United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
M. ROWLAND UNITED STATES MAGISTRATE JUDGE.
Isaac Banks (Plaintiff) filed this action seeking reversal of
the final decision of the Commissioner of Social Security
denying his application for Disability Insurance Benefits and
Supplemental Security Income under Titles II and XVI 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 filed cross motions for summary judgment. For the
reasons stated below, the case is remanded for further
proceedings consistent with this Opinion.
THE SEQUENTIAL EVALUATION PROCESS
recover DIB or SSI, a claimant must establish that he or she
is disabled within the meaning of the Act. 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), 416.905(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 and is expected to last at least 12
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
5. Is the claimant unable to perform any other work?
20 C.F.R. §§ 404.1509, 404.1520, 416.909, 416.920;
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.
protectively applied for Disability Insurance Benefits (DIB)
and Supplemental Security Income (SSI) on May 24, 2013,
alleging that he became disabled on December 20, 2012, due to
a fractured spine. (R. at 20, 77, 84). These claims were
denied initially and upon reconsideration, after which
Plaintiff filed a timely request for a hearing. (Id.
at 20, 140-41). On December 9, 2015, Plaintiff, represented
by counsel, testified at a hearing before Administrative Law
Judge (ALJ) Luke Woltering. (Id. at 20, 33-75). The
ALJ also heard testimony from Jackie Bethel, a vocational
expert (VE). (Id.).
denied Plaintiff's request for benefits on January 22,
2016. (R. at 17- 28). Applying the five-step sequential
evaluation process, the ALJ found, at step one, that
Plaintiff had not engaged in substantial gainful activity
since his alleged onset date of December 20, 2012.
(Id. at 22). At step two, the ALJ found
Plaintiff's cervical spinal stenosis with cervical
radiculopathy and chronic pain syndrome to be severe
impairments. (Id.). At step three, the ALJ
determined that Plaintiff does not have an impairment or
combination of impairments that meet or medically equal the
severity of any of the listings enumerated in the
regulations. (Id. at 24).
then assessed Plaintiff's Residual Functional Capacity
(RFC) and determined that Plaintiff has the RFC
to perform light work with the following additional
limitations: “no overhead reaching; occasional reaching
in other directions; occasional handling, fingering, and
feeling with the left non-dominant upper extremity; no
crawling or climbing ladders, ropes or scaffolds; occasional
stooping, kneeling and crouching.” (R. at 24). The ALJ
determined at step four that Plaintiff was capable of
performing his past relevant work in general merchandise
sales. (Id. at 27). Accordingly, the ALJ concluded
that Plaintiff was not under a disability, as defined by the
Act, from the alleged onset date through the date of the
ALJ's decision. (Id. at 28).
Appeals Council denied Plaintiff's request for review on
June 24, 2016. (R. at 1-3). Plaintiff now seeks judicial
review of the ALJ's decision, which stands as the final
decision of the Commissioner. Villano v. Astrue, 556
F.3d 558, 561-62 (7th Cir. 2009).
STANDARD OF REVIEW
review of the Commissioner's final decision is authorized
by § 405(g) of the Act. 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.”) (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).
the 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) (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.
RELEVANT MEDICAL EVIDENCE
injuries reportedly stem from a July 2012 altercation in
which he was hit in the back/neck with a crowbar. (R. at
327). In January 2013, Plaintiff began experiencing symptoms
of numbness and tingling in the left arm and hand, and pain
in the left shoulder and elbow. (Id.) A January 14,
2013 MRI of the cervical spine revealed severe spinal
stenosis with spinal cord compression at ¶ 6-C7,
associated with a prominent disc protrusion that was more
marked on the left. (Id. at 303). The interpreting
radiologist indicated that alteration of the spinal cord
signal at this level was consistent with myelomalacia
(softening of the spinal cord) and/or edema. (Id.).
The MRI also revealed evidence of underlying congenital
cervical spinal stenosis, as well as a smaller disc
protrusion and less marked cord compression at ¶ 5-C6.
was referred to the neurology department at Rush University
Medical Center and met with Laura Jawidzik, M.D., on January
29, 2013, for further evaluation. (R. at 339-42). Dr.
Jawidzik assessed cervical myelopathy from severe spinal
stenosis. (Id. at 342). Given the degree of
compression, Dr. Jawidzik referred Plaintiff to neurosurgeon
Harel Deutsch, M.D., for an urgent surgical evaluation.
(Id.). Due to the degree of pain and Plaintiff's
failure to improve with more conservative measures, Dr.
Deutsch recommended surgery. (Id. at 309).
February 22, 2013, Plaintiff underwent at ¶ 6-C7
anterior cervical discectomy and fusion performed by Dr.
Deutsch. (R. at 343). At a May 2013 follow-up visit,
Plaintiff reported tingling and numbness in his left arm and
hand, although no abnormalities were noted on physical
examination. (Id. at 306). Dr. Deutsch assessed
cervical spinal stenosis. (Id.). On August 7, 2013,
Plaintiff returned to Dr. Deutsch with complaints of
intermittent neck pain, upper back pain, left arm pain
(described as a burning sensation), and continued numbness
and tingling in the fingers on his left hand. (Id.
at 305). Dr. Deutsch's findings on physical examination
remained unchanged from Plaintiff's prior visit.
(Id.). Dr. Deutsch again assessed cervical spinal
stenosis and noted that Plaintiff continued to take Neurontin
and Norco for his pain. (Id.).
began treating with a new primary care physician, Michael
Appiagyei, M.D., on August 30, 2013. (R. at 369-71). The
medical records reflect an ongoing treatment relationship
where Plaintiff met with Dr. Appiagyei on an almost monthly
basis between August 2013 and November 2015. (Id. at
369-435). Dr. Appiagyei's diagnoses included: cervical
radiculopathy (id. at 370, 403, 411); displaced
cervical intervertebral disc (id. at 376, 385);
cervical disc disorder with myelopathy (id. at 373);
displaced lumbar intervertebral disc (id. at 388);
lumbago with sciatica on the right side (id. at
437); and chronic pain syndrome (id. at 371, 375,
377, 379, 388, 393, 399, 401, 409, 414, 418, 420, 422, 427,
records indicate that Plaintiff benefitted from the use of
Norco and Neurontin and that his pain was generally noted to
be “controlled”; however, Plaintiff consistently
reported pain levels of 7-8/10. (See, e.g., R. at
369, 374, 376, 378, 381, 392, 397, 408, 410, 413, 416, 419,
421, 429, 429, 433, 438). Aggravating factors included
lifting, movement, and prolonged sitting. (Id. at
369, 372, 374, 404, 408, 429). Plaintiff demonstrated
decreased and/or limited range of motion in his back and neck
at nearly every visit. (Id. at 370, 375, 377, 379,
382, 392, 393, 399, 403, 409, 411, 414, 430, 439). Most
physical examinations demonstrated normal musculoskeletal
symmetry, tone, and strength; however, diminished strength
and tone were noted in December 2013 and January 2015.
(Id. at 379, 402). Wasting/atrophy of the left arm
and hand was documented in September 2013, January and
February 2014, and January 2015. (Id. at 373, 385,
388, 402). Plaintiff frequently reported symptoms of
numbness, tingling, and pain radiating into his arms.
(Id. at 369, 384, 387, 389, 392, 402, 410, 416,
433). Tenderness in Plaintiff's cervical and lumbar
paraspinal muscles was noted in August and September 2013,
May 2014, and April 2015. (Id. at 370, 373, 393,
September 13, 2013, Towfig Arjmand, M.D., a nonexamining DDS
consultant, reviewed Plaintiff's records and completed a
physical RFC assessment. (R. at 77-82). Dr. Arjman opined
that Plaintiff could lift and/or carry up to 50 pounds
occasionally and 25 pounds frequently, could stand and/or
walk for up to six hours in an eight-hour workday, and could
sit for up to six hours in an eight-hour workday.
(Id. at 80). Dr. Arjmand additionally concluded that
objective evidence alone ...