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Sarah J. v. Saul

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

November 15, 2019

SARAH J., Plaintiff,
v.
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.

          MEMORANDUM OPINION AND ORDER [2]

          GABRIEL A. FUENTES, UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Sarah J.[3] ("Plaintiff), has moved for summary judgment seeking reversal or remand of the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her claims for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB"), brought pursuant to Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 405(g), 423. (D.E. 11, 12: Pl.'s Mot. for Sum. J. and Mem. in Support of Sum. J.) The Commissioner has filed his own motion seeking affirmance of the decision denying benefits (D.E. 24: Def.'s Mem. in Support of Sum. J.), and Plaintiff has filed a reply. (D.E. 26.) For the following reasons, Plaintiffs motion for remand is granted and the Commissioner's motion is denied.

         I. PROCEDURAL HISTORY

         Plaintiff filed an application for benefits on April 1, 2013, alleging that she was disabled due to chronic discoid lupus ("DLE"), [4] cognitive delays and dyslexia, and that her disability began on March 1, 2013. (R. 187, 199.) Her date last insured was June 30, 2017. (R. 565.) After her claims were denied, Plaintiff participated in a hearing before an Administrative Law Judge ("ALJ") on November 17, 2014. (R. 16.) The ALJ issued a ruling on May 12, 2015, finding that Plaintiff was not disabled. (R. 16 - 24.) On appeal, the district court issued a written opinion remanding the case on the ground that the ALJ had not adequately explained his reasons for discounting the opinion of Plaintiff s treating doctor, David Ellens, M.D. Johnson v. Berryhill, No. 16 C 8850, 2017 WL 3620807 at *2 (N.D.I11. August 23, 2017) ("Johnson F). The court declined to address Plaintiffs other arguments but instructed that on remand, the ALJ was to "reevaluate Plaintiffs physical and mental impairments and RFC, considering all of the evidence of record." Id. at * 12.

         The Appeals Council then remanded the case for the ALJ to take further proceedings consistent with the opinion of the District Court. (R. 683.). Thereafter, on March 5, 2018, Plaintiff participated in a second hearing before the same ALJ at which Plaintiff and a vocational expert

         ("V.E.") testified; on March 30, 2018 the ALJ issued a second ruling finding Plaintiff was not disabled. Plaintiff appealed, and the Appeals Council declined to review the ALJ's decision, making it the final decision of the Commission. 20 C.F.R. § 404.981; Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015).

         II. BACKGROUND

         A. Medical Evidence

         Plaintiff has been treated for DLE, primarily involving the scalp, since 2009. In late 2012, just prior to her alleged onset date, Plaintiff began experiencing a flare-up of her lupus symptoms, including hair loss, the increase of sores, boils, and dry patches of skin on her head and elsewhere, and sore joints.[5] See Johnson I, 2017 WL 3620807 at *3-4. Between March 2013 and December 2014, Plaintiff had regular appointments with dermatologist, Michelle Ovando, M.D., rheumatologist, Raymond Kazmar, M.D., and internist, David Ellens, M.D. (R. 344, 351, 358, 394, 402, 488-89.) These doctors prescribed Plaintiff a number of different medications, including Plaquenil, [6] Bactrim to treat an infection on her scalp, lotions and creams for her skin, and the steroid Prednisone. (Id., R. 307.) Several months later, Bactrim was discontinued due to unspecified side effects. (R. 352.)

         At these appointments, at times Plaintiff complained of fatigue, tiredness and knee pain, in addition to her skin problems on her scalp. (R. 393-94, 483, 485.) In October 2013, Dr. Kazmar diagnosed arthritis pain in the knees and spine. (R. 488.) On January 14, 2014, Plaintiff complained to Dr. Ellens about intermittent chest pain and that she had also had pain in her legs for the past few months. (R. 391.) Plaintiff then followed up with cardiologist, Kelly Rychter, D.O., complaining of chest pain, shortness of breath with exertion, joint aches, fatigues, and dizziness. (R. 374, 376, 371.) X-rays of Plaintiffs lumbar spine in April 2014 were negative. (R. 482.) At additional appointments with Dr. Ellens in August and September 2014, Plaintiff continued to complain of occasional tiredness and fatigue, shortness of breath with exercise, as well as a scalp flare-up. (R. 387-89.) Dr. Ellens referred Plaintiff to dermatology and rheumatology for treatment. (Id.)

         The record contains two medical opinions, both dated prior to the first hearing: that of Dr. Ellens and that of the state agency doctors who reviewed the record as part of Plaintiff s claim for benefits. On June 5, 2013, these non-examining state agency doctors determined Plaintiffs impairments did not meet Listing 8.04, "chronic infections of skin or mucous membranes" and that therefore, she was not disabled. (R. 64-69.) The doctors relied on a March 2013 examination report that noted scalp lesions and inflamed areas on Plaintiffs head and found a full range of motion without pain in all extremities. (R. 69-70.) The doctors acknowledged Plaintiffs reports of pain but found her only partially credible. (Id.) On reconsideration, Francis Vincent, M.D. acknowledged Plaintiffs complaints of worsening pain and her scalp flare-up in August 2013, but considered all of her issues addressed with the medication Plaquenil. (R. 86.) Dr. Vincent affirmed the finding that Plaintiff was not disabled on December 18, 2013. (R. 90.)

         Dr. Ellens' January 31, 2014 opinion consisted of a pre-printed form that contained the requirements for Listing for 14.02 - Systemic Lupus Erythematosus ("SLE"), [7] which requires:

         A. Involvement of two or more organs/body systems, with:

1. One of the organs/body systems involved to at least a moderate level of severity; and
2. At least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss).

         OR

         B. Repeated manifestations of SLE, with at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight ...


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