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Peterson v. Berryhill

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

July 23, 2018

NANCY BERRYHILL, Acting Commissioner of Social Security, Respondent.



         Claimant Daniel J. Peterson (“Claimant”) seeks review of the final decision of Respondent Nancy Berryhill, Acting Commissioner of Social Security (“the Commissioner”), denying Claimant's application for Supplemental Security Income Benefits (“SSI”) under Title XVI of the Social Security Act (“Act”). Pursuant to 28 U.S.C. § 636(c) and Local Rule 73.1, the parties have consented to the jurisdiction of a United States Magistrate Judge for all proceedings, including entry of final judgment. [ECF No. 8.] The parties have filed cross-motions for summary judgment [ECF Nos. 21 and 28] pursuant to Federal Rule of Civil Procedure 56. For the reasons stated below, Claimant's Motion for Summary Judgment [ECF No. 23] is granted, and the Commissioner's Motion [ECF No. 28] is denied. The decision of the Commissioner is reversed, and the case is remanded for further proceedings consistent with this Memorandum Opinion and Order.


         On May 8, 2014, Claimant filed an application for SSI, alleging a disability onset date of November 1, 2012. (R. 14.) This application was denied initially and upon reconsideration, after which Claimant requested an administrative hearing before an administrative law judge (“ALJ”). (Id.) On February 1, 2016, Claimant, represented by a non-attorney representative, appeared and testified at an administrative hearing before ALJ Karen Sayon. (R. 29-69.) The ALJ also heard testimony from vocational expert (“VE”) Ronald Malik. (Id.)

         On June 23, 2016, the ALJ denied Claimant's application for SSI, based on a finding that she was not disabled under the Act. (R. 14-23.) The opinion followed the five-step evaluation process required by Social Security Regulations (“SSR”).[1] 20 C.F.R. § 404.1520. At step one, the ALJ found that Claimant had not engaged in substantial gainful activity (“SGA”) since the application date of May 8, 2014. (R. 16.) At step two, the ALJ found that Claimant had the severe impairments of mild aortic stenosis with moderate aortic insufficiency. (Id.) The ALJ further found that Claimant had the non-severe impairments of hypertension, hyperlipidemia, and cervical and thoracic degenerative disc disease. (Id.) At step three, the ALJ found that Claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 416.920(d), 416.925 and 416.926). (R. 17.)

         The ALJ then assessed Claimant's residual functional capacity (“RFC”)[2] and concluded Claimant had the RFC to perform the full range of medium work as defined in 20 CFR 416.967. (R. 17.) Based on this RFC, the ALJ determined at step four that Claimant could not perform any past relevant work. (R. 709.) Finally, at step five, the ALJ found that there were jobs that exist in significant numbers in the national economy that Claimant could perform. (R. 22.) Specifically, the ALJ found Claimant could work as a packer, order picker, or machine offbearer. (R. 65.) Because of this determination, the ALJ found that Claimant was not disabled under the Act. (R. 23.) The Appeals Council declined to review the matter on October 24, 2016, making the ALJ's decision the final decision of the Commissioner and, therefore, reviewable by this Court under 42 U.S.C. § 405(g). See Haynes v. Baumhart, 416 F.3d 621, 626 (7th Cir. 2005).


         A decision by an ALJ becomes the Commissioner's final decision if the Appeals Council denies a request for review. Sims v. Apfel, 530 U.S. 103, 106-07 (2000). Under such circumstances, the district court reviews the decision of the ALJ. (Id.) Judicial review is limited to determining whether the decision is supported by substantial evidence in the record and whether the ALJ applied the correct legal standards in reaching his or her decision. Nelms v. Astrue, 553 F.3d 1093, 1097 (7th Cir. 2009). The reviewing court may enter a judgment “affirming, modifying, or reversing the decision of the [Commissioner], with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g).

         Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 42 U.S. 389, 401 (1971). A “mere scintilla” of evidence is not enough. Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002). Even where there is adequate evidence in the record to support the decision, the findings will not be upheld if the ALJ does not “build an accurate and logical bridge from the evidence to the conclusion.” Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 2008). In other words, if the Commissioner's decision lacks evidentiary support or adequate discussion of the issues, it cannot stand. Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009). Though the standard of review is deferential, a reviewing court must “conduct a critical review of the evidence” before affirming the Commissioner's decision. Eichstadt v. Astrue, 534 F.3d 663, 665 (7th Cir. 2008). It may not, however, “displace the ALJ's judgment by reconsidering facts or evidence.” Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).

         III. ANALYSIS

         On appeal, Claimant asserts that the ALJ made four errors. First, Claimant argues that the ALJ improperly categorized his degenerative disc disease as a non-severe impairment. Second, Claimant argues that the ALJ erred by failing to submit evidence to medical scrutiny and, instead, reached her own conclusions regarding medical imaging. Third, Claimant contends that the ALJ erred by giving non-examining state agency medical consultants' opinions great weight. Finally, Claimant argues that the ALJ's evaluation of Claimant's subjective allegations was legally insufficient. The Court finds that the ALJ did err in failing to submit a potentially decisive MRI to medical scrutiny and that, as a result of this error, the ALJ erred in her assessment by categorizing Claimant's degenerative disc disease as non-severe, improperly weighed the medical opinion evidence, and improperly assessed Claimant's subjective allegations and credibility.

         The ALJ relies heavily on the medical opinions of the state agency medical consultants, Dr. Young-Ja Kim and Dr. Phillip Galle, giving their opinions great weight. (R. 21.) Dr. Kim completed a medical source statement on October 9, 2014, and Dr. Galle affirmed Dr. Kim's assessment on August 27, 2015. (R.73, 84.) However, Claimant underwent an MRI on November 25, 2015. (R. 396.) This MRI revealed multiple findings along with a final impression of “multilevel degenerative disc disease.” (R. 396.) The ALJ did not submit this new evidence to the state agency medical consultants as she should have done, despite its showing of increased findings in Claimant's condition. See Goins v. Colvin, 764 F.3d 677, 680 (7th Cir. 2014) (finding that an ALJ's critical failure was her failure to obtain a medical report on the results of an MRI that was new and “potentially decisive medical evidence.”).

         Neither Dr. Kim's nor Dr. Galle's findings show an impairment of multilevel degenerative disc disease, as those findings were not revealed until the November 25, 2015 MRI. (R. 73, 84.) The ALJ reached her own conclusions about the findings of the November 25, 2015 MRI and whether it showed any clear limitations for Claimant. The Seventh Circuit often has reminded the Commissioner that administrative law judges may not play doctor and make their own medical findings. See Moon v. Colvin, 763 F.3d 718, 722 (7th Cir. 2014) (stating “ALJs are required to rely on expert opinions instead of determining the significance of particular medical findings themselves.”); Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996) (“ALJs must not succumb to the temptation to play doctor and make their own independent medical findings.”).

         Here, the ALJ gives the November 2015 MRI no more consideration than three sentences, in which she concludes that its findings contrast with the two treating physicians' opinions regarding Claimant's physical limitations, as well as bolster the findings of the state agency medical consultants. (R. 20-22.) The ALJ is in no position to make independent ...

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