The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
KIMBERLY A. H.,1 )
)
Plaintiff, )
)
v. ) Case No. 20-cv-00026-RJD2
)
COMMISSIONER of SOCIAL SECURITY, )
)
Defendant. )
)
MEMORANDUM AND ORDER
DALY, Magistrate Judge:
In accordance with 42 U.S.C. § 405(g), Plaintiff, represented by counsel, seeks judicial
review of the final agency decision denying her application for Disability Insurance Benefits (DIB)
and Supplemental Income Security (SSI) benefits pursuant to 42 U.S.C. § 423.
Procedural History
Plaintiff applied for disability benefits in May 2016, alleging disability as of May 17, 2016.
After holding an evidentiary hearing, an ALJ denied the application on January 16, 2019. (Tr.
15-24). The Appeals Council denied review, and the decision of the ALJ became the final agency
decision. (Tr. 1). Administrative remedies have been exhausted, and a timely complaint was
filed in this Court.
Issues Raised by Plaintiff
Plaintiff raises the following points:
1 In keeping with the court’s practice, Plaintiff’s full name will not be used in this Memorandum and Order due to
privacy concerns. See, Fed. R. Civ. P. 5.2(c) and the Advisory Committee Notes thereto.
2 This case was assigned to the undersigned for final disposition upon consent of the parties pursuant to 28 U.S.C.
§636(c). See, Docs. 8 & 12.
Page 1 of 17
1. The ALJ erred by failing to evaluate the opinion of Plaintiff’s treating physician
consistent with the regulations and Seventh Circuit precedent.
Applicable Legal Standards
To qualify for DIB or SSI, a claimant must be disabled within the meaning of the applicable
statutes.3 Under the Social Security Act, a person is disabled if she has an “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 twelve months.” 42 U.S.C. § 423(d)(1)(a).
To determine whether a plaintiff is disabled, the ALJ considers the following five questions
in order: (1) Is the plaintiff presently unemployed? (2) Does the plaintiff have a severe impairment?
(3) Does the impairment meet or medically equal one of a list of specific impairments enumerated
in the regulations? (4) Is the plaintiff unable to perform her former occupation? and (5) Is the
plaintiff unable to perform any other work? 20 C.F.R. § 404.1520.
An affirmative answer at either step three or step five leads to a finding that the plaintiff is
disabled. A negative answer at any step, other than at step three, precludes a finding of disability.
The plaintiff bears the burden of proof at steps one through four. Once the plaintiff shows an
inability to perform past work, the burden then shifts to the Commissioner to show that there are
jobs existing in significant numbers in the national economy which Plaintiff can perform.
Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001).
It is important to recognize that the scope of review is limited. “The findings of the
3 The statutes and regulations pertaining to DIB are found at 42 U.S.C. § 423, et seq., and 20 C.F.R. pt. 404. The
statutes and regulations pertaining to SSI are found at 42 U.S.C. §§ 1382 and 1382c, et seq., and 20 C.F.R. pt. 416.
As is relevant to this case, the DIB and SSI statutes are identical. Furthermore, 20 C.F.R. § 416.925 detailing medical
considerations relevant to an SSI claim, relies on 20 C.F.R. Pt. 404, Subpt. P, the DIB regulations. Most citations
herein are to the DIB regulations out of convenience.
Page 2 of 17
Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be
conclusive. . .” 42 U.S.C. § 405(g). Thus, this Court must determine not whether Plaintiff was,
in fact, disabled at the relevant time, but whether the ALJ’s findings were supported by substantial
evidence and whether any errors of law were made. Lopez ex rel. Lopez v. Barnhart, 336 F.3d
535, 539 (7th Cir. 2003). The Supreme Court defines substantial evidence as, “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v.
Berryhill, 139 S. Ct. 1148, 1154 (2019) (internal citations omitted).
In reviewing for “substantial evidence,” the entire administrative record is taken into
consideration, but this Court does not reweigh evidence, resolve conflicts, decide questions of
credibility, or substitute its own judgment for that of the ALJ. Burmester v. Berryhill, 920 F.3d
507, 510 (7th Cir. 2019). However, while judicial review is deferential, it is not abject; this Court
does not act as a rubber stamp for the Commissioner. See, Parker v. Astrue, 597 F.3d 920, 921
(7th Cir. 2010), and cases cited therein.
The Decision of the ALJ
The ALJ followed the five-step analytical framework described above. He determined
that Plaintiff had not worked at the level of substantial gainful activity since the alleged onset date.
Plaintiff is insured for DIB through December 31, 2020.
The ALJ found that Plaintiff has severe impairments of “type I diabetes mellitus and
gastroparesis, esophageal stricture, and mild chronic gastritis; and left knee osteoarthritis.” (Tr.
18).
The ALJ found that Plaintiff “has the residual functional capacity to perform the full range
of light work as defined in 20 CFR 404.1567(b) and 416.967(b).” (Tr. 20).
Page 3 of 17
Based on the testimony of a vocational expert, the ALJ concluded that Plaintiff is able to
perform past relevant work as a cashier, parts clerk, and data entry clerk because “[t]his work does
not require the performance of work-related activities precluded by the claimant’s residual
functional capacity…” (Tr. 23).
The Evidentiary Record
The Court has reviewed and considered the entire evidentiary record in formulating this
Memorandum and Order. The following summary of the record is directed to Plaintiff’s
arguments.
1. Agency Forms
Plaintiff was born in 1963 and was 55 years old on the date of the ALJ’s decision. (Tr.
242). Plaintiff said she stopped working in July 2016 because of her conditions. She worked as
a manager at a tobacco shop from 2010 to 2012; a retail counter attendant from 2012 to 2014; and
a data entry specialist from 2015 to 2016. (Tr. 246-47).
In a Function Report submitted in March 2017, Plaintiff said she has neuropathy in her
stomach, numbness in her lower extremities, pain, gastroparesis, an inability to lift items, weakness
in her hands, and an inability to regulate her blood sugar. Plaintiff said she does the dishes, helps
with grandkids, and rests in between doing things. She said she prepares meals like sandwiches,
salads, and meat and potatoes two to three days a week, and she does some baking. However,
Plaintiff said she now is unable to stand while cooking or peel foods easily because of her hands.
Plaintiff said she does laundry, some dusting, some vacuuming, and normal housework, but she
cannot stand for long periods. (Tr. 284-86). Plaintiff said she visits with friends on the phone
and in person about once a month, and she does not go anywhere on a regular basis. Plaintiff said
Page 4 of 17
her conditions impair her lifting, squatting, bending, standing, reaching, walking, sitting, kneeling,
stair-climbing, seeing, and hand usage. Plaintiff said she can only walk half a block before
needing to rest for ten minutes. (Tr. 288-89).
2. Evidentiary Hearing
Plaintiff was represented by an attorney at the evidentiary hearing in September 2018. (Tr.
31). Plaintiff testified the gastroparesis is her most limiting condition. Plaintiff said she has
issues regarding bowel movements. She testified that she often throws up and feels like her
stomach is going to explode. She said she sometimes does not eat for two days simply because
she is unable to. Plaintiff said she had Botox procedures to open her passages which helped the
first time but not the second time. Plaintiff said her toes are numb, her ankle nerves are broken,
her feet turn purple, and her legs have tingling and burning sensations. The medication helps this
but does not take it away completely. Plaintiff testified that she cannot sit for long periods of time
before having to get up due to her neuropathy symptoms. Her legs will buckle and she could fall
to the floor after sitting for long periods of time. Plaintiff said she can only stand about thirty
minutes, and she has a hard time walking. She said she can only lift five to ten pounds now
because of her hands. (Tr. 45-50). Plaintiff said she used to cook all the time, but she does not
cook much anymore because she has a hard time mixing, standing, and peeling. Plaintiff said she
helps take care of her grandchildren by helping with homework, and her leg issues keep her from
going many places. (Tr. 54-55). Plaintiff said she rarely drives anymore and does not get out
much. (Tr. 55, 57). Plaintiff said she has balance issues. (Tr. 58).
A vocational expert (VE) testified at the hearing. After the VE described Plaintiff’s past
work, the ALJ dismissed the VE saying, “…I believe between a combination of the GRID rules
Page 5 of 17
and sub-regulatory policy in the form of SSR as I have sufficient information to make a decision,
in either direction without hypothetical questions.” (Tr. 66).
3. Relevant Medical Records
Plaintiff presented to Andrew Hosman, a physician assistant at Ferrell Hospital Family
Practice, on June 16, 2015. A physical examination revealed Plaintiff’s abdomen was soft,
nontender, and nondistended; positive bowel sounds; and no edema. (Tr. 340-41).
Plaintiff presented to Elliott Partridge, a family medicine physician, around eighteen times
between June 2015 and August 2018 reporting low pelvis pain; prominent fecal stasis; bowel
trouble due to gastroparesis; abdominal pain; intractable vomiting; nausea; constipation; weight
gain; numbness, tingling, and pain in her legs and feet; fatigue; over-sleeping; weakness; diarrhea;
severe muscle spasms; hot coal sensations on the bottom of her feet; A1C levels over 10; rising
blood sugars in the afternoon; swollen legs; falling; trouble eating; an inability to walk normally;
a left knee injury due to a fall; neuropathy; an inability to go long without drinking something; and
night sweats. (Tr. 345, 349, 352, 356, 361, 366, 599, 603, 609, 614, 626, 632, 638, 645, 752, 773,
777, 781).
Dr. Partridge noted Plaintiff had no pedal edema; had no CVA punch tenderness4; had a
rotund but benign abdomen; had a soft, nondistended, nontender abdomen; had a tender but benign
abdomen at one point; had mild epigastric tenderness; had positive bowel sounds; had ice cold
feet; had a zero score on a proprioception and monofilament test; had leg and feet pain; had some
4 CVA punch tenderness refers to, “a medical test in which pain is elicited by percussion of the area of the back
overlying the kidney (the costovertebral angle, an angle made by the vertebral column and the costal margin). The test
is positive in people with an infection around the kidney (perinephric abscess), pyelonephritis, hemorrhagic fever with
renal syndrome or renal stone. Because the kidney is directly anterior to this area, known as the costovertebral angle,
tapping disturbs the inflamed tissue, causing pain.”
https://encyclopedia.thefreedictionary.com/costovertebral+angle+tenderness, visited on October 20, 2020.
Page 6 of 17
left ankle edema; had some crepitus and some tenderness in her left knee; had no acute bony
abnormality in the left knee joint; had mild OA5 and grade 2 sprain of the medial collateral
ligament and of the proximal fibular collateral ligament; and had tenderness in the medial aspect
of the left knee with pain with full extension. (Tr. 345, 352, 357, 362, 366, 600, 604, 610, 614,
627, 633, 639, 646, 752-53, 774, 778, 782). The assessment included poorly-controlled type 2
diabetes mellitus without complication with long-term insulin use, gastroparesis, obstipation,
neuropathy, muscle cramps, generalized abdominal pain, fall, gastroesophageal reflux disease,
esophagitis, osteoarthritis of the left knee, peripheral vascular disease, sprain of the left knee, and
strain of the left knee, and plans included medications, follow-ups, A1C testing, a balance
evaluation, physical therapy, blood testing, and gastrointestinal and endocrinology appointments.
(Tr. 345, 352-53, 357, 362, 366, 600, 604, 610, 614, 627-28, 633-34, 639-40, 646-47, 753, 774,
778, 782).
Plaintiff presented to Memorial Hospital of Carbondale on July 9, 2015, reporting
uncontrolled blood sugars. A physical examination revealed Plaintiff had a soft, nontender
stomach; hyperactive bowel sounds; and 1 to 2+ pedal edema bilaterally. The assessment
included type 2 diabetes and diabetic gastroparesis, and plans included monitoring bowel
movements and blood sugars. (Tr. 523-24).
Plaintiff presented to Bruce Schneider, a gastroenterologist at Deaconess Clinic, on
September 25, 2015, reporting gastroparesis. Dr. Schneider noted Plaintiff had a soft,
nondistended and nontender abdomen; present bowel sounds; and no edema. The assessment
included nausea, vomiting, and history of gastroparesis, and plans included an endoscopic exam
5 OA refers to Osteoarthritis. https://medical-dictionary.thefreedictionary.com/osteoarthritis, visited on October 20,
2020.
Page 7 of 17
with Botox injection, abdomen and pelvis imaging, iron studies, and nausea treatment. (Tr. 377-
79).
Plaintiff received a Botox injection for her gastroparesis on September 26, 2015, at
Deaconess Clinic. (Tr. 380).
Plaintiff underwent a colonoscopy on September 27, 2015, and the impression was,
“Diminutive Rectal Polyps x2.” (Tr. 381). Recommendations included, “Monitor. Treat iron
deficiency. Await path reports. Consideration for small bowel capsule.” (Tr. 381).
Plaintiff presented to Dr. Schneider on March 27, 2016, for an
esophagogastroduodenoscopy6 (EGD) with small bowel capsule deployment. (Tr. 381-82).
The impression was, “EGD with small bowel capsule placement into small bowel.” (Tr. 383).
Recommendations were, “Follow clinically. Await small bowel capsule. Patient will return this
tomorrow morning. Further recommendations to follow. Continue to monitor lab work.” (Tr.
383).
Plaintiff presented to Dr. Partridge on May 17, 2016, for a bilateral arterial ultrasound of
her lower extremities, and they were “completely normal.” (Tr. 366).
Plaintiff underwent a capsule endoscopy on May 26, 2016, and the findings included,
“…few small AVMs7 seen in the small bowel.” (Tr. 746). Recommendations included iron
supplementation and a follow-up. (Tr. 746).
Plaintiff presented to Dr. Schneider on June 13, 2016, for a follow-up. Dr. Schneider
6 Esophagogastroduodenoscopy (EGD) refers to an exam used “to evaluate or treat symptoms relating to the upper
gastrointestinal tract…” https://medical-dictionary.thefreedictionary.com/esophagogastroduodenoscopy, visited on
October 20, 2020.
7 AVM refers to, “Arteriovenous malformation.” https://medical-dictionary.thefreedictionary.com/AVM, visited on
October 20, 2020.
Page 8 of 17
noted Plaintiff had a soft and nondistended abdomen; had no hepatosplenomegaly8; and had no
peripheral edema. Plans included following CBC and iron levels, possible CT imaging of the
abdomen and pelvis, and continued monitoring. (Tr. 383).
Plaintiff presented to Memorial Hospital of Carbondale on September 11, 2016, reporting
stomach pain and nausea with no vomiting or loose stool. (Tr. 496). A physical examination
revealed Plaintiff was pale; was afebrile; and had a soft and tender abdomen. (Tr. 498). The
diagnosis included acute abdominal pain and bowel obstruction. (Tr. 511). Plaintiff underwent
a CT scan of her abdomen and pelvis. (Tr. 517). The impression was, “1. There is no bowel
obstruction or acute inflammatory changes seen within the abdomen and pelvis. 2. There is no
ureteral obstruction.” (Tr. 517).
Plaintiff presented to Angie Hampton, a licensed clinical professional counselor, on
November 18, 2016, reporting suffering from gastroparesis, difficulty digesting food, diabetes,
and neuropathy. (Tr. 595).
Plaintiff presented to Issa Abedmahmoud, an internist, once in April 2017 and once in May
2017 reporting blood sugar issues; severe gastroparesis; an inability to eat; nausea/vomiting;
GERD; fatigue; polydipsia; blurry vision; bloating; abdominal pain; constipation; arthralgias;
myalgias; leg cramps; peripheral neuropathy; lower extremity edema; brittle diabetes; weakness;
excessive thirst; excessive sweating; diarrhea; gas; leg pain, numbness, burning and tingling; foot
pain; and lower extremity edema. (Tr. 709, 712, 714, 716). Dr. Abedmahmoud noted Plaintiff
had an A1C of 9.2; had a soft, nontender abdomen; had normal blood sugars; had no abdominal
masses; had normal bowel sounds; and had no edema. (Tr. 709, 711, 716). The assessment
8 Hepatosplenomegaly refers to, “Enlargement of the liver and spleen.” https://medical-
dictionary.thefreedictionary.com/hepatosplenomegaly, visited on October 20, 2020.
Page 9 of 17
included uncontrolled type 1 diabetes mellitus, gastroparesis, and peripheral neuropathy, and plans
included managing diabetes with insulin, not skipping meals, checking blood sugars four times
daily, taking medications, dietary efforts, and lab work. (Tr. 709-10, 716).
Plaintiff presented to Joseph Jackson, a family medicine doctor, on April 25, 2017. A
physical examination revealed Plaintiff had a soft, nontender abdomen; had no abdominal
guarding; had no abdominal masses; had normal bowel sounds; and had no edema. The
assessment included poorly controlled diabetes mellitus, and plans included handling her blood
sugars and attending endocrinology appointments. (Tr. 785-87).
Plaintiff presented to Victor Mwansa, a cardiologist, four times between May 2017 and
January 2018 reporting diabetes mellitus; claudication9; severe reflux; epigastric pain; and leg
cramping, swelling, and pain. (Tr. 676-78, 680-81, 683-85). A physical examination revealed
Plaintiff had a nontender, nondistended abdomen; had no abdominal brit or masses; had a
nontender liver and spleen; and had no edema. The assessment included claudication, swelling
of the lower leg, and epigastric pain, and plans included an ankle brachial index, using compression
stockings, and a surgical referral. (Tr. 678, 681, 683, 686).
Plaintiff presented to Megan Moore, an optometrist at Marion Eye Center, LTD, on May
10, 2017, reporting diabetes with worsening vision. (Tr. 701). The assessment included type 1
diabetes with ocular complications and blurred vision, and plans included systemic diabetes
control, monitoring her conditions, and regular dilated eye exams. (Tr. 703).
Plaintiff presented to Ukeme Umana, an ophthalmologist at Marion Eye Center, LTD, on
May 11, 2017, reporting vision issues. (Tr. 704). The assessment included type 2 diabetes with
9 Claudication refers to, “Limping.” https://medical-dictionary.thefreedictionary.com/claudication, visited on
October 20, 2020.
Page 10 of 17
ocular complications, and plans included systemic diabetes control with regular dilated eye exams
and monitoring her conditions. (Tr. 706).
Plaintiff underwent an ankle brachial index10 on June 9, 2017, and the impression was,
“Resting ABI bilaterally.” (Tr. 692).
Plaintiff underwent a bilateral lower extremity duplex venous ultrasound of the deep veins
and bilateral evaluation for superficial venous reflux on June 20, 2017. (Tr. 688). The
impression was, “No evidence of deep vein thrombosis. No evidence of deep venous reflux. Right
side: Mild venous reflux of the right greater saphenous vein as above. Left side: Severe venous
reflux of the left greater saphenous vein as above.” (Tr. 689).
Plaintiff had her A1C checked on January 20, 2018, and the value was 8.7. (Tr. 719).
Plaintiff presented to Clay DeMattei, a general surgery specialist, on February 12, 2018,
reporting epigastric bowel pain; dyspepsia11; dysphagia12; and diabetes. Dr. DeMattei noted
Plaintiff had no visible epigastric pulsation of the abdomen; had normal bowel sounds; had no
abdominal guarding; had no abdominal muscle rigidity; had no ascites13; had no direct tenderness
to the abdomen; had no abdominal rebound tenderness; had no palpated mass in the abdomen; had
a normal liver and spleen; and had no tissue injury to her abdomen. The assessment included
esophageal stricture, and plans included an endoscopy of the upper gastrointestinal tract and a
10 An ankle brachial index refers to, “The ankle-to-arm ratio of systolic blood pressure, which is useful in diagnosing
peripheral arterial disease.” https://medical-dictionary.thefreedictionary.com/ankle+brachial+index, visited on
October 20, 2020.
11 Dyspepsia refers to, “painful, difficult, or disturbed digestion, which may be accompanied by symptoms such as
nausea and vomiting, heartburn, bloating, and stomach discomfort.” https://medical-
dictionary.thefreedictionary.com/dyspepsia, visited on October 20, 2020.
12 Dysphagia refers to, “difficulty in swallowing.” https://medical-dictionary.thefreedictionary.com/dysphagia,
visited on October 20, 2020.
13 Ascites refers to, “an abnormal accumulation of fluid in the abdomen.” https://medical-
dictionary.thefreedictionary.com/ascites, visited on October 20, 2020.
Page 11 of 17
possible esophageal dilatation. (Tr. 668-70).
Plaintiff underwent an MRI of her left knee on February 23, 2018. The impression was,
“No acute bony abnormality in the knee joint. Mild osteoarthritis of the medial tibiofemoral
compartment and patellofemoral joint. Grade 2 sprain of the medial collateral ligament. Grade 2
sprain of the proximal fibular collateral ligament.” (Tr. 662).
Plaintiff underwent an esophagogastroduodenoscopy with balloon dilation to 20
millimeters and esophagogastroduodenoscopy with biopsy for H. pylori 14 and permanent
pathology on March 16, 2018, to address dyspepsia, bloating, and gastroparesis. The
postoperative diagnoses were gastroparesis and pyloric stenosis. Pathology was negative for H.
Pylori, intestinal metaplasia, and dysplasia. (Tr. 672-73).
Plaintiff presented to Keri Claybourn, a physical therapist, on April 12, 2018, reporting
having a fall; having to use steps sideways; a weak left leg; knee aches; anterior left knee pain that
improves with staying off of it; throbbing, catching, intermittent pain; and pain that is aggravated
with steps and walking. PT Claybourn noted Plaintiff ambulated with a slight limp on the left
with decreased stance at times. The assessment included left knee pain, and plans included further
physical therapy. (Tr. 735-37).
Dr. Partridge filled out a treating source statement on September 24, 2018. Dr. Partridge
said he treated Plaintiff every six weeks to three months for over thirty years. Dr. Partridge said
Plaintiff is likely to be off task more than twenty-five percent of a typical workday. He said
Plaintiff is likely to maintain attention and concentration for less than fifteen minutes before
requiring a break due to her symptoms. Dr. Partridge estimated Plaintiff would be absent from
14 H. pylori refers to, “a gram-negative spiral bacterium that causes gastritis and pyloric ulcers in humans.”
https://medical-dictionary.thefreedictionary.com/H.+pylori, visited on October 20, 2020.
Page 12 of 17
work four or more days a month on average. Dr. Partridge believed Plaintiff could frequently lift
or carry less than ten pounds; occasionally lift ten pounds; rarely carry ten pounds; rarely lift
twenty pounds; never carry twenty or more pounds; and never lift fifty or more pounds. Dr.
Partridge noted Plaintiff could sit for seven hours in a workday and could stand or walk only one
hour in a workday due to uncontrolled blood sugars and numbness in Plaintiff’s feet. Dr.
Partridge said Plaintiff would require the option to lie down or recline throughout the workday
every twenty to thirty minutes for one to two hours each time. Plaintiff would require elevating
her legs when sitting and would require the use of a cane or other assistive device to ambulate.
Dr. Partridge noted Plaintiff would frequently have issues with handling, fingering, and feeling
due to pain and numbness, and Plaintiff would rarely be able to use foot controls due to numbness
and neuropathy. (Tr. 798-800).
Analysis
Plaintiff asserts the ALJ erred by failing to evaluate the opinion of Plaintiff’s treating
physician consistent with the regulations and Seventh Circuit precedent. The ALJ was not
required to fully credit Dr. Partridge’s opinion because of that status; “while the treating
physician’s opinion is important, it is not the final word on a claimant’s disability.” Books v.
Chater, 91 F.3d 972, 979 (7th Cir. 1996) (internal citation omitted). A treating source’s medical
opinion is entitled to controlling weight only where it is supported by medical findings and is not
inconsistent with other substantial evidence in the record. Brown v. Colvin, 845 F.3d 247, 252
(7th Cir. 2016), citing Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000).
Plaintiff filed her application before March 27, 2017. The applicable regulation, 20 C.F.R.
§ 404.1527(c)(2), provides, in part:
Page 13 of 17
Generally, we give more weight to opinions from your treating sources, since these
sources are likely to be the medical professionals most able to provide a detailed,
longitudinal picture of your medical impairment(s) and may bring a unique
perspective to the medical evidence that cannot be obtained from the objective
medical findings alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations. If we find that a treating
source's opinion on the issue(s) of the nature and severity of your impairment(s) is
well-supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial evidence in your case
record, we will give it controlling weight.
If the ALJ decides not to give the opinion controlling weight, he is to weigh it applying the factors
set forth in § 404.1527(c)(1)-(6). Supportability and consistency are two important factors to
consider in weighing medical opinions. In a nutshell, “[t]he regulations state that an ALJ must
give a treating physician’s opinion controlling weight if two conditions are met: (1) the opinion is
supported by ‘medically acceptable clinical and laboratory diagnostic techniques [,]’ and (2) it is
‘not inconsistent’ with substantial evidence in the record.” Schaaf v. Astrue, 602 F.3d 869, 875
(7th Cir. 2010).
Here, the ALJ explained that he gave Dr. Partridge’s opinion “less weight than the State
agency medical consultant’s assessment” because the severity of Dr. Partridge’s limitations is
inconsistent with the evidence. (Tr. 22). More specifically, the ALJ said, “The claimant reported
good response to her ADHD medication…Further, treatment notes do not establish that the
claimant was seeking acute care at least four days a month, contradicting Dr. Partridge’s
conclusion.” (Tr. 22-23). The ALJ further noted that Dr. Partridge’s opinion received less
weight than the State agency medical consultants because his opinion “is not well supported and
is inconsistent with the record as a whole.” (Tr. 23). Defendant argues that, “The ALJ identified
enough evidence conflicting with Dr. Partridge’s opinions to instead reasonably rely on the
opinions of the state-agency medical experts.” (Doc. 28, p. 7). However, what Defendant fails
Page 14 of 17
to acknowledge here is the extent of Dr. Partridge’s physician-patient relationship with Plaintiff
and how it involved much more than simply a treating source statement. Acknowledgement of
that is necessary to provide a logical bridge within the ALJ’s decision.
This Court agrees with Plaintiff’s argument. Although Plaintiff makes many very specific
assertions, it is important to note that they all revolve around the same overarching assertion: The
ALJ neither provided legally sufficient reasons for giving Dr. Partridge’s opinion less weight than
the State agency medical consultants’ opinions nor did he apply the checklist of factors provided
by 20 C.R.F. § 404.1527.
The ALJ need not explicitly discuss each factor of the checklist, and some are implied
simply within the discussion of medical records. See Henke v. Astrue, 498 Fed.Appx. 636 (7th
Cir. 2012). However, an ALJ’s decision must be supported by substantial evidence, and the
ALJ’s discussion of the evidence must be sufficient to “provide a ‘logical bridge’ between the
evidence and his conclusions.” Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009), internal
citations omitted. The ALJ did discuss some treatment provided by Dr. Partridge for Plaintiff’s
left knee injury at Tr. 22. The ALJ also acknowledged a few of Dr. Partridge’s conclusions from
his treating source statement and Dr. Partridge’s thirty years of familiarity with Plaintiff and her
impairments. (Tr. 22). However, the ALJ’s error is in his lack of providing a logical bridge
between the evidence and his conclusions. The Court must conclude the ALJ failed to build the
requisite logical bridge here.
It is clear from the medical records that Plaintiff saw Dr. Partridge for more medical issues
than just her left knee injury. Plaintiff saw Dr. Partridge for impairments regarding her diabetes,
gastroparesis, and esophageal issues, to name a few. The ALJ’s failure to discuss more
Page 15 of 17
thoroughly Plaintiff’s medical records regarding Dr. Partridge created a gap in the record, and this
directly affected the validity of the ALJ’s assessment of Dr. Partridge’s medical opinion versus
the State agency medical consultants’ opinions.
In light of the deferential standard of judicial review, the ALJ is required only to
“minimally articulate” his reasons for accepting or rejecting evidence, a standard which the
Seventh Circuit has characterized as “lax.” Berger v. Astrue, 516 F.3d 539, 545 (7th Cir. 2008);
Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008). The ALJ was not required to specifically
indicate each factor as he considered them. However, as mentioned above, the ALJ is required to
provide a logical bridge, and this precedes the minimal articulation standard here. The ALJ’s
discussion leaves a gap in the record regarding Plaintiff’s treatment with Dr. Partridge and,
therefore, fails to build a logical bridge regarding the ALJ’s decision on the weight to give Dr.
Partridge’s medical opinion. This requires remand.
Plaintiff further argues that the ALJ relied on his own lay opinion of the medical evidence,
suggesting the ALJ essentially played doctor. The ALJ “must consider the entire record, but the
ALJ is not required to rely entirely on a particular physician's opinion or choose between the
opinions. . .” Schmidt v. Astrue, 496 F.3d 833, 845 (7th Cir. 2007). The determination of RFC
is an administrative finding that is reserved to the Commissioner. 20 C.F.R. §404.1527(d)(2).
That said, the fact that the ALJ made a decision while considering the medical evidence does not
alone indicate the ALJ played doctor. This argument by Plaintiff ignores the basic duties of an
ALJ and, therefore, does not stand.
This Memorandum and Order should not be construed as an indication that the Court
believes Plaintiff was disabled during the relevant period or that she should be awarded benefits.
Page 16 of 17
On the contrary, the Court has not formed any opinions in that regard and leaves those issues to be
determined by the Commissioner after further proceedings.
Conclusion
The Commissioner’s final decision denying Plaintiff’s application for social security
disability benefits is REVERSED and REMANDED to the Commissioner for rehearing and
reconsideration of the evidence, pursuant to sentence four of 42 U.S.C. §405(g).
The Clerk of Court is directed to enter judgment in favor of Plaintiff.
IT IS SO ORDERED.
DATED: October 22, 2020
s/ Reona J. Daly
Hon. Reona J. Daly
United States Magistrate Judge
Page 17 of 17