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Lauren J. v. Saul

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

November 7, 2019

LAUREN J., Plaintiff,
ANDREW M. SAUL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Lauren J.[1] seeks judicial review of the final decision of the Commissioner of Social Security denying her application for Disability Insurance Benefits. Specifically, Lauren seeks an award of benefits, or in the alternative, a remand to the Commissioner for further proceedings. The Commissioner filed a motion for summary judgment, asking the Court to affirm the ALJ's denial of benefits. For the reasons set forth below, the ALJ's decision is reversed and this case is remanded for further proceedings consistent with this Memorandum Opinion and Order.

         I. BACKGROUND

         On September 30, 2011, Lauren was performing as a dancer for Disneyland Resort in California when she felt a snap in her mid-back. (R. 456). Days later, she was presented to a Disneyland doctor, who was the first of many doctors to examine Lauren's spine. Id. at 457. Dr. William Shapiro diagnosed Lauren with an acute thoracic spine sprain and prescribed her anti- inflammatory medication and physical therapy. Id. Lauren was sent back to work but restricted to modified work with no dancing or lifting greater than 10 pounds. Id.

         When the pain in her back and neck worsened and Lauren began feeling numbness and tingling in her fingers, (see, e.g., R. 525, 534, 539), she pursued medical help in connection with a workers' compensation claim. In the two years following her injury, Lauren received treatment from at least eight doctors in California, including specialists in orthopedic surgery and occupational medicine. Id. at 312-21, 576-83. Lauren likewise received several MRI scans, which showed varying levels of cervical and thoracic spinal injury. For example, an MRI scan from May 2012 indicated that Lauren had “a C6-7 disc herniation in the cervical and [ ] a disc herniation at T7-8 and T9-10 with a sequestered fragment at that point and also degeneration at T8-9 left side.” Id. at 489. Whereas an earlier scan from November 2011 indicated a “moderate right paracentral disc protrusion at C6-C7 . . . a minimal disc bulge . . . at C5-C6 without significant central or foraminal stenosis” and a “possible disc extrusion posterior to the T9 vertebral body . . . .” Id. at 533. Lauren was prescribed various medicines for her pain, such as Medrol Doesepak, Tramadol, Norco, Vicodin, and Lidoderm patches. Id. at 221, 313-14. In addition, Lauren received epidural injections to her cervical spine and thoracic spine. Id. at 410, 440. After exhausting Lauren's non-surgical treatment options, it was recommended that she have spinal surgery. Id.

         Around July 2013, after being out of work for nearly 2 years, Lauren moved back to Chicago to live with her mother and step-father. (R. 569, 573, 583, 682). She continued to seek medical treatment for her symptoms, which by that time included: neck pain, upper back pain, numbness and tingling in her fingers, and muscle spasms throughout her right cervical musculature and arms. Id. at 410, 434. According to Lauren, standing, walking, and sitting exacerbated her symptoms. Id. at 410. While in Chicago, Lauren was evaluated by a psychologist and received treatment from a pain specialist and a neurosurgeon. Id. at 611-16, 672-79, 681-88. As part of Lauren's workers' compensation claim, she was also evaluated by California orthopedic surgeon, Dr. Steven Silbart, in February 2016. By that time, Lauren reported constant numbness in some of her fingers, as well as burning and tingling. Id. at 656. She also stated that she had neck and back pain, which were made worse by: looking up and down, bending, stooping, sitting more than 15-20 minutes, standing for more than a few minutes, and walking more than a block. Id. at 655-57. Lauren additionally informed Dr. Silbart that she was beginning to feel some numbness and tingling in her feet, and that she had an episode of bowel control loss. Id. at 657.

         Lauren filed applications for disability benefits in January 2014, alleging disability beginning October 15, 2011. (R. 23). Lauren's claims were initially denied on May 8, 2014, and upon reconsideration on November 25, 2014. Id. Upon Lauren's written request for a hearing, she appeared and testified at a hearing held on July 12, 2016 before ALJ Joel G. Fina. Id. at 34. The ALJ also heard testimony from a medical expert, Dr. Ashok G. Jilhewar, and a vocational expert, Glee Ann L. Kehr. Id. at 23.

         On August 30, 2016, the ALJ issued a decision denying Lauren's applications for disability benefits. (R. 34). The opinion followed the required five-step evaluation process. 20 C.F.R. § 404.1520. At step one, the ALJ found that Lauren had not engaged in substantial gainful activity since October 15, 2011, the alleged onset date. Id. at 25. At step two, the ALJ found that Lauren had the severe impairments of chronic pain syndrome secondary to degenerative disc disease of the cervical and thoracic spine with cervical radiculopathy. Id. At step three, the ALJ determined that Lauren 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 27.

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

can never climb ladders, ropes or scaffolds but can occasionally climb ramps or stairs. The claimant can occasionally balance, stoop or crouch but can never kneel or crawl. She can perform frequent reaching bilaterally except that she can only occasionally reach overhead bilaterally. She can engage in frequent handling of objects defined as gross manipulation and frequent fingering, defined as fine manipulation. The claimant must avoid concentrated exposure to dangerous moving machinery and must avoid all exposure to unprotected heights.

(R. 28). Based on this RFC, the ALJ determined at step four that Lauren could not perform her past relevant work as a dancer, waitress, or bartender. Id. at 32. At step five, the ALJ found that there were jobs that exist in significant numbers in the national economy that Lauren could perform. Id. at 33-34. Specifically, the ALJ found Lauren could work as a telephone clerk, an order clerk, or an account clerk. Id. at 33. Because of this determination, the ALJ found that Lauren was not disabled. Id. at 34. The Appeals Council denied Lauren's request for review on September 12, 2017, leaving the ALJ's decision as the final decision of the Commissioner. Id. at 1; McHenry v. Berryhill, 911 F.3d 866, 871 (7th Cir. 2018).


         Under 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). To determine whether a claimant is disabled, the ALJ conducts a five-step inquiry: (1) whether the claimant is currently unemployed; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals any of the listings found in the regulations, see 20 C.F.R. § 404, Subpt. P, App. 1 (2004); (4) whether the claimant is unable to perform her former occupation; and (5) whether the claimant is unable to perform any other available work in light of her age, education, and work experience. 20 C.F.R. § 404.1520(a)(4); Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). These steps are to be performed sequentially. 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.” Clifford, 227 F.3d at 868 (quoting Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985)).

         Judicial review of the ALJ's decision is limited to determining whether the ALJ's findings are supported by substantial evidence or based upon a legal error. Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). “Although this standard is generous, it is not entirely uncritical.” Steele, 290 F.3d at 940. Where the Commissioner's decision “lacks evidentiary support or is so poorly articulated as to prevent meaningful review, the case must be remanded.” Id.

         The ALJ found Lauren not disabled at step five of the sequential analysis because she retains the RFC to perform other work that exists in significant numbers in the national economy. Lauren asserts that the ALJ committed several reversible errors. First, Lauren argues that the ALJ erred in finding that her impairments did not meet Listed Impairments 1.04, 12.04, and 12.15. Second, Lauren asserts that the ALJ erred in failing to give controlling weight to treating physician Dr. Timothy Lubenow. Third, Lauren contends that the ALJ erred because the vocational expert's testimony was inconsistent with her RFC. Fourth, Lauren states that the ALJ relied upon multiple erroneous facts to support his denial of benefits.

         The Court finds that the ALJ failed to properly weigh the opinion of treating physician Lubenow.[2] Accordingly, for the reasons ...

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