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Molly K. v. Saul

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

August 16, 2019

MOLLY K., Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.


          Hon. Jeffrey Cummings United States Magistrate Judge

         Claimant Molly K. (“Claimant”)[1] 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 [8] is granted and the Commissioner's motion for summary judgment [19] is denied.

         I. BACKGROUND

         A. Procedural History

         On July 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.

         B. Medical Evidence

         1. Evidence from Claimant's Treatment History

         Claimant 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.[2] 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).

         Claimant's 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.[3] (R. 843).

         Claimant 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. 662-63).

         On June 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).

         2. Evidence from State-Agency Doctors

         On 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.[4] (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).

         On 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).

         State-agency 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).

         3. Evidence from Claimant's Treating Physician

         On 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).

         C. Evidence From Claimant's Testimony

         Claimant 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).

         Claimant 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).

         D. The ALJ's Decision

         On 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. (R. 26).

         Before 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).

         Based 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 ...

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