The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
JOLEAN H.,1 )
)
Plaintiff, )
)
v. ) Case No. 3:21-cv-598-RJD2
)
COMMISSIONER of SOCIAL SECURITY, )
)
Defendant. )
MEMORANDUM AND ORDER
DALY, Magistrate Judge:
In accordance with 42 U.S.C. § 405(g), Plaintiff seeks judicial review of the final agency
decision denying her application for Disability Insurance Benefits (DIB) pursuant to 42 U.S.C. §
423.
Procedural History
Plaintiff applied for DIB in June 2016, alleging she became unable to work because of her
disabling condition on January 1, 2016 (Tr. 170). Plaintiff’s claim was denied through the
administrative process following a hearing, resulting in an unfavorable ALJ decision dated October
26, 2018 (Tr. 12-36). The Appeals Council affirmed the ALJ’s decision in October 2019 (Tr. 1-
6). The claim proceeded to this Court, resulting in the entry of an Order dated June 15, 2020,
remanding the claim to the Commissioner for hearing (Tr. 785). In accordance with the District
Court’s remand order, the Appeals Council instructed the ALJ to hold a new hearing and further
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 Pursuant to 28 U.S.C. §636(c), this case was assigned to the undersigned for final disposition upon consent of the
parties (Doc. 12).
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consider the claimant’s maximum residual functional capacity, obtain evidence from an
appropriate medical expert related to functional limitations if necessary, further evaluate the
claimant’s alleged symptoms and provide rationale in accordance with the disability regulations,
and obtain supplemental evidence from a vocational expert to clarify the effect of the assessed
limitations on the claimant’s occupational base (Tr. 795). Upon rehearing, the ALJ issued an
unfavorable decision on December 18, 2020 (Tr. 686-712). The Appeals Council denied
Plaintiff’s request for review, making the ALJ decision final (Tr. 679-85). Accordingly, Plaintiff
has exhausted all administrative remedies.
Issues Raised by Plaintiff
Plaintiff raises the following issues:
1. The ALJ’s decision is not supported by substantial evidence.
2. The RFC is not supported by substantial evidence.
3. The ALJ’s credibility determination is not supported by substantial evidence.
Applicable Legal Standards
To qualify for DIB a claimant must be disabled within the meaning of the applicable
statutes3. Under the Social Security Act, a person is disabled if he 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).
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 and regulations 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.
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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 his 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).
This Court reviews the Commissioner’s decision to ensure that the decision is supported
by substantial evidence and that no mistakes of law were made. It is important to recognize that
the scope of review is limited. “The findings of the 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). This Court uses the
Supreme Court’s definition of substantial evidence, i.e., “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
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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
In his opinion, ALJ Scurry followed the five-step analytical framework described above.
The ALJ determined that Plaintiff met the insured status requirements of the Social Security Act
through December 31, 2020 (Tr. 691). The ALJ determined that Plaintiff had not engaged in
substantial gainful activity since her alleged onset date of January 1, 2016 (Tr. 691).
The ALJ found that Plaintiff has the following severe impairments: cervical degenerative
disc disease; lumbar degenerative disc disease; sacroiliitis; osteoarthritis; left foot arthritic changes
and spurs; obesity; myofascial pelvic floor dysfunction; pudendal neuralgia; and obstructive sleep
apnea (Tr. 691). However, the ALJ found that these impairments do not meet or equal a listed
impairment.
The ALJ found that Plaintiff has the residual functional capacity (“RFC”) to perform
sedentary work with the following exceptions and/or qualifications: never climb ladders, ropes or
scaffolds; occasionally climb ramps and stairs; occasionally stoop, kneel, crouch and crawl; and
avoid concentrated exposure to noise and hazards such as unprotected heights.
Based on the testimony of a vocational expert (“VE”), the ALJ found Plaintiff could not
do her past relevant work as a security guard or livestock sales representative. However, she was
not disabled because she is able to do other jobs that exist in significant numbers in the national
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economy.
The Evidentiary Record
The Court 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 1975 and was 45 on the date of the ALJ’s December 2020 decision
(Tr. 170). Plaintiff indicated she was disabled because of back problems, nerve damage, anxiety,
depression, hip issues, and migraines. She was 5’7” tall and weighed 350 pounds. She indicated
that because of her condition she stopped working on December 31, 2015 (Tr. 191). She had
received her GED and had worked in home care, in a factory, kennel cleaning, and with horses
(Tr. 192).
2. Evidentiary Hearing
Plaintiff was represented by an attorney at the November 23, 2020 hearing (Tr. 689).
Plaintiff testified she lives with her adult daughter and boyfriend (Tr. 721). She experiences pain
in her legs, back, neck, hips, and arms (Tr. 727). Plaintiff’s pain was treated with steroid
injections, but she has only experienced limited relief from the same, so the treatment plan is to
“burn the nerve” (Tr. 728). Plaintiff was told surgery may make her better or worse (Tr. 731).
One surgeon told Plaintiff she would need to lose weight before he would perform the procedure
(Tr. 731).
Plaintiff reclines or lays down flat approximately fifty percent of the time over the course
of the day (Tr. 731). She does not read as it “doesn’t make any sense” and she usually sits in her
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chair in a stupor (Tr. 729). Plaintiff may do one load of laundry a week, but often forgets to move
the load from the washer to the dryer (Tr. 729).
A vocational expert (VE) also testified. The VE testified that a person with Plaintiff’s
RFC assessment could not do Plaintiff’s past work, but that jobs such as assembler, document
preparer, and tube operator, would be available that exist in the national economy (Tr. 737). The
VE also testified that if a hypothetical individual with Plaintiff’s RFC assessment required
unscheduled breaks and absences at will on an unpredictable basis, there would not be any work
for them in the national economy (Tr. 738).
Finally, the Court notes Plaintiff’s counsel moved to amend her onset date at the hearing
from January 1, 2016 to April 7, 2017, the date on which an MRI of Plaintiff’s lumbar spine was
completed (Tr. 733). It does not appear that this request to move the onset date was granted as
the ALJ’s decision still referred to the alleged onset date as January 1, 2016. The parties do not
address this issue in their briefing.
3. Relevant Medical Records
In 2015, prior to the alleged disability onset date, an MRI of Plaintiff’s lumbar spine was
completed that showed bilateral radiculopathy without sensory or motor deficit, and lumbar
degenerative disk disease, with a small midline disk herniation at L5-S1 (Tr. 300-01). Plaintiff’s
condition was treated with epidural steroid injections, but it was recommended she consult with a
spine surgeon (Tr. 301). An MRI of Plaintiff’s cervical spine in 2015 indicated mild foraminal
narrowing at C4-C5, but no central canal stenosis or neural foraminal narrowing.
Plaintiff reported to the emergency department in April 2016 complaining of chronic back
pain located in the coccyx area that radiated to the right and left legs (Tr. 315). On examination,
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Plaintiff had full range of motion with no parathesis or numbness (Tr. 315). She was diagnosed
with sacroiliitis and, despite the provider’s concerns about opioid use in chronic pain, she was
given IV Dexamethasone and Nalbuphine, and discharged home (Tr. 316).
Plaintiff presented to the emergency department again in June 2016 reporting pain after
swimming (Tr. 304). There were no neurological deficits, and her pedal push/pull was strong (Tr.
304). Plaintiff was administered Tramadol, Orphenadrine, and Methylprednisolone (Tr. 305). A
notation in Plaintiff’s medical record indicated Plaintiff stated, “I should have came in and fought
for my Nubain” (Tr. 307).
Plaintiff established care with a new pain management specialist, Dr. Shane Fancher, in
July 2016 (Tr. 451). An MRI showed some mild neural foraminal stenosis and a smaller disk
bulge at L3 with some arthritic changes (Tr. 451). Plaintiff’s straight leg was positive, and she
was tender in the lateral groove, but was in no acute distress and her neurological systems were
intact (Tr. 451). Dr. Fancher performed transforaminal lumbar epidural steroid injections on July
15 and August 22, 2016 (Tr. 447, 476).
An MRI of Plaintiff’s cervical spine was taken in February 2017 that showed foraminal
narrowing, but no spinal canal narrowing (Tr. 514). The findings were compatible with some
form of chronic sinusitis (Tr. 514). Plaintiff saw her primary care physician, Dr. Jason Jerabek,
multiple times in 2017 for complaints of chronic low back pain and neck pain (Tr. 520-41). In
July 2017, Dr. Jerabek diagnosed Plaintiff with foraminal stenosis of lumbar region and indicated
he would see if a neurosurgeon would evaluate Plaintiff to see if she could be a surgical candidate
(Tr. 535). In October 2017, Plaintiff reported to Dr. Jerabek that she had seen a neurologist at
SLU, but they did not see “eye- to eye” and she walked out at the end of the exam (Tr. 520). At
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this October 2017 exam, Dr. Jerabek ordered an EMG/NCV study to address Plaintiff’s paresthesia
of bilateral legs (Tr. 520).
On June 27, 2018, Plaintiff presented to Dr. Jerabek with complaints of neck pain for which
she had gone to the emergency department (Tr. 1164). Plaintiff reported she was given fentanyl
for her pain in the emergency department, but indicated it did not help (Tr. 1164). In October
2018, Plaintiff saw Dr. Jerabek and complained of bilateral arm pain that she believed originated
in her neck (Tr. 1168). Dr. Jerabek’s examination revealed a normal neck examination with
moderately reduced range of motion in Plaintiff’s lumbar spine (Tr. 1168-71).
On May 6, 2019, Plaintiff was examined by Nurse Practitioner Billie Toland for complaints
of musculoskeletal pain (Tr. 1193). Plaintiff was again seen for similar complaints of pain in
August 2019 by Dr. Jerabek, wherein Plaintiff reported her Demerol shots were lasting only 1-2
days (Tr. 1205). Plaintiff’s physical examination was essentially normal (Tr. 1208-09). Plaintiff
again saw NP Toland on October 17, 2019 for complaints of pain (Tr. 1216). Plaintiff indicated
she was upset because her disability claim was denied and she has pain every day and she felt the
denial was Dr. Jerabek’s fault (Tr. 1216). Plaintiff was notified that her standing order for
Demerol had expired and neither NP Toland nor Dr. Jerabek would renew the same (Tr. 1216).
Plaintiff saw NP Toland in December 2019 related to sleep issues and Toland noted she had a
“fairly harsh” conversation with Plaintiff regarding her behaviors and she counseled Plaintiff to
get out of bed during the day and take pain medication if necessary (Tr. 1221). Plaintiff saw NP
Toland again on March 13, 2020 complaining of musculoskeletal pain, specifically in her right
shoulder (Tr. 1226). Plaintiff refused imaging and physical therapy and NP Toland suggested
Plaintiff go to pain management for further evaluation (Tr. 1226). Plaintiff’s physical
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examination on this date showed mildly reduced range of motion (Tr. 1229). NP Toland
administered an injection for the pain (Tr. 1230). Upon Plaintiff’s request, NP Toland
administered another injection on April 17, 2020 (Tr. 1232).
Plaintiff presented to the emergency department on June 16, 2020 complaining of back
pain (Tr. 1242). On examination, Plaintiff had tenderness at the right low back; range of motion
was painful with all movement; vertebral tenderness was not appreciated; muscle spasms were not
present; Plaintiff refused to allow straight leg raise testing; there were no motor or sensory deficits
present; and she had a steady gait (Tr. 1246). Plaintiff was given an injection and a prescription
for Hydrocodone (Tr. 1246). Plaintiff again reported to the emergency department on June 19,
2020, complaining of back pain (Tr. 1048). On examination, Plaintiff had an antalgic gait;
increased tenderness to her lower lumbar sacral region; right SI joint with point tenderness to right
gluteus max; and increased pain with right straight leg raises (Tr. 1051). The clinical impression
was acute midline low back pain with right-sided sciatica (Tr. 1052). Plaintiff was issued
prescription medication for pain and muscle spasms (Tr. 1053).
An updated MRI of Plaintiff’s cervical spine was taken in June 2020 that showed mild
degenerative changes at the mid-cervical levels with mild disc bulges at C5-6 and C6-7, and mild
facet disease at C3-4 and C4-5 with mild narrowing of the neural foramen (Tr. 1084-85). Plaintiff
received cervical steroid injections at C5-6 in July, August, and September 2020 (Tr. 1074-1081).
On October 28, 2020, Plaintiff presented to Dr. Eaton for a pain consultation (Tr. 1490).
Plaintiff reported that her neck and low back pain was gradually worsening (Tr. 1490). Plaintiff
described the pain in her neck as primarily across the right-side top of her head radiating down the
back of her neck and into her shoulder and occasionally down her arm (id.). The pain in her low
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back was on the right-hand side and radiated laterally and anteriorly down her right side as far as
her knee (Tr. 1490). On examination, Plaintiff was found to have 5/5 muscle strength; 2/4 deep
tendon reflexes; grossly intact sensations; tenderness over the cervical facets; no tenderness to
palpation over greater and lesser occipital nerves; and normal cervical range of motion (Tr. 1493).
The assessment included: cervical facet joint arthropathy/spondylosis; history of cervical
radiculopathy; lumbar radiculopathy; lumbar facet joint arthropathy; and chronic pain (Tr. 1493-
94). Dr. Eaton recommended a repeat lumbar MRI and diagnostic cervical medial branch blocks
(Tr. 1494). An MRI of Plaintiff’s lumbar spine was conducted on November 12, 2020, and
revealed multilevel degenerative disc disease and facet arthropathy (Tr. 1487).
4. Non-Examining State Agency Consultant Physicians
Dr. Richard Lee Smith reviewed Plaintiff’s treatment records in August 2016 and opined
that Plaintiff was not disabled and was capable of light work. Dr. Smith opined that Plaintiff
could occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or
walk about 6 hours in an 8-hour workday; sit about 6 hours in an 8-hour workday; occasionally
climb ramps/stairs; never climb ropes, ladder, scaffolds; occasionally stoop, kneel, crouch, and
crawl; and avoid concentrated exposure to noise and hazards (Tr. 72-82).
Dr. Sumanta Mitra reviewed Plaintiff’s file on a request for reconsideration in November
2016 due to a change in her physical condition. Dr. Mitra reviewed Plaintiff’s updated records
and agreed with the limitations set forth in Dr. Smith’s opinion.
5. Treating Physician Dr. Jason Jerabek – Residual Functional Capacity Report
In this document, which was apparently created and submitted into evidence by Plaintiff’s
attorney, Dr. Jerabek noted Plaintiff’s diagnoses of: disk herniation – lumbar spine; spinal stenosis
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– cervical spine; foraminal stenosis – cervical and lumbar region; paresthesia – bilateral legs; and
muscle spasms – bilateral lower extremities (Tr. 668). Dr. Jerabek did not provide any response
to the second question on this form questioning whether Plaintiff’s subjective complaints are
credible since he began treating her (Tr. 668). Dr. Jerabek did respond to questions three and
four. This form also includes the following paragraphs; however, they did not require any input
from Dr. Jerabek:
[Plaintiff] would not be able to perform any work, even at the
sedentary work level, which requires only minimal lifting of less
than 10 pounds and standing and walking less than 2 hours in an 8-
hour workday, as of January 1, 2016.
[Plaintiff] subjectively states that, since at least January 1, 2016, she
would not be able to meet the demands of full-time employment at
any exertional level due to her physical impairments, including side-
effects of her pain medications.
Analysis
Plaintiff first asserts the ALJ’s decision is not supported by substantial evidence. In
support of this point, Plaintiff complains the ALJ did not fully develop the record by failing to
obtain evidence from a medical expert or otherwise obtain evidence concerning whether Plaintiff’s
limitations equaled listing 1.04. Counsel asserts numerous requests were made at the hearing for
a medical expert and the Appeals Council directed the ALJ to obtain evidence from an appropriate
medical expert if necessary.
For clarification, the Court notes that the District Court’s remand order directed the ALJ to
evaluate whether Plaintiff could perform her past relevant work or a significant number of jobs
existing in the national economy. The Appeals Council’s directive also noted an expert may be
employed to obtain evidence related to the nature and severity of, and functional limitations
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resulting from, the Plaintiff’s physical impairments. In these orders, there was no indication of
any issues with the ALJ’s listing determination.
In any event, Plaintiff now asserts the ALJ’s finding that her spinal degeneration did not
equal the criteria of Listing 1.04 is inadequate. Plaintiff asserts her overlap of symptoms related
to the multi-level stenosis of her spine and morbid obesity deserve consideration by a medical
expert as to whether they reach the necessary requirements of equaling 1.04.
Defendant did not specifically address the listing argument in his brief. However,
Defendant generally contends the additional medical evidence submitted after the state agency
consultants’ review did not “change the picture” so much as to warrant or require a new medical
opinion.
A finding that a claimant’s condition meets or equals a listed impairment is a finding that
the claimant is presumptively disabled. The Listings are found at 20 C.F.R. Pt. 404, Subpt. P,
App. 1. In order to be found presumptively disabled, the claimant must meet all of the criteria in
the listing; an impairment “cannot meet the criteria of a listing based only on a diagnosis.” 20
C.F.R. §404.1525(d). The claimant bears the burden of proving that he meets or equals a listed
impairment. Filus v. Astrue, 694 F.3d 863, 868 (7th Cir. 2012); Maggard v. Apfel, 167 F.3d 376,
380 (7th Cir. 1999). When evaluating whether an impairment is presumptively disabling under a
listing, the ALJ “must discuss the listing by name and offer more than a perfunctory analysis of
the listing.” Jeske v. Saul, 955 F.3d 583, 588 (7th Cir. 2020) (quoting Barnett v. Barnhart, 381
F.3d 664, 668 (7th Cir. 2004)). The Seventh Circuit has highlighted three requirements for an
ALJ’s step three determination to meet the “substantial evidence” standard upon review. First,
the ALJ “must discuss the listing by name.” Barnett v. Barnhart, 381 F.3d 664, 668 (7th Cir.
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2004). Second, the ALJ is required to “offer more than a perfunctory analysis of the listing.” Id.
Finally, because the determination of “[w]hether a claimant’s impairment equals a listing is a
medical judgment,” the ALJ “must consider an expert’s opinion on the issue.” Id. at 670.
Here, the ALJ addressed Listing 1.04 by name and indicated Plaintiff’s spinal degeneration
did not meet the criteria by restating the listing requirements. The ALJ also noted that he had
considered the impact of Plaintiff’s obesity and found that the evidence failed to show that her
obesity increased the severity of her other impairments to an extent that the combination of the
same would meet a listing.
The Court concludes this cursory statement does not meet the “substantial evidence”
standard. The brief explanation given by the ALJ in regard to Listing 1.04 is clearly perfunctory.
While the consulting physicians, Drs. Smith and Mitra indicated they had considered Listing 1.04,
there is no discussion concerning the same. Moreover, the Court cannot find any medical opinion
that addresses the issue of equivalency. The Seventh Circuit has held that an ALJ’s assumption
about equivalency “cannot substitute for evidence and does not support the decision to deny
benefits.” Barnett, 381 F.3d at 671. Accordingly, the Court cannot determine whether the ALJ’s
step three determination is supported by substantial evidence. The ALJ’s failure to consider
whether Plaintiff’s impairments equaled Listing 1.04 requires remand.
Next, Plaintiff asserts the ALJ’s RFC findings are not supported by substantial evidence.
More specifically, Plaintiff contends the ALJ impermissibly “played doctor” in evaluating MRIs
conducted after the state agency consultants’ review and assessing Plaintiff’s residual functional
capacity without input from a medical expert. Plaintiff asserts the ALJ was not qualified to
conclude the MRI results were consistent with his assessment of Plaintiff’s condition and her RFC.
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Plaintiff further asserts that based on updated imaging, the ALJ indicated it was more reasonable
to limit Plaintiff to sedentary work, but asserts there was no discussion of how the evidence or
what evidence supported this determination.
Defendant contends the ALJ’s RFC was properly supported and he was not required to
obtain a new medical opinion merely because additional records were submitted. More
specifically, Defendant asserts the subsequent MRI records did not “change the picture” of
Plaintiff’s condition so the ALJ could still partially rely on the state agency determinations.
Defendant also asserts the ALJ never equated MRI findings to impairments; but rather reasonably
added greater limitations by finding Plaintiff could do a range of sedentary work instead of light
work due to a combination of impairments.
The crux of the issue is whether Plaintiff’s MRIs that post-date the state agency
consultants’ review of Plaintiff’s records warrant a medical opinion to support the ALJ’s RFC
determination. Plaintiff relies on Goins v. Colvin, wherein the ALJ failed to submit the claimant’s
2010 MRI to the consulting physicians for review, despite said MRI being new and “potentially
decisive medical evidence.” 764 F.3d 677, 680 (7th Cir. 2014). The Seventh Circuit deemed
this a “critical failure” and noted the only MRI available to the consulting physicians was taken in
1998 and, when compared to the 2010 MRI, included significant changes, such as degeneration all
along the cervical and lumbar regions of the spine compared to degenerative disease in only one
disk. Id. at 680, 682.
Defendant points to Stage v. Colvin, wherein the Seventh Circuit found that a doctor’s
report diagnosing the claimant with a hip deformity, a restricted range of motion, and the need for
a total left hip replacement “changed the picture so much that the ALJ erred by continuing to rely
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on an outdated assessment by a non-examining physician and by evaluating the significance of the
[doctor’s] report.” 812 F.3d 1121, 1125 (7th Cir. 2016). In citing Stage, Defendant asserts the
MRI results at issue here do not present such a change in circumstance to warrant further
assessment by a physician. The Court disagrees. Much like the ALJ, the undersigned is not a
physician and is not qualified to understand the differences noted in the MRIs that were reviewed
by the state agency consultants and those, such as the MRI taken in November 2020, that were not.
It is well settled that “ALJs must rely on expert opinions instead of determining the
significance of particular medical findings themselves.” Lambert v. Berryhill, 896 F.3d 768, 774
(7th Cir. 2018). In this instance, it appears the ALJ was interpreting Plaintiff’s more recent MRI
results to evaluate Plaintiff’s limitations. Without the input of a medical expert, the ALJ’s
conclusion regarding Plaintiff’s limitations is not supported by the record.
Finally, Plaintiff asserts the ALJ failed to build a logical bridge between the evidence and
his conclusion that Plaintiff’s testimony was not credible.
ALJs use a two-step process for evaluating a claimant’s impairment-related symptoms.
SSR 16-3p, 2017 WL 5180304, at *1. First, the ALJ must “determine whether the individual has
a medically determinable impairment (MDI) that could reasonably be expected to produce the
individual’s alleged symptoms. Id. at *3. Second, the ALJ must “evaluate the intensity and
persistence of an individual’s symptoms such as pain and determine the extent to which an
individual’s symptoms limit his or her ability to perform work-related activities.” Id. at *4.
“In considering the intensity, persistence, and limiting effects of an individual’s symptoms,
[the ALJ must] examine the entire case record, including the objective medical evidence; an
individual’s statements about the intensity, persistence, and limiting effects of symptoms;
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statements and other information provided by medical sources and other persons; and any other
relevant evidence in the individual’s case record.” Id.
Reviewing courts “will overturn an ALJ’s decision to discredit a claimant’s alleged
symptoms only if the decision is ‘patently wrong,’ meaning it lacks explanation or support.”
Cullinan v. Berryhill, 878 F.3d 598, 603 (7th Cir. 2017) (quoting Murphy v. Colvin, 759 F.3d 811,
816 (7th Cir. 2014). The findings of the ALJ as to the accuracy of the plaintiff’s allegations are
to be accorded deference, particularly in view of the ALJ’s opportunity to observe the witness.
Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000). However, Social Security regulations and
Seventh Circuit cases “taken together, require an ALJ to articulate specific reasons for discounting
a claimant's testimony as being less than credible, and preclude an ALJ from ‘merely ignoring’ the
testimony or relying solely on a conflict between the objective medical evidence and the claimant's
testimony as a basis for a negative credibility finding.” Schmidt v. Barnhart, 395 F.3d 737, 746-
747 (7th Cir. 2005), and cases cited therein.
Plaintiff asserts the ALJ did not explain whether Plaintiff’s daily activities were consistent
or inconsistent with the limitations she alleges and, if inconsistent, how so. Plaintiff further
argues the ALJ focused on Plaintiff’s ability to ambulate and mentions her ability to perform some
daily activities, but did not link these activities to Plaintiff’s specific claims.
Defendant contends the ALJ’s analysis of Plaintiff’s credibility was adequately supported
and that the ALJ considered factors such as Plaintiff’s treatment as a whole, use of medications,
physical examinations, mental status examinations, and activities in finding Plaintiff was
functional in the record. Defendant cites specific instances wherein the ALJ noted inconsistencies
between Plaintiff’s subjective reports and corresponding objective examinations, such as when
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Plaintiff arrived ambulatory to the ER complaining of the worst pain she had ever had and her
examination revealed full extension and normal range of motion with no functional deficits.
An ALJ is not required to do a “point-by-point credibility assessment” as long as she
“consider[ed] the relevant evidence, compare[d] the consistency of [Plaintiff’s] testimony against
the objective record and ground[ed] h[er] credibility finding in medical evidence.” McCurrie v.
Astrue, 401 F. App’x 145, 149 (7th Cir. 2010). Here, the ALJ conducted a thorough analysis of
Plaintiff’s medical history and objective medical findings, specifically noting that despite
Plaintiff’s complaints of extreme pain, Plaintiff’s treating sources failed to support the intensity,
persistence, and limiting effects of her alleged symptoms. As mentioned by Defendant, the ALJ
specifically noted that throughout the record Plaintiff was functional and ambulatory, even
managing to ride a horse in 2017.
For these reasons, the Court finds the ALJ’s assessment of Plaintiff’s subjective complaints
was adequately supported. However, because of the errors cited above concerning the decision
at step three and inadequate support for the RFC determination, remand is required.
Conclusion
For these reasons, Plaintiff’s request for a remand is GRANTED IN PART as discussed
above. 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.
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DATED: March 30, 2023
s/ Reona J. Daly
Hon. Reona J. Daly
United States Magistrate Judge
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