United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
David Weisman, United States Magistrate Judge.
Veronica H. appeals the Social Security Administration
Commissioner's decision denying her application for
benefits. For the reasons set forth below, the Court
generally grants Plaintiff's motion for summary judgment
, denies Defendant's motion for summary judgment 
and remands this case for further proceedings.
applied for benefits on May 9, 2013, alleging a disability
onset date of June 26, 2012. (R. 235.) Her application was
denied initially on August 2, 2013, and upon reconsideration
on March 6, 2014. (R. 148-68.) Plaintiff requested a hearing,
which was held by an Administrative Law Judge
(“ALJ”) on February 3, 2015. (R. 77.) At the
hearing, Plaintiff amended her onset date to May 23, 2013.
(R. 80-81.) On March 13, 2015, the ALJ issued an unfavorable
decision finding Plaintiff not disabled. (R. 2404-49.) The
Appeals Council declined to review the decision (R. 1-4),
leaving the ALJ's decision as the final decision of the
Commissioner. See Villano v. Astrue, 556 F.3d 558,
561-62 (7th Cir. 2009).
September 3, 2015, Plaintiff filed a complaint in the
Northern District of Illinois. Following briefing by the
parties, this Court remanded the case on July 27, 2017. (R.
2472-78.) Another hearing was held before an ALJ on May 17,
2018. (R. 2340-03.) On June 28, 2018, the ALJ found Plaintiff
not disabled between May 23, 2013 and March 13, 2015. (R.
2517-68.) The Appeals Council declined to review the decision
on September 8, 2018. (R. 2334-39.)
Court reviews the ALJ's decision deferentially, affirming
if it is supported by “substantial evidence in the
record, ” i.e., “‘such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.'” White v. Sullivan,
965 F.2d 133, 136 (7th Cir. 1992) (quoting Richardson v.
Perales, 402 U.S. 389, 401 (1971)). While generous, this
standard “is not entirely uncritical, ” and the
case must be remanded if the “decision lacks
evidentiary support.” Steele v. Barnhart, 290
F.3d 936, 940 (7th Cir. 2002).
the Social Security Act, disability is defined as the
“inability 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). The regulations prescribe a five-part
sequential test for determining whether a claimant is
disabled. See 20 C.F.R. § 404.1520. Under the
regulations, the Commissioner must consider: (1) whether the
claimant has performed any substantial gainful activity
during the period for which he claims disability; (2) if not,
whether the claimant has a severe impairment or combination
of impairments; (3) if so, whether the claimant's
impairment meets or equals any listed impairment; (4) if not,
whether the claimant retains the residual functional capacity
(“RFC”) to perform his past relevant work; and
(5) if not, whether he is unable to perform any other work
existing in significant numbers in the national economy.
Id.; Zurawski v. Halter, 245 F.3d 881, 885
(7th Cir. 2001). The claimant bears the burden of proof at
steps one through four, and if that burden is met, the burden
shifts at step five to the Commissioner to provide evidence
that the claimant is capable of performing work existing in
significant numbers in the national economy. See 20
C.F.R. § 404.1560(c)(2).
one, the ALJ found that Plaintiff had not engaged in
substantial gainful activity since May 23, 2013, the alleged
onset date. (R. 2524.) At step two, the ALJ found that
Plaintiff had the following severe impairments:
“congenital right eye blindness; sleep apnea; knee
degenerative joint disease; history of right ankle fracture;
sciatica/degenerative disc disease; obesity;
depression/bipolar disorder; and post-traumatic stress
disorder.” (Id.) At step three, the ALJ found
that Plaintiff did not have “an impairment or
combination of impairments that meets or medically equals the
severity” of one of the listed impairments. (R. 2525.)
This finding led the ALJ to conclude at step four that prior
to March 14, 2015, Plaintiff had the residual functional
capacity to “perform sedentary work” with certain
exceptions. (R. 2528-29.) At step five, the ALJ determined
that “there were jobs that existed in significant
numbers in the national economy that [Plaintiff] could have
performed.” (R. 2555.) Accordingly, the ALJ concluded
that Plaintiff was not disabled prior to March 14, 2015 under
the Social Security Act, but became disabled on that date.
Medical Opinion Evidence
is required to give a treating physician's opinion
controlling weight if it is “well-supported by
medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial
evidence in [the] case record.” 20 C.F.R §
404.1527(c)(2);Scott v. Astrue, 647 F.3d 734, 739
(7th Cir. 2011). The ALJ must give good reasons for the
weight that she assigns a treating physician's opinion.
Bates v. Colvin, 736 F.3d 1093, 1101 (7th Cir.
2013); Roddy v. Astrue, 705 F.3d 631, 636-37 (7th
Cir. 2013). If an ALJ chooses not to give a treating
physician's opinion controlling weight, “the
regulations require the ALJ to consider the length, nature,
and extent of the treatment relationship, frequency of
examination, the physician's specialty, the types of
tests performed, and the consistency and supportability of
the physician's opinion.” Moss v. Astrue,
555 F.3d 556, 561 (7th Cir. 2009); see also 20
C.F.R. § 404.1527(c).
challenges the ALJ's determination to give the March 2014
and February 2015 opinions of her treating psychiatrist, Dr.
Eler, “little weight” because the opinions - both
of which fall within the disputed disability timeframe - were
inconsistent with: (1) treatment notes that documented high
Global Assessment Functioning (“GAF”) scores at
times; (2) evidence of Plaintiff's improvement; and (3)
evidence Plaintiff had the ability to drive, take
medications, and follow-up with treatment. (R. 2550-51.) With
respect to the GAF scores, the ALJ called into question Dr.
Eler's assignment of a 40 GAF score in March 2014 and
between 30 and 40 in February 2015 when Plaintiff received
GAF scores between 70 and 90 in 2013 (R. 3424-26) and a 55
GAF in February 2014 (R. 3420). GAF scores, “without
more, carry little probative value.” Land v.
Colvin, No. 12 C 9189, 2014 WL 2198373, at *5 (N.D. Ill.
May 27, 2014). They are viewed as problematic as they only
provide a “snapshot of a particular moment”
rather than a longer-term prognosis. Sambrooks v.
Colvin, 566 Fed. App'x 506, 511 (7th Cir. 2014);
see, e.g., Barnica v. Colvin, No.
13-C-1012, 2014 WL 4443279, at *5 (N.D. Wis. Sept. 9, 2014)
(“GAF scores can . . . be troublesome if an ALJ plucks
a single score out of the record and places too much emphasis
on it.”). Here, the ALJ did not error by pointing out
significant changes in Plaintiff's GAF score in a
relatively short period of time. Rather than
“cherry-picking” a single inconsistent GAF score,
the ALJ cited several differing scores from the same provider
that cast doubt on Dr. Eler's March 2014 and February
the ALJ adequately addressed Plaintiff's GAF scores, she
failed to sufficiently explain how Plaintiff's modest
response to treatment undermines Dr. Eler's opinions.
See, e.g., Scott v. Astrue, 647 F.3d 734,
739-40 (7th Cir. 2011) (“There can be a great distance
between a patient who responds to treatment and one who is
able to enter the workforce.”); Bauer v.
Astrue, 532 F.3d 606, 609 (7th Cir. 2008) (noting that
“[a] person who has a chronic disease, whether physical
or psychiatric, and is under continuous treatment for it with
heavy drugs, is likely to have better days and worse
days”). In March 2014, Dr. Eler found Plaintiff
markedly limited in the ability to, among other things, (1)
remember locations and work like procedures; (2) understand
and remember detailed instructions; (3) maintain attention
and concentration for extended periods; and (4) work with
co-workers or peers without distracting them or exhibiting
behavioral extremes. (R. 1201-03.) Dr. Eler's findings in
February of 2015 again confirmed these various limitations in
addition to others. (R. 3406.) Although the ALJ discounted
these opinions in part because Plaintiff was “generally
progressing/improving, ” she failed to point to
specific evidence of this improvement that adequately
undermines the assessment of a treating physician. (R. 2550.)
In addition, the ALJ's reliance on Plaintiff's
activities of daily living, including her ability to
“drive, take numerous medications, [and] follow up with
treatment, ” overlooked the critical differences
between activities of daily living and activities in a
full-time job. (R. 2550.) See, e.g., Scrogham v.
Calvin, 765 F.3d 685, 700 (7th Cir. 2014) (claimant
rarely driving, mowing the lawn, and performing yardwork was
not evidence that he could participate in gainful activity).
The ALJ needed to include a more fulsome discussion of how
Plaintiff's sporadic activities of daily living
contradicted the findings of her treating physician regarding
Plaintiff's ability to function in a work environment.
See, e.g., Scott v. Astrue, 647 F.3d 734,
739 (7th Cir. 2011) (“An ALJ must offer good reasons
for discounting the opinion of a treating physician.”).
Critically, the ALJ also failed to assess Dr. Eler's
opinion using the required regulatory factors. See
20 C.F.R. § 404.1427(c) (stating that an ALJ “will
evaluate every medical opinion” by considering the
nature, extent, and length of the treatment relationship, the
frequency of examination, the physician's specialty, and
the consistency and supportability of the opinion). Before
discounting the opinion of a psychiatrist who treated
Plaintiff on a regular basis for years and whose treatment
focused on Plaintiff's disabling impairments, the ALJ had
an obligation to assess these regulatory factors.
next argues that the ALJ found the March 2014 opinion of her
treating internist, Dr. Forys, was “not fully
supported” without adequate explanation, and failed to
address Dr. Forys' December 2017 statement entirely. (R.
2548, 2552.) The Court agrees that the ALJ did not
sufficiently discuss why she found Dr. Forys' conclusions
regarding Plaintiff's restrictions not fully supported.
The ALJ failed to identify inconsistent evidence to challenge
Dr. Forys' March 2014 findings, which were generated
during the heart of the disputed disability period (May 23,
2013 through March 13, 2015). Instead, the ALJ provided a
sweeping criticism of the opinions of Dr. Forys and Dr.
Birn-Forys without much more: “These doctors apparently
relied quite heavily on the subjective report of symptoms and
limitations provided by the claimant, and seemed to
uncritically accept as true most, if not all, of what the
claimant reported.” (R. 2545.) Dr. Forys' March
2014 treatment notes indicate, however, that clinical
findings supported his conclusions and corroborated
Plaintiff's complaints of severe knee pain. Among other
diagnostic findings, he cited cracking and popping in the
knees, a positive x-ray for joint space narrowing, and a
positive straight leg raise test. (R. 1189.) If an ALJ
declines to give controlling weight to the opinion of a
treating physician, a sound explanation must be given for
that decision.” Punzio v. Astrue, 630 F.3d
704, 710 (7th Cir. 2011). Such an explanation is lacking
here. Moreover, the ALJ did not assess Dr. Forys' opinion
using the required regulatory factors. See 20 C.F.R.
§ 404.1427(c). As Dr. Forys regularly treated Plaintiff
(once a month or so) for several years and the nature of the
treatment focused on Plaintiff's disabling physical
impairments, the ALJ needed to provide a more thorough
explanation for why Dr. Forys' opinion was not given more
than “limited weight.” (R. 2548.) The Court also
agrees that the ...