology follow-up, during which he told his doctor that he was unable to work because of low-back syndrome, not because of cardiac or respiratory issues. (Id. at 384.) The notes reflect that he was compliant with his medication and was counseled to quit smoking and to “keep walking and exercising legs as tolerated.” (Id.) He was diagnosed as having peripheral artery disease. (Id.)

         In December 2012 consulting physician Dr. Reynaldo Gotanco provided opinions regarding Ray's residual functional capacity (“RFC”) in connection with the denial of his claims at the initial level of review. (Id. at 72-89.) Dr. Gotanco opined that Ray could sit, stand, or walk for about six hours in an eight-hour day, that he could occasionally lift 20 pounds and frequently lift 10 pounds, that he was unlimited in pushing or pulling, and that he had postural limitations allowing him to climb ramps and stairs, stoop, kneel, crouch, and crawl only frequently, and to climb ladders, ropes, or scaffolds only occasionally. (Id. at 77.) Dr. Gotanco also opined that Ray should avoid concentrated exposure to hazards. (Id. at 78.) He found Ray's statements regarding his symptoms only partially credible because Ray has no problems with personal care and can perform light housework. (Id. at 76.) Dr. Gotanco also found Ray's statement that he could only climb a few stairs unsupported by the medical records. (Id.)

         The record reflects that other than one visit to a family practice in March 2013, from November 2012 through September 2013 there is a gap in Ray's medical treatment.[2] (See Id. at 422, 723.) In June 2013, however, Ray reported for a consultative examination with Dr. Charles Carlton at the request of the Bureau of Disability Determination Services. (Id. at 429-33.) Ray reported to Dr. Carlton that he stopped having follow-up visits for treatment for his back pain because workers' compensation stopped paying for the visits. (Id. at 430.) He had not had an epidural steroid injection since 2012, but he said the injections only made his pain worse. (Id.) Ray reported that he was independent with activities of daily living but could only walk for a quarter of a block before experiencing back pain. (Id. at 430-31.) Dr. Carlton examined Ray and noted that he appeared to be in no acute distress and was able to rise from sitting to standing without help, but that he walked with a slow and rigid gait and complained of pain while walking and performing other maneuvers. (Id. at 431.) Nonetheless, Dr. Carlton noted that Ray was able to walk more than 50 feet without a cane and exhibited a full painless range of motion in all of his joints. (Id. at 431-32.) Although he had some decrease in his range of motion in his lumbar spine and tenderness to palpation in his low back, there was no sign of cervical or lumbar nerve root compression or neuropathy. (Id. at 432.) Dr. Carlton opined that Ray is able to sit, stand, and walk more than 50 feet without a cane. (Id. at 433.)

         In July 2013 consulting physician Dr. Charles Wabner reviewed Ray's file at the administrative reconsideration level and provided an RFC assessment that largely echoed Dr. Gotanco's. (Id. at 92-113.) The only difference between the two opinions is that Dr. Wabner added an environmental limitation requiring Ray to avoid concentrated exposure to extreme cold and heat. (Id. at 99.) Dr. Wabner explained that he added those limitations to accommodate dizziness Ray was experiencing. (Id.) He ...


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