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Mayra M. v. Saul

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

December 10, 2019

MAYRA M., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.


          SHEILA FINNEGAN United States Magistrate Judge

         Plaintiff Mayra M. seeks to overturn the final decision of the Commissioner of Social Security (“Commissioner”) denying her applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI, respectively, of the Social Security Act (“SSA”). (Doc. 1). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and the case was reassigned to this Court. (Docs. 11-13). The parties filed cross-motions for summary judgment. (Docs. 16, 18). After careful review of the record and the parties' respective arguments, the Court concludes that the case must be remanded for further proceedings as outlined below. The Court therefore denies the Commissioner's motion and grants Plaintiff's request for remand.


         I. Procedural History

         Plaintiff applied for DIB and SSI on October 21, 2015, alleging disability since October 21, 2015 due to bulging discs, thumb injury, leg pain, vertigo, and nausea. (R. 20, 73, 83, 197, 201, 216).[1] Born in October 1975, Plaintiff was 39 years old at the time of the alleged onset date (R. 24, 197, 201, 216), which is defined as a younger individual. 20 C.F.R. § 404.1563(c).[2] Her date last insured is December 31, 2019. (R. 20, 216).

         The Social Security Administration denied Plaintiff's applications initially on December 17, 2015 and on reconsideration on March 23, 2016. (R. 93, 94, 119, 120). Plaintiff then requested a hearing, which was later held before Administrative Law Judge (“ALJ”) Melissa Santiago on May 9, 2017, where Plaintiff was represented by counsel. (R. 32-72, 126-27, 139-49). Both Plaintiff and Vocational Expert (“VE”) Cheryl Hoiseth testified at the hearing. (R. 32-72).

         The ALJ denied Plaintiff's claims in a decision dated September 28, 2017. (R. 18-26). The ALJ found that Plaintiff's vertigo and cervical spine disc bulging with cervical radiculopathy are severe impairments, but they do not meet or equal any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 20-21). The ALJ concluded that Plaintiff was not disabled from her October 21, 2015 alleged onset date through the date of the decision because she retains the residual functional capacity (“RFC”) to perform light work with certain postural, manipulative, and environmental limitations, as described to the VE, and is capable of performing jobs that exist in significant numbers in the national economy. (R. 19, 21, 25-26, 63-64).

         The Appeals Council denied Plaintiff's request for review on November 1, 2018 (R. 1-6), rendering the ALJ's September 2017 decision the final decision of the Commissioner reviewable by this Court. Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012). Plaintiff commenced this action on December 21, 2018 and now seeks reversal or remand, arguing that the ALJ erred in (1) evaluating the treating source opinions and (2) assessing Plaintiff's subjective symptom allegations. As explained below, the Court concludes that remand is required for the ALJ to reevaluate the opinion evidence and reassess Plaintiff's subjective statements.

         II. Work and Medical History

         Plaintiff completed three years of high school. (R. 57). She has three children: a 22 year-old daughter, 15 year-old son, and 13 year-old daughter. (R. 48-49). She lives with her two youngest children. (Id.). Plaintiff worked as a credit clerk and, most recently, an office messenger (R. 24, 40, 42-44, 62-63, 232), but she stopped working in October 2015 because of pain in her right arm (R. 40, 44-45).[3]

         Plaintiff received treatment for seven months before the October 21, 2015 alleged onset date. In late March 2015, Plaintiff went to the emergency room, complaining of right-sided neck pain radiating to her right arm, and she was diagnosed with trapezius muscle spasm and prescribed medication. (R. 354, 356-57). At another emergency room visit in early April 2015, she reported a headache and photosensitivity. (R. 364, 368). In late June 2015, Plaintiff went to the emergency room, complaining of neck pain radiating down her back. (R. 374). She exhibited tenderness to palpation and palpable muscle spasm, and she was diagnosed with trapezius muscle strain and prescribed medication. (R. 374-76, 449).

         In early July 2015, Plaintiff went to the emergency room, complaining of right-sided neck and shoulder pain and weakness/tingling radiating down her right arm. (R. 312). A nurse noted that she “[a]ppear[ed] uncomfortable, tearful.” (R. 315). A physical examination showed no significant weakness or sensory or neurological deficits, and the doctor attributed mild reduction in strength to pain. (R. 313). She was diagnosed with trapezius muscle spasm and prescribed medication. (R. 320-21). Throughout the rest of July 2015, Plaintiff saw internist Eric Mizuno, M.D., complaining of pain and initially dizziness, and was diagnosed with back and muscle spasms. (R. 334-36, 455).[4] She reported improvement with medication, but could not tolerate physical therapy. (R. 334).

         On August 1, 2015, an x-ray of Plaintiff's cervical spine was unremarkable, and an x-ray of her right shoulder revealed “[n]o significant osseous abnormality[.]” (R. 325-26). Plaintiff saw Dr. Mizuno later in August 2015 for muscle spasms in her right shoulder. (R. 333). He diagnosed Plaintiff with cervical radiculopathy, made a “pain referral[, ]” and prescribed medication. (R. 333, 455).[5] A September 19, 2015 MRI of Plaintiff's cervical spine revealed “diffuse disc bulging and spurring with large superimposed right posterior lateral disc herniation” at ¶ 6-C7. (R. 345). The next week, Dr. Mizuno diagnosed Plaintiff with persistent muscle spasms and prescribed medication. (R. 332). On October 20, 2015, Dr. Mizuno again diagnosed Plaintiff with persistent muscle spasms and cervical radiculopathy and prescribed medication. (R. 331). The next day, Plaintiff applied for DIB and SSI. (R. 18, 93, 94, 119, 120).

         On October 24, 2015, Plaintiff went to the emergency room, complaining of dizziness, lightheadedness, blurred vision, and nausea, but left without being seen. (R. 395-96). Three days later, Plaintiff saw Dr. Mizuno for help completing disability paperwork and reported her recent visit to the emergency room. (R. 330). At that appointment, Dr. Mizuno diagnosed Plaintiff with vertigo. (Id.). On November 2, 2015, Roberto Levi, M.D. noted that Plaintiff had vertigo for about a week, and he recommended that she not drive and be accompanied when she went out. (R. 341). The next day, Plaintiff complained to Dr. Mizuno of vertigo going on two weeks, and he diagnosed “migrainous vertigo[.]” (R. 329).

         On November 4, 2015, Gita Rupani, M.D. examined Plaintiff. (R. 338-39).[6] She was not in significant distress, rated her current neck pain as 5/10, and described pain radiating down her arm and numbness in her fingers with average pain rated as 9/10. (R. 339). She did not have an antalgic gate. (Id.). Examination of Plaintiff's head and neck was “significantly painful[, ]” she exhibited tenderness, Spurling was positive on the right, pain affected her right shoulder range of motion, and sensation was subjectively diminished in all fingers. (Id.). Her upper extremity strength was adequate, but there was “limited effort in trying to do muscle testing.” (Id.). Dr. Rupani administered trigger point injections, after which Plaintiff “felt significant relief in her right shoulder[, ]” and prescribed a cervical epidural steroid injection. (Id.). Two weeks later, Dr. Rupani noted positive Spurling on the right and diagnosed Plaintiff with cervical radiculitis. (R. 410). On December 4, 2015, Dr. Rupani performed a cervical epidural steroid injection at ¶ 6-C7, noting that Plaintiff was “aware that the injection may not help significantly due to the disc herniation.” (R. 411-13). That day, Plaintiff reported “significant pain relief.” (R. 413).

         Plaintiff saw Dr. Mizuno throughout 2016, and he continued to diagnose muscle spasms, herniated disc, and cervical radiculopathy and to prescribe medication. (R. 417, 444, 496-505). In January 2016, Plaintiff complained of vertigo, dizziness, and pain. (R. 417).[7] On the same day as that visit, Dr. Mizuno completed a physical residual functional capacity questionnaire. (R. 440-42). Dr. Mizuno stated that Plaintiff had severe cervical radiculopathy, for which she pursued epidural steroid injection and medication was not helpful, and he described her prognosis as fair. (R. 440). He also stated that she had right hand tingling and numbness and severe neck and arm pain. (R. 441-42). Dr. Mizuno opined that Plaintiff was limited in how long she could continuously stand and sit and alternately sit or stand; needed to lay down during the day; could walk two blocks without stopping; could lift and carry five to ten pounds; and could travel alone. (Id.). The extent of the limitation on standing, sitting, and alternating between sitting and standing is unclear because Dr. Mizuno wrote either “1-20” or “1-2°” without including the word minutes or hours. (R. 441). Plaintiff read the limitation as “1-20, ” meaning minutes, but the ALJ interpreted it as “1-2°, ” using the symbol “°” to denote hours. (R. 23-24, 38-39, 441).

         In February 2016, Plaintiff saw Dr. Mizuno and reported right side tingling and numbness. (R. 444). In April 2016, she complained of leg pain exacerbated by walking and prolonged standing. (R. 505). In June 2016, Dr. Mizuno referred Plaintiff for physical therapy. (R. 503). She attended numerous physical therapy sessions from June through August 2016 and, in July 2016, reported that it was “working very well[.]” (R. 485-95, 501, 503).[8] In August and September 2016, Plaintiff had no new complaints. (R. 500, 502). In early October 2016, Plaintiff complained of migraines going on two weeks, especially in the morning, and lasting one to two hours. (R. 499). At that visit, Dr. Mizuno diagnosed Plaintiff with migraine headaches related to cervicalgia. (Id.). Later in October 2016, Plaintiff reported dizziness going on three days, and Dr. Mizuno diagnosed vertigo. (R. 498). A November 21, 2016 MRI of Plaintiff's brain and internal auditory canals was normal. (R. 459-61).

         Plaintiff also saw Dr. Mizuno in January and mid-March 2017, and he continued to diagnose muscle spasms and herniated disc and to prescribe medication. (R. 496-97).[9]In late March 2017, James Diesfeld, M.D. saw Plaintiff for pain management on referral from the nurse practitioner in Dr. Mizuno's practice. (R. 510-12). Dr. Diesfeld noted that Plaintiff had received a cervical epidural steroid injection that provided around five days of pain relief and multiple trigger point injections, and she had physical therapy a year ago that was “helpful at the time.” (R. 510).[10] Examination revealed normal gait, intact sensation, tenderness to palpation, decreased right side range of motion, muscle strength of 4/5 with effort, and some guarding on the right side due to pain. (Id.). Dr. Diesfeld's impression was possible cervical degenerative disc disease with secondary myofascial trigger points/spasm and non-specific right arm paresthesias. (Id.). He administered TENS therapy, from which Plaintiff “had good relief.” (Id.).[11] He recommended continuing TENS therapy at home “to treat chronic refractory pain, unresponsive to 3 or more months of medical therapy[, ]” using a cervical collar and heating pad, obtaining an MRI, scheduling manual therapy, and following up in six weeks; he also prescribed medication. (R. 510-11). The record includes four appointment reminders dated April 2017 and May 2017, including for therapy and “one day surgery[, ]” but no accompanying treatment notes. (R. 513).

         At the May 9, 2017 administrative hearing, the ALJ requested that Plaintiff contact Dr. Mizuno to clarify his opinion on her need to lay down and to provide an update if his opinion had changed. (R. 39). On May 30, 2017, Dr. Mizuno completed an updated residual functional capacity questionnaire. (R. 514-16). Dr. Mizuno confirmed that Plaintiff still suffered from cervical radiculopathy with severe neck and arm pain and stated that her condition had not changed. (R. 514, 516). He also stated that she received physiotherapy and cervical epidural injection with no improvement. (R. 514). Dr. Mizuno opined that Plaintiff could continuously stand and sit for 30 minutes and alternate between sitting and standing for an unspecified number of hours; needed to lay down during the day because of pain and dizziness; could walk two blocks without stopping; could lift or carry less than five pounds; and had problems grasping, pulling, pushing, or doing fine manipulations with her right hand due to tingling and numbness. (R. 514-15).

         III. State Agency Reviewing ...

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