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Charah C. v. Saul

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

July 26, 2019

CHARAH C., Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration, [1] Defendant.


          Susan E. Cox, United States Magistrate Judge.

         Plaintiff Charah C.[2] appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his disability benefits. Plaintiff has filed Plaintiff's Brief [dkt. 19], which the Court has construed as a motion for summary judgment. The Commissioner has filed a cross-motion for summary judgment [dkt. 26]. As detailed below, the Court grants the Commissioner's motion for summary judgment [dkt. 26] and denies the Plaintiff's motion for summary judgment [dkt. 19].

         I. Background

         a. Procedural History

         On March 9, 2015, Plaintiff applied for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423(d), alleging a disability onset date of February 15, 2015. [Administrative Record (“R.”) 20, 148.] Plaintiff cited the following conditions as the basis of his claim: blindness in the right eye and visual disturbance in the left. [R. 124.] He also noted that he had a colostomy bag, the result of a perirectal abscess, though he did not list this as a disability basis. [R. 102-110, 124, 162.]

         At the time of Plaintiff's DIB application, Plaintiff was receiving Supplemental Security Income (“SSI”) benefits under Title XVI of the Social Security Act, 42 U.S.C. § 1382, in accordance with Administrative Law Judge (“ALJ”) Shirley Moscow Michaelson's December 15, 2009 decision, finding him disabled. [R. 94-100, 160, 223.] ALJ Michaelson concluded Plaintiff's visual impairment met the requirements of Listing 2.03: Contraction of the Visual Field in the Better Eye. 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 2.03. Plaintiff was “legally blind, ” lacking central vision in his right eye (20/200 with pinhole vision) and sufficient visual acuity in the “better” eye, the left (20/80 at best, also with pinhole vision).[3] Id.

         On June 19, 2015, the Social Security Administration (“SSA”) determined that Plaintiff was no longer disabled under the Social Security Act, namely because his left eye had improved. [R. 102-109, 120-23.] On July 29, 2015, Plaintiff completed a request for reconsideration with the SSA. [R. 125-26.] On August 21, 2015, the SSA issued a notice to Plaintiff maintaining its denial of his claim. [R. 127.] The notice indicated that the initial and additional records were reviewed by a physician and disability examiner in the State agency. Id. The reviewers found that Plaintiff's conditions-his right eye's blindness, left eye's visual disturbance, as well as his perirectal abscess and colostomy bag[4]-prevented him from doing some work but did not exclude him working altogether. Id.

         After his DIB applications were denied initially and on reconsideration, Plaintiff requested an administrative hearing. [R. 110, 119, 131-32.] In January 2017, Plaintiff appeared pro se,[5] having waived his right to representation, at a hearing before ALJ Bonny S. Barezky. [R. 71-93.] During the hearing, Plaintiff and a vocational expert (“VE”) Brian L. Harmon testified. Id. On May 24, 2017, the ALJ determined that Plaintiff was not disabled under the Act. [R. 20-28.]

         On June 8, 2017, Plaintiff, still pro se, submitted his request for review of the ALJ's decision to the Appeals Council. [R. 144.] A month later, he retained counsel. [R. 10-12.] On or about September 8, 2017 Counsel supplemented Plaintiff's request for review. [R. 223-34.] In his supplementary letter to the Appeals Council, Plaintiff's counsel contended ALJ Barezky's decision was “not logical” and failed to “reflect a properly developed record, ” establishing Plaintiff as disabled. Additionally, counsel asserted specifically, “[t]he entire basis of his disability is blindness.” [R. 223.]

         On April 10, 2018, after a review of the ALJ's decision, the Appeals Council denied Plaintiff's Request for Review of ALJ Barezky's decision. [R. 1-3.] Thus, the Decision of the Appeals Council is the final decision of the Commissioner. Plaintiff filed an action in this Court on May 8, 2018, seeking review of the Commissioner's decision.

         b. Relevant Medical Background

         Plaintiff, born in 1970, was 44 years old on his alleged disability onset date. [R. 148-49.] Plaintiff's relevant medical conditions are his macular degeneration of the right eye and limited visual acuity of the left eye, referenced in the first part of this section, as well as his perirectal abscess and colostomy, referenced in the second part of this section.

         i. Plaintiff's Vision

         In May 2008, Plaintiff sustained blunt force trauma to his right eye when he was struck by a pistol. [R. 99.] Plaintiff underwent consultative evaluations in July and September of 2008, as well in January of 2009 with Dr. Tracy Matchinski, O.D. [R. 99.] With respect to the right eye, the results were consistent, and the physicians reached a consensus. Id. Plaintiff had significant vision loss that left him legally blind. Id. More specifically, his right eye's visual acuity was less than 20/200 with a pinhole field of vision. Id. Additionally, it was determined Plaintiff would not, in all likelihood, recover that vision. Id. This was so because the eye presented with a “full thickness macular tear, ” the consequence of an irreversible condition: macular degeneration. Id.

         Unlike the right eye, the physicians found the left eye to be healthy at first. Id. At the September 8, 2008 evaluation, Plaintiff's left eye vision tested as 20/20. Id. However, by January 2009, his left eye vision declined; Dr. Matchinski's results ranged from 20/80 to 20/200. Id. At the time of ALJ Michaelson's December 2009 decision, according to the records, Plaintiff was shown to have “no central vision” in the right eye and in the left “visual acuity [of] 20/100 with only a pinhole vision, ” when corrected. Id. Both eyes had pinhole vision. Id. These findings taken together meant that, in 2009, Plaintiff was legally blind. [R. 100.]

         At the time of Plaintiff's 2015 DIB application, he maintained that he qualified as disabled under the Act because of his vision. [R. 102, 159-60, 222-24.] On May 29, 2015, Plaintiff was examined by Dr. David Hillman, M.D., who performed an Ophthalmology Consultative Examination. [R. 446-47.] At that examination, Dr. Hillman found that Plaintiff had significant vision loss in the right eye: his vision in that eye “could not be plotted due to poor vision, ” and the only metric obtained demonstrated that, when using the right eye alone, Plaintiff could recognize hand motions from a distance of two feet. [R. 446.] As for his left eye vision, Dr. Hillman found that, when corrected, Plaintiff's visual acuity in the left eye was 20/40. Id. Dr. Hillman noted Plaintiff's left eye was healthy and its field of vision was “essentially full.” Id. This constituted a dramatic improvement from the left eye vision results from 2009. [R. 99.]

         Dr. Hillman's findings are consistent with the 2015 record, which notes Plaintiff's macular degeneration and baseline blindness in the right eye throughout but references only “decreased vision” the left eye, if even that. [R. 254, 260, 468, 483.] Plaintiff has not disputed the 2015 record or consultative examination results with respect to his left eye vision, nor has he indicated his vision in that eye has since declined. [R. 73-93.]

         ii. Plaintiff's Perirectal Abscess and Colostomy Bag

         On February 15, 2015, the alleged disability onset date, Plaintiff was admitted to the hospital with symptoms of gluteal pain, swelling, and draining. [R. 246.] Plaintiff underwent perianal abscess drainage with primary fistulotomy. Id. Plaintiff was then diagnosed with a necrotizing soft tissue infection affecting the right and left perirectal and gluteal areas, the left ischiorectal fossa, and the anterior perineum. [R. 284.] On February 16, and 23, 2015, physicians performed surgeries on Plaintiff to remedy his physical ailments; among them was a sigmoid loop colostomy. [R. 260.]

         On July 2, 2015, Plaintiff attended a follow-up appointment with his surgeon, Dr. Joanne Favuzza, M.D. [R. 477-78.] The surgeon found that Plaintiff's wound was healed and no further dressing changes were needed. Id. The wound site looked good and Plaintiff showed no bodily “fluctuance or swelling.” Id. However, while Plaintiff did complain of right scrotal pain and occasional perineal pain, Dr. Favuzza noted that Plaintiff had not sought treatment for any pain prior to this follow-up visit. Id. In fact, when it came to his pain, Plaintiff indicated he stopped using Tylenol and Ultram for pain management due to their “side effects.” Id. He reported he was instead “self treating his pain [though] he would not disclose how he was ‘dealing' with this pain” Id. Dr. Favuzza noted Plaintiff “should not require any pain medication and will not be receiving any prescriptions for narcotics.” [R. 478.] She referred him to a urologist to discuss his scrotal pain. Id.

         On July 9, 2015, Plaintiff then followed up with Dr. Megan Gayeski, M.D., to whom he reported groin irritation and pain. [R. 473-76.] Plaintiff was prescribed topical creams and referred him to dermatology and urology. Id. Dr. Gayeski reiterated to Plaintiff “that his surgeon [Dr. Favuzza] stated that he should not need narcotics at this time.” [R. 476.]

         There is no indication that Plaintiff sought additional pain treatment beyond that date in the record. In October of 2015, Plaintiff attended his last follow-up appointment with Dr. Favuzza. [R. 658.] At that appointment, it was determined that Plaintiff's groin pain was resolved, and the wound was healed. Id. There were no reported ...

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