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Charles B. v. Saul

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

August 1, 2019

CHARLES B., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.



         Plaintiff Charles B.[1] seeks judicial review of the final decision of Andrew M. Saul, Commissioner of Social Security, denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. Charles moves for a reversal of the ALJ's decision and an award of benefits, or alternatively, a remand, while the Commissioner asks for affirmance of the ALJ's decision to deny benefits. For the reasons stated below, the ALJ's decision is reversed and this case is remanded for further proceedings consistent with this opinion.

         I. BACKGOUND

         Charles graduated high school and previously worked as a loader, packer, and school bus driver. (R. 39, 54, 69). The medical record indicates that Charles has long suffered from neck and back impairments. Charles originally injured his back in 1999 while lifting heavy boxes at work. Id. at 43, 794. Since then, he has undergone three surgeries on his neck and four surgeries on his back. Id. at 51. Charles received benefits for a closed period between December 15, 2007 and June 2, 2010 following a work-related injury to his cervical spine in late 2007 which resulted in a large disc herniation at ¶ 2-C3 and a smaller herniation at ¶ 3-C4. Id. at 92-103. Charles testified that he has eighteen screws, nine spacers, two rods, four hinges, and eighteen nuts in his neck. Id. Four screws, two rods, and four nuts had to removed from his back when he was having back pain. Id. Charles uses a cane or walker when ambulating. Id. at 60. Charles last worked in November 2014 as a school bus driver when he alleges that symptoms from severely herniated C5, C6, and C7 discs in his neck forced him to stop working. Id. at 54-56.

         Charles filed an application for DIB on July 25, 2014, alleging he became disabled on November 24, 2014 due to depression, anxiety, high blood pressure, sleep apnea, chronic pain, and spinal fusion. (R. 225-26, 244). Charles is also morbidly obese: he is 6'5” and in 2017 weighed as much as 377 pounds with a body mass index of 44.7. Id. at 839. Charles's DIB application was initially denied on December 1, 2015, and upon reconsideration on April 12, 2016, after which he requested an administrative hearing. Id. at 104-29, 150-51. On September 12, 2017, Charles, represented by counsel, appeared and testified at a hearing before ALJ Matthew Johnson. Id. at 34-81. The ALJ also heard testimony from vocational expert (“VE”) Pamela Tucker. Id. at 69-79.

         On October 4, 2017, the ALJ issued a decision denying Charles's application for DIB. (R. 16-28). The opinion followed the required five-step evaluation process. 20 C.F.R. § 404.1520. At step one, the ALJ found that Charles had not engaged in substantial gainful activity since November 24, 2014, his alleged onset date. Id. at 18. At step two, the ALJ found that Charles had the severe impairments of obesity, spine disorder status post cervical fusion, and degenerative disc disease. Id. The ALJ found Charles's hypertension, sleep apnea, gastroesophageal reflux disease, and depression and anxiety to be non-severe. Id. at 18-19. At step three, the ALJ determined that Charles 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. §§ 404.1520(d), 404.1525, and 404.1526). Id. at 20.

         The ALJ then concluded that Charles retained the residual functional capacity (“RFC”) to perform sedentary work[2] as defined in 20 C.F.R. § 404.1567(a), except that:

he can handle items frequently with the left hand or the right hand. He can perform fingering on a frequent basis with the left hand or the right hand. He cannot climb ladders, ropes, or scaffolds or kneel. He can occasionally climb ramps or stairs, balance, stoop, crouch, or crawl. He can frequently work in hazardous environments such as around unprotected heights; with moving mechanical parts; or operate a motor vehicle. He can assume no position for longer than thirty minutes. If he does sit, stand, or walk for thirty minutes at one time, he must be allowed to assume a different position for five minutes before resuming the prior position without abandoning his workstation or losing concentration on his assigned work duties. He is limited to being allowed to use an assisted device up to 100% of the time for balance and/or ambulation.

(R. 21). Based on this RFC, the ALJ determined at step four that Charles could not perform his past relevant work as a loader and a packer. Id. at 26. At step five, the ALJ found that there were jobs that exist in significant numbers in the national economy that Charles could perform. Id. at 26-27. Specifically, the ALJ found Charles could work as a circuit board assembler, document preparer, and circuit board inspector. Id. at 27. Because of this determination, the ALJ found that Charles was not disabled. Id. The Appeals Council denied Charles's request for review on February 18, 2018, leaving the ALJ's decision as the final decision of the Commissioner. Id. at 1-6; McHenry v. Berryhill, 911 F.3d 866, 871 (7th Cir. 2018).


         Under the Social Security Act, a person is disabled if he is unable “to engage in 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.” 42 U.S.C. § 423(d)(1)(A). To determine disability within the meaning of the Social Security Act, the ALJ conducts a sequential five-step inquiry, asking: (1) Is the claimant presently unemployed? (2) Does the claimant have a severe impairment? (3) Does the claimant's impairment meet or equal an impairment specifically listed in the regulations? (4) Is the claimant unable to perform a former occupation? and (5) Is the claimant unable to perform any other work in the national economy? Young v. Sec'y of Health & Human Servs., 957 F.2d 386, 389 (7th Cir. 1992); Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985); 20 C.F.R. § 404.1520(a)(4). “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, 760 F.2d at 162 n.2.

         Judicial review of the ALJ's decision is limited to determining whether it adequately discusses the issues and is based upon substantial evidence and the proper legal criteria. See Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009); Scheck v. Barnhart, 357 F.3d 697, 699 (7th Cir. 2004). Substantial evidence means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971)). In reviewing an ALJ's decision, the Court may “not reweigh the evidence, resolve conflicts, decide questions of credibility, or substitute [its] own judgment for that of the Commissioner.” Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). Although the Court reviews the ALJ's decision deferentially, the ALJ must nevertheless “build an accurate and logical bridge” between the evidence and his conclusions. See Steele v. Barnhart, 290 F.3d 936, 938, 941 (7th Cir. 2002) (internal citation and quotations omitted). When the ALJ's “decision lacks evidentiary support or is so poorly articulated as to prevent meaningful review, the case must be remanded.” Id. at 940.

         The ALJ found Charles not disabled at step five of the sequential analysis because he retains the RFC to perform other work that exists in significant numbers in the national economy. Charles asserts that the ALJ committed several reversible errors. First, Charles argues that the ALJ erred at step two by finding that his sleep apnea and depression and anxiety are non-severe impairments. Second, Charles contends that the ALJ mischaracterized the evidence when determining his RFC. Third, Charles argues the ALJ improperly discounted the opinions of his treating physician and surgeon. Fourth, Charles asserts that the ALJ improperly assessed his subjective symptoms statements. The Court agrees that the ALJ improperly assessed Charles's RFC by failing to consider the combined impact of Charles's impairments, mischaracterizing the evidence, and rejecting Charles's treating physician's and surgeon's opinions. Because these errors require remand, the Court need not address Charles's remaining argument that the ALJ's subjective symptom evaluation was patently wrong.

         A. Non-Severe Impairments

         Charles first argues that the ALJ erred in finding that his obstructive sleep apnea and anxiety and depression were non-severe impairments at step two. The ALJ determined that Charles's obstructive sleep apnea was not severe because the state agency physicians opined that Charles's sleep-related breathing disorders were not a severe impairment and “the medical records documented no persistent symptoms of obstructive sleep apnea and few if any complaints of daytime fatigue.” (R. 19). The ALJ also concluded that Charles's depression and anxiety were non-severe because he “gets good benefit and control on his medication regime which consists of only psychotropic medications prescribed by his primary care physician.” Id. The ALJ noted that Charles takes Duloxetine and Xanax but that he does not see a psychiatrist, psychologist, therapist, or counselor and has not been psychiatrically hospitalized. Id. The ALJ then proceeded to consider the four broad areas of mental functioning, also known as the “paragraph B” criteria. The ALJ determined that Charles has: (1) no limitation in understanding, remembering, or applying information; (2) no limitation in interacting with others; (3) mild limitations in concentration, persistence, or pace; and (4) no limitation in adapting or managing oneself. Id. at 19-20. The ALJ found Charles's obesity, spine disorder status post cervical fusion, and degenerative disc disease are severe impairments and proceeded to the remaining steps of the five-step sequential evaluation process. Id. at 18, 20-28.

         At step two, the ALJ determines whether the claimant has a “severe medically determinable physical or mental impairment ... or a combination of impairments that is severe....” 20 C.F.R. § 404.1520(a)(4)(ii). Step two is a threshold step and “[a]s long as the ALJ determines that the claimant has one severe impairment, the ALJ will proceed to the remaining steps of the evaluative process.” Castile v. Astrue,617 F.3d 923, 926-27 (7th Cir. 2010). Here, the ALJ's failure to find Charles's obstructive sleep apnea and depression and anxiety as a severe impairment at step two is not a reversible error because the ALJ categorized three other impairments as severe and proceeded to step four. Arnett v. Astrue,676 F.3d 586, 591 (7th Cir. 2012) (stating “even if there was a mistake at Step 2, it does not matter. Deciding ...

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