United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
Jeffrey Cummings United States Magistrate Judge
Molly K. (“Claimant”) brings a motion for summary
judgment to reverse the final decision of the Commissioner of
Social Security (“Commissioner”) that denied
Claimant's claim for Supplemental Security Income
(“SSI”) under Title VI of the Social Security
Act. 42 U.S.C. §§ 1382c(3)(A). The Commissioner has
brought a cross-motion for summary judgment seeking to uphold
the Social Security Agency's decision to deny SSI
benefits. The parties have consented to the jurisdiction of
the United States Magistrate Judge pursuant to 28 U.S.C.
§ 636(c). This Court has jurisdiction to hear this
matter pursuant to 42 U.S.C. §§ 405(g) and
138(c)(3). For the reasons stated below, Claimant's
motion for summary judgment  is granted and the
Commissioner's motion for summary judgment  is
29, 2014, Claimant filed a disability application alleging a
disability onset date of February 2, 2014. (R. 23). Her claim
was denied initially on January 7, 2015 and upon
reconsideration on June 15, 2015. (R. 90, 122). On August 29,
2017, an Administrative Law Judge (“ALJ”) issued
a written decision denying benefits to Claimant. (R. 23-36).
The Appeals Council denied review on March 9, 2018, making
the Appeals Council's decision the Commissioner's
final decision. (Tr. 1-10). Zurawski v. Halter, 245
F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed
this action in District Court.
Evidence from Claimant's Treatment History
suffers from lower back pain, fibromyalgia, anxiety, and
depression. On May 6, 2014, Claimant was admitted to
UnityPoint Methodist Hospital in Peoria, Illinois with
complaints of depression and lower back pain that did not
radiate into her legs. (R. 683). Treating physician Dr.
Mohammed Shakaib noted severe pain that prevented Claimant
from performing a straight leg test. An MRI of Claimant's
lumbar spine showed no disc herniation or spinal stenosis
though degenerative changes were noted throughout the lumbar
spine and at ¶ 12-L1. (R. 685-86). Claimant was given an
epidural injection that only provided partial relief for four
to five days. (R. 470).
primary physical pain is related to her fibromyalgia. She
began treatment with rheumatologist Dr. Vaughn Hanna in 2004.
(R. 980). The record contains multiple treatment notes from
Dr. Hanna showing that Claimant had no swelling in her
peripheral joints, no weakness or focal neurological
deficits, and an active range of motion in her cervical
spine, lumbar spine, shoulders, and hips. (R. 536, 732).
Nevertheless, Dr. Hanna credited Claimant's multiple
complaints of fibromyalgia pain and prescribed an array of
pain medications and muscle relaxants to treat it. These
included Norco, Naproxen, methadone, Lyrica, Valium,
Celebrex, and Fentanyl. (R. 537, 608). Dr. Hanna prescribed
these medications throughout Claimant's alleged
disability period and often did so by combining them with one
another. On March 18, 2017, Dr. Hanna approved the ongoing
use of narcotics for Claimant by filing a Letter of Medical
Necessity for Long-Term Opioid Use with the Illinois
Department of Healthcare and Family Services. The letter
states that Claimant required continued use of Norco to treat
her fibromyalgia pain without tapering off it. (R. 843).
also suffers from depression and anxiety. On November 18,
2014, Dr. Atul Sheth evaluated her mental status. Claimant
told Dr. Sheth that she was stressed by her fibromyalgia pain
and by financial difficulties that required her to live in
her mother's basement. (R. 648). Claimant alleged
anxiety, difficulty breathing, and feeling mentally foggy.
Dr. Sheth prescribed Klonopin, Wellbutrin, and Celexa. (R.
650). He noted on February 24, 2015 that Claimant's
condition had improved and continued her medications. (R.
24, 2016, Claimant began treatment with psychiatrist Dr.
Benjamin Shepherd. Dr. Shepherd noted that Claimant was
extremely fatigued during the day but still needed to take
Ambien to sleep at night. He diagnosed an anxiety disorder
and a major depressive disorder. (R. 855). Claimant continued
her treatment with Dr. Shepherd through at least January 10,
2017. Dr. Shepherd found on that date that Claimant's
mood was euthymic, her attention span was within normal
limits, and her fund of knowledge was good. Dr. Shepherd
revised his diagnosis to reflect an anxiety disorder and a
major depressive disorder in partial remission. (R. 861).
Evidence from State-Agency Doctors
December 11, 2014, Dr. Charles Carlton examined Claimant at
the request of the SSA and issued a report. Dr. Carlton's
report shows that he reviewed a “partial medical
record” without having access to Claimant's
complete records including those from rheumatologist Dr.
Hanna. (R. 508). Dr. Carlton noted that Claimant
showed multiple tender points throughout her body that were
consistent with fibromyalgia but that she also had a full and
painless range of motion in all joints except the hips, knees
and the lumbar spine. She also had normal grip s strength
bilaterally as well as normal fine and gross motor skills in
both hands. (R. 511). Dr. Carlton concluded that Claimant
could lift more than 20 pounds, “safely” sit and
stand, and could walk more than 50 feet without an assistive
device. (R. 511).
January 7, 2015, state-agency medical expert Dr. Vidya Madala
found that Claimant could carry out light work, meaning that
she could occasionally push or pull up to 20 pounds and lift
or carry up to 10 pounds frequently. Claimant could also
stand and stand/walk up to six hours a day. (R. 97). At the
time that Dr. Madala issued her report, however, the SSA had
not determined that fibromyalgia constituted a severe medical
impairment for Claimant. (R. 95). Based on additional records
that demonstrated such an impairment, Dr. Mina Khorshidi
concluded on June 11, 2015 that Claimant was more limited
than Dr. Madala stated. Dr. Khorshidi found that Claimant
could frequently lift or carry up to 10 pounds, sit for six
hours a day, but only stand or walk up to four hours. Dr.
Khorshidi also noted that Claimant was obese by having a body
mass index of 34. (R. 115). Claimant could occasionally climb
ramps and stairs, crouch, stoop, and crawl but could never
climb ladders, ropes, or scaffolds. (R. 116).
psychologist Dr. Ellen Rozenfeld also issued a report
concerning Claimant's mental status on May 14, 2015. Dr.
Rozenfeld found that Claimant would be moderately limited in
her ability to carry out detailed instructions, maintain
attention for extended periods, and carry out a normal
workday without interruptions from her psychological
symptoms. She would have no significant restrictions in her
capacity to carry out short and simple instructions, would be
able to maintain work attendance, and could make
“simple work-related decisions.” (R. 117). Dr.
Rozenfeld further found that Claimant could tolerate
“typical supervision” and perform simple work
“of a routine and repetitive type.” (R. 118).
Evidence from Claimant's Treating Physician
January 22, 2015, Dr. Hanna issued a medical letter stating
that Claimant's medical condition rendered her
“totally disabled.” (R. 534). Dr. Hanna
supplemented this statement on May 26, 2017 with a
Fibromyalgia Residual Functional Questionnaire and an RFC
assessment for Claimant. He stated that Claimant would be
absent from work more than three times a month and would
suffer sedation from her medications. (R. 981). Pain and
fatigue would also impair her ability to work full time. (R.
981, 982). Claimant would only be able to sit for 30 minutes
at a time, stand for 15 minutes, and walk for 10 minutes. (R.
983). Dr. Hanna also included other exertional restrictions
by limiting Claimant to lift and carry ten to 15 pounds
occasionally but only five pounds frequently. She could not
push or pull from a sitting position for six hours a day,
would be off task up to 30 percent of the time, and would be
absent from work five or more days each month. (R. 985).
Evidence From Claimant's Testimony
appeared at the administrative hearing held on June 15, 2017.
She told the ALJ that she sees rheumatologist Dr. Hanna every
three months for fibromyalgia and also seeks treatment for
depression every three months from psychiatrist Dr. Ben
Shepherd. (R. 49, 63). Claimant lives alone and has custody
of her two small children two days a week. She tries to drive
them to school but her mother often has to drive instead when
Claimant's pain and fatigue prevent her from doing so.
(R. 52-53; 64; 71, “Just trying to even get them where
they need to go, like school in the morning and stuff like
that is a huge issue”). Claimant is unable to cook for
her children when they are with her and often misses their
baseball games and parent-teacher conferences. (R. 71).
told the ALJ that her symptoms wax and wane and that she has
good days and bad days, though the bad days outnumber the
good ones. (R. 74). On good days Claimant is able to get out
of the house, visit people, and do errands; on bad days she
struggles to get the mail. (R. 74). Her symptoms include
nausea, pain, migraine headaches, and fatigue. (R. 64).
Claimant stated that she performs only a few household
chores. (R. 66-67). A friend helps her do many normal tasks
such as making the bed or taking out the trash. (R. 68-69).
Claimant also needs help at times with bathing and normally
showers only once every three days. (R. 74). Sleep is not
refreshing for Claimant and she is exhausted only hours after
awakening even if she has slept all night. (R. 71). At times
she needs to nap up to four hours a day and sometimes sleeps
for periods as long as 26 to 32 hours. (R. 72).
The ALJ's Decision
August 29, 2017, the ALJ issued a decision finding that
Claimant was not disabled. Applying the five-step sequential
analysis that governs disability decisions, the ALJ found at
Step 1 that Claimant had not engaged in substantial gainful
activity since her application date of July 29, 2014. (R.
25). Claimant's severe impairments at Step 2 were a spine
disorder, fibromyalgia, an affective disorder, and an anxiety
disorder. (R. 25). None of these impairments met or medically
equaled a listing at Step 3 either singly or in combination.
moving to Step 4, the ALJ considered Claimant's testimony
on the severity and frequency of her symptoms and found that
they “were not entirely consistent with the medical
evidence.” (R. 29). The ALJ also assigned weights to
the reports of several medical experts. She gave great weight
to non-examining expert Dr. Khorshidi's finding that
Claimant could carry out light work but assigned little
weight to the report of treating physician Dr. Hanna, who
found that Claimant was significantly more restricted. (R.
33-34). The ALJ also gave “significant” weight to
the report of state-agency psychologist Dr. Rozenfeld. (R.
33). Based on these findings the ALJ concluded that Claimant
had the residual functional capacity (“RFC”) to
carry out sedentary work as that term is defined under 20
C.F.R. § 404.1567(a) except that Claimant could only
walk or stand for four hours in an eight-hour workday. She
could occasionally climb ramps and stairs but never climb
ladders, ropes or scaffolds. Claimant's mental
impairments limited her to tolerating “only a few
changes” in a routine work setting, performing simple,
routine, and repetitive tasks, and being off task up to 15
percent of the time. (R. 28).
on the testimony of a vocational expert (“VE”),
the ALJ found at Step 4 that a person with Claimant's RFC
would be unable to perform Claimant's past relevant work
as a massage therapist. (R. 34). The VE testified that jobs
existed in the national economy that a person with
Claimant's RFC assessment could perform. Accordingly, the
ALJ determined at Step 5 that ...