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Moore v. Berryhill

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

May 22, 2018

ROBERT MOORE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration, Defendant.

          MEMORANDUM OPINION AND ORDER [1]

          SIDNEJ I. SCHENKIER United States Magistrate Judge

         Robert Moore has filed a motion for summary judgment seeking reversal or remand of the final decision of the Acting Commissioner of Social Security ("Commissioner") denying his claim for Supplemental Security Income benefits ("SSI") (doc. # 23: PL's Mot. for Summ. J.). The Commissioner has filed a motion seeking affirmance of the decision denying benefits (doc. # 25), and claimant has filed a reply (doc. # 30). For the following reasons, we grant Mr. Moore's motion and remand the case.

         I.

         Mr. Moore filed his claim for benefits on September 19, 2013, claiming a disability due to high blood pressure, diabetes, depression, "feet, " and "mental" (R. 101). He alleged an onset date of January 24, 2013 (Id.). His claim was initially denied on December 5, 2013 and on reconsideration on August 29, 2014 (R, 107, 125). Mr, Moore then appeared at a hearing in front of an Administrative Law Judge ("ALT') on April 8, 2016 (R. 27-61). On June 6, 2016, the ALJ ruled that Mr. Moore was not disabled, and Mr. Moore filed a request for review (R. 7-26). On October 27, 2016, the Appeals Council upheld the ALJ's determination, making the ALJ's determination the final opinion of the Commissioner (R. 1-6). See 20 C.F.R. § 404.981; Varga v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015).

         I.

         Mr. Moore was born on February 22, 1959 (R. 101). He is an army veteran who was honorably discharged after one year of service; he receives the majority of his medical treatment through the Veterans Administration ("VA") (R. 37, 77-80). The parties do not dispute that Mr. Moore has a longstanding problem with alcohol abuse (R. 31-33). As we explain below, the lead issue on which we grant summary judgment concerns the ALJ's analysis of Mr. Moore's impairments and how they affect his ability to work both when abusing alcohol and when sober.

         Beginning at least as early as 2009, Mr. Moore visited the Jesse Brown VA hospital regularly for treatment of a number of health conditions, including diabetes, high blood pressure, pancreatitis, depression, post-traumatic stress disorder, and alcoholism (see generally, R. 268-270, 299, 305-340, 527-550).[2] On May 16, 2011, Mr. Moore underwent a consultative examination with Sujatha Neerukonda, M.D., in connection with his first claim for benefits (R. 498-506), Mr. Moore's physical health was mostly normal, but with respect to his mental health, Dr. Neerukonda noted that Mr, Moore reported being too depressed to leave his apartment (R. 500) Dr. Neerukonda assessed Mr, Moore's affect as "significantly depressed" and noted that he did not make eye contact, was passively cooperative, distant, and guarded, and his hygiene and grooming were good (Id.).

         Also on May 16, 2011, Mr. Moore underwent a mental health consultative examination with Patricia Morrin, Psy.D. (R. 507-511). Dr. Morrin noted that Mr. Moore was appropriately groomed, cooperative and polite (R. 507). Mr. Moore reported that he drank alcohol daily, that he did not like to be around other people, and that he only enjoyed drinking alcohol (R. 508-09). Dr. Morrin assessed Mr. Moore as having a downcast mood and moderately depressed affect (R. 511). She diagnosed alcohol dependence and substance induced mood disorder (Id.). Neither Dr. Neerukonda nor Dr. Morrin opined on whether Mr. Moore was able to work.

         Mr. Moore continued to visit the VA for treatment of his various physical and mental health issues. Medical records from June 2011 through January 2012 document his continued alcohol abuse and disinterest in seeking treatment for his alcoholism (R, 628, 635, 651). In July and August 2011, Mr. Moore visited the VA complaining of "depression from isolation, " reporting that he had been depressed "for years" (R. 639-40, 655), He was diagnosed with depressive disorder, alcohol-induced mood disorder, and alcohol abuse (R. 646). During this time, Mr. Moore's diabetes was not well-controlled, in part because of his pancreatitis; progress notes indicate that his pancreatitis and liver problems were a direct result of his drinking (see generally, R. 636-62).

         On July 21, 2013, Mr. Moore was hospitalized for two days for acute pancreatitis, likely caused by his drinking (R. 767, 770). Intake notes from his visit to the emergency room note that Mr. Moore had a similar episode in 2010 (Id., 771). After being released from the hospital on July 23, 2013, Mr. Moore began an outpatient alcohol treatment program; VA progress notes indicated he was discharged from the program for "noncompliance" on September 3, 2013, and was reinstated, at his request, on September 18, 2013 (R. 794). After being reinstated in the program, Mr. Moore stopped drinking until early 2014 (R. 750-762, 797, 836).[3]

         Medical records from Mr. Moore's monthly appointments at the VA show that he reported abstaining from alcohol from approximately October 2013 to January 2014 (R. 797, 808). The records indicate that Mr. Moore was aware of the way that his alcoholism affected his physical health, and that he was in generally good spirits (Id.). However, in response to a mental health diagnostic study performed in November 2013, Mr. Moore indicated that he felt "depressed, anxious, angry or very upset" and had trouble sleeping 9 to 15 days per month (R. 806). Mr. Moore relapsed and began drinking again around late January 2014 (R. 814-17, 836). Although other medical records discuss renewing Mr. Moore's treatment plan, it is not clear from the medical record if or when he reentered an alcohol treatment program, or how much or often he was drinking after February 2014 (R. 794-797, 839, 845).

         On July 25, 2014, Mr. Moore underwent a mental health consultative exam with Edmond Yomtoob, Psy.D. (R. 894-96). Dr. Yomtoob described Mr. Moore as uncooperative during the examination, but stated that he obtained enough information to make an assessment (R. 894). Mr. Moore told Dr. Yomtoob that he experienced depression during the day and sometimes heard voices in his head (R. 895). Dr. Yomtoob diagnosed Mr. Moore with alcohol abuse and depressive disorder, and suggested additional testing to rule out post-traumatic stress disorder and antisocial traits (Id.)[4] Dr. Yomtoob agreed that Mr. Moore had some mental health issues, but also stated that "his overriding difficulty may be that of alcohol abuse" (Id.). Given Mr.Moore's alcoholism, Dr, Yomtoob also stated that Mr. Moore would not be a good candidate for managing his funds (R. 896).

         The medical record is then silent until July 2015, when Mr. Moore was hospitalized at Norwegian American Hospital with acute pancreatitis; he reported on admission that he had been ...


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