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William B. v. Saul

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

September 19, 2019

William B. Plaintiff,
Andrew Marshall Saul, Commissioner of Social Security, Defendant.



         Plaintiff William B. brings this action under 42 U.S.C. § 405(g) challenging the partially favorable decision granting disability benefits. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). The Commissioner's decision is reversed, and this case is remanded.

         I. BACKGROUND

         A. Procedural History

         Plaintiff filed an application for disability benefits on July 31, 2012, alleging disability beginning December 26, 2007. R. 768. Plaintiff's date last insured is September 30, 2011. R. 769. His application was denied initially and upon reconsideration. R. 768. Following a hearing held on December 9, 2014, Administrative Law Judge (ALJ) Cynthia Bretthauer issued an opinion denying benefits on January 22, 2015. R. 13–27. Plaintiff appealed the decision, and, upon the Commissioner's agreed motion to remand, the case was remanded from the U.S. District Court for the Northern District of Illinois. R. 856. Another hearing was held by ALJ Bretthauer on October 5, 2017. R. 789. Plaintiff, represented by an attorney, appeared and testified. R. 791. Dr. Ronald Semerdjian, an impartial medical expert, and Susan Entenberg, an impartial vocational expert (VE), also appeared and testified. Id. Pursuant to the District Court remand order, the Appeals Council directed the ALJ to obtain evidence from a medical expert to clarify the nature and severity of Plaintiff's impairments, determine whether Plaintiff's impairments met or medically equaled the criteria of any listing, particularly 1.07 (Fracture of an upper extremity), give further consideration to Plaintiff's residual functional capacity (RFC), evaluate Plaintiff's alleged symptoms and provide rationale in accordance with disability regulations pertaining to evaluation of symptoms, and obtain, if necessary, supplemental vocational expert testimony to determine what jobs exist in significant numbers for Plaintiff in the national economy. R. 768.

         On November 6, 2017, the ALJ issued a partially favorable decision, finding that Plaintiff was disabled from December 26, 2007 to June 30, 2013. R. 768–82. Under the regulations, "when a case is remanded by a Federal court for further consideration, the decision of the administrative law judge will become the final decision of the Commissioner after remand on your case unless the Appeals Council assumes jurisdiction of the case." 20 C.F.R. § 404.984. There is no evidence that the Appeals Council assumed jurisdiction of this case so the ALJ's decision is the final decision of the Commissioner. Plaintiff now seeks judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g).

         B. Medical background

         The Court will briefly summarize Plaintiff's medical history that is relevant to this appeal. This section does not represent Plaintiff's entire medical history. On December 26, 2007, Plaintiff suffered several injuries after a ten-foot fall off a roof. R. 339. X-rays of the right elbow showed a comminuted fracture of the proximal radius/radial head fracture. R. 356. A right radial head replacement in his elbow was performed on December 28, 2007. R. 358. A February 2008 MRI showed a mild bulge at the L4-L5 and L5-S1 level of his spine but without significant stenosis or impingement neural elements. R. 326. In a March 2008 follow-up, Plaintiff complained of low back pain, numbness in the left thigh, and weakness in the right forearm. R. 300.

         On August 8, 2008, an orthopedic surgeon performed surgery to release the intersection area between the thumb abductors and extensors and the second dorsal compartment radial wrist extensors. R. 329. On April 27, 2009, Plaintiff underwent a functional capacity evaluation (FCE) and was rated at constant lifting 10 pounds, frequent lifting 24 pounds, occasional lifting 50 pounds, and rarely lifting 100 pounds. R. 398. A July 29, 2009 x-ray of Plaintiff's hip revealed no evidence of fracture, dislocation, or gross bony destructive lesion. R. 345. However, a December 2009 MRI suggested a labral tear of his left hip joint. R. 454. On July 8, 2010, Plaintiff had a left hip arthroscopy, with ossicle removal and labral debridement, and an osteal chondroplasty of the femoral head/neck junction in the hip. R. 1041–43.

         Due to a tear in his left wrist, Plaintiff had a left wrist arthroscopy to repair the tear with a synovectomy on August 24, 2009. R. 441. On September 20, 2011, Plaintiff had an arthrogram of the shoulder, which showed a SLAP (superior lateral anterior posterior) lesion, a split tear of biceps tendon, and a partial tear of supraspinatus. R. 540–42. On April 3, 2012, Plaintiff had several procedures on his right wrist: right wrist arthroscopy with debridement of the triangular fibrocartilage complex and ulnocarpal synovitis, ulnar (forearm bone) shortening osteotomy, and distal radius autograft to the osteotomy. R. 611. Due to a failure of consolidation of bone graft, a repair of the ulnar nonunion with iliac crest (from the hip) was performed on September 13, 2012. R. 614.

         On June 13, 2013, Plaintiff had a left shoulder arthroscopy with extensive debridement. R. 706. On April 22, 2014, Plaintiff underwent a second FCE. R. 726. Plaintiff put out a high level of physical effort, and his pain reports (left hip, right elbow, wrist pain) were reliable. Id. The physical therapist, Michael Toman, who wrote the FCE opined that Plaintiff was unable to return to his pre-injury carpenter job because he did not meet the lifting, carrying, or pushing demands of his pre-injury work. However, Mr. Toman stated that Plaintiff could meet the demands for standing, walking, and sitting of his pre-injury job. But in the same FCE, Mr. Toman recommended that Plaintiff should be limited to light work for material handling and limit standing and walking to an "occasional" basis. R. 727.

         C. The ALJ's decision

         The ALJ went through a five-step analysis to determine whether Plaintiff was disabled under the Social Security Act. See 20 C.F.R. § 404.1520(a)(4). At step one of the five-step analysis, the ALJ found that Plaintiff had not been engaging in substantial gainful activity since December 26, 2017 when Plaintiff became disabled. R. 772. At step two, the ALJ found that Plaintiff had the following severe impairments from December 26, 2007 to June 30, 2013: right radial head fracture, status post surgery, with residual intersection syndrome; lumbar spinal arthralgias; left hip arthralgias; and obesity. Id. At step three, the ALJ found that Plaintiff's right radial head fracture status post surgery with residual intersection syndrome met the criteria of listing 1.07 (Fracture of an upper extremity) of 20 C.F.R. Part 404, Subpart P, Appendix 1 from December 26, 2007 to June 20, 2013. R. 773.

         The ALJ began by summarizing Plaintiff's medical history and his subjective complaints. The ALJ gave great weight to Dr. Semerdjian's testimony at the hearing. R. 778. Dr. Semerdjian opined that Plaintiff met listing 1.07 through June 2013 (allowing several months after the September 2012 surgery for healing). R. 777. Because the ALJ found that Plaintiff met listing 1.07 at step three and that Plaintiff was disabled from December 26, 2007 to June 30, 2013, the ALJ did not need to go on to the next step. See 20 C.F.R. § 404.1520(a)(4).

         After determining that Plaintiff was entitled to disability benefits, the ALJ then went through an eight-step analysis to determine if Plaintiff’s disability continued or ended. See 20 C.F.R. § 404.1594(f). At step one, the ALJ already determined that Plaintiff was not performing substantial gainful activity. R. 772. At step two, the ALJ relied on Dr. Semerdjian's finding that Plaintiff no longer met or equaled the severity of an impairment beginning July 1, 2013. R. 778. At step three, the ALJ found that medical improvement occurred as of July 1, 2013. Id. At step four, the ALJ determined that the medical improvement was related to the ability to work because Plaintiff no longer had an impairment or combination of impairments that met or medically equaled the severity of a listing. Id. If the ALJ found that the medical improvement was not related to the ability to work, then the ALJ would have considered if an exception applied. But because the medical improvement was related to the ability to work, the analysis proceeded to step six, where the ALJ determined that Plaintiff's current impairments in combination were severe. Id. At step seven, the ALJ determined that Plaintiff's RFC was to perform light work except Plaintiff can: occasionally push and/or pull with the right upper extremity, frequently stoop, crawl, climb, crouch, and kneel, do no overhead reaching with right upper extremity with weights, and should avoid concentrated exposure to extreme cold. Id. The ALJ noted that an April 2014 FCE supported Dr. Semerdjian's opinion that Plaintiff did not have functional limitations with standing or walking. Id. The ALJ determined that Plaintiff was unable to perform past relevant work since July 1, 2013 because the ALJ limited Plaintiff to light work and Plaintiff's past work as a carpenter was heavy in exertion. R. 781. Finally, at step eight, the ALJ found that beginning July 1, 2013, considering Plaintiff's age, education, work experience, and RFC, there were jobs in significant numbers in the national economy that Plaintiff could perform. Id.


         The reviewing court reviews the ALJ's determination to see if it is supported by "substantial evidence, " meaning "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moore v. Colvin, 743 F.3d 1118, 1120–21 (7th Cir. 2014) (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). Accordingly, the reviewing court takes a very limited role and cannot displace the decision by reconsidering facts or evidence or by making independent credibility determinations. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). "The ALJ is not required to mention every piece of evidence but must provide an 'accurate and logical bridge' between the evidence and the conclusion that the claimant is not disabled, so that 'as a reviewing court, we may assess the validity of the agency's ultimate findings and afford [the] claimant meaningful judicial review.'" Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008) (quoting Young v. Barnhart, 362 F.3d 995, 1002 (7th Cir. 2004)). An ALJ only needs to "minimally articulate his reasons for crediting or rejecting evidence of disability." Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000). But even when adequate record evidence exists to support the ALJ's decision, the decision will not be affirmed if the ALJ does not build ...

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