Willis v. Commissioner of Social Security

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

SOUTH BEND DIVISION

DAVID E. WILLIS II,

Plaintiff,

v. Case No. 3:21-CV-178 JD

ACTING COMMISSIONER OF SOCIAL

SECURITY,

Defendant.

OPINION AND ORDER

Plaintiff David Willis has appealed an Administrative Law Judge’s denial of his claim for

disability and disability insurance benefits after the ALJ found that Mr. Willis was not disabled

and thus not entitled to benefits. Mr. Willis and the Acting Commissioner have fully briefed Mr.

Willis’s appeal. After considering the parties’ briefing and the filed administrative record, the

Court finds, for the following reasons, that a remand of the case to the Acting Commissioner for

further proceedings is warranted.

A. Factual Background

Mr. Willis applied for disability benefits in November 2018 alleging that he had become

unable to work starting on January 1, 2018, because of his health conditions. (R. 179.) In his

application, Mr. Willis alleged that his disability was based on a variety of conditions, including

chronic inflammation, chronic pain due to multiple surgeries, chronic fatigue, hardening in the

lungs, osteoarthritis, and an assortment of heart problems. (DE 194.) In July and September of

2019, the Social Security Administration denied Mr. Willis’ claim at the initial and

reconsideration levels of review. (R. 114, 121.)

Mr. Willis appealed and an ALJ held a hearing on Mr. Willis’s claim in August 2020.

During the course of the hearing, the ALJ heard testimony from Mr. Willis about his conditions

and testimony from a vocational expert about the possibility of Mr. Willis being able to work in

spite of his conditions. (R. 57–87.) After holding the hearing and reviewing Mr. Willis’s medical

records, the ALJ issued an opinion finding that Mr. Willis was not disabled. (R. 26–36.) The ALJ

determined that Mr. Willis suffers from multiple severe impairments, including degenerative disc

disease of the lumbar spine, left supraspinatus tear, chronic obstructive pulmonary disease, and

congenital heart disease with non-ischemic cardiomyopathy. (R. 28.) However, the ALJ found

that Mr. Willis’s abdominal wall hernia, obesity, and urethral stricture conditions were non-

severe impairments. (Id.)

The ALJ did not find that any of the impairments or combinations of impairments was

equal in severity to the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 29–

30.) After reviewing the record and listening to Mr. Willis at the hearing, the ALJ concluded that

Mr. Willis has the residual functional capacity (“RFC”):

to perform sedentary work as defined in 20 C.F.R. 404.1567(a) except can never

climb ladders, ropes or scaffolds, kneel, crouch or crawl; can occasionally climb

ramps and stairs, balance and stoop; can never reach overhead with the left, non-

dominant, upper extremity; can frequently reach in all other directions with the left,

non-dominant , upper extremity; can tolerate occasional exposure to extreme cold,

extreme heat, humidity and pulmonary irritants, such as fumes, noxious odors,

dusts, mists, gases and poorly ventilated areas; [and] cannot operate a motor vehicle

at work.

(R. 30–31.) Based on that RFC and the ALJ’s questioning of the vocational expert at the hearing,

which included the vocational expert relying solely on her professional experience instead of the

Dictionary of Occupational titles at certain times (R. 85), the ALJ found Mr. Willis could not

perform his prior job as a nurse but that Mr. Willis was not disabled. (R. 34–35.) Mr. Willis

requested that the Appeals Council review the ALJ’s decision. The Appeals Council denied Mr.

Willis’s request on December 11, 2020 (R. 5), making the ALJ decision the final decision of the

Acting Commissioner for purposes of judicial review. See 42 U.S.C. § 405(g).

B. Standard of Review

Because the Appeals Council denied review, the Court evaluates the ALJ’s decision as

the final word of the Acting Commissioner of Social Security. Schomas v. Colvin, 732 F.3d 702,

707 (7th Cir. 2013). This Court will affirm the Acting Commissioner’s findings of fact and

denial of benefits if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668,

673 (7th Cir. 2008). Substantial evidence consists of “such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389,

401 (1971). This evidence must be “more than a scintilla but may be less than a preponderance.”

Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Even if “reasonable minds could differ”

about the disability status of the claimant, the Court must affirm the Acting Commissioner’s

decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).

The ALJ has the duty to weigh the evidence, resolve material conflicts, make

independent findings of fact, and dispose of the case accordingly. Perales, 402 U.S. at 399–400.

In evaluating the ALJ’s decision, the Court considers the entire administrative record but does

not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the Court’s

own judgment for that of the Acting Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d

535, 539 (7th Cir. 2003). Nevertheless, the Court conducts a “critical review of the evidence”

before affirming the Acting Commissioner’s decision. Id. An ALJ must evaluate both the

evidence favoring the claimant as well as the evidence favoring the claim’s rejection and may

not ignore an entire line of evidence that is contrary to his or her findings. Zurawski v. Halter,

245 F.3d 881, 887 (7th Cir. 2001). The ALJ must provide a “logical bridge” between the

evidence and any conclusions. Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009).

C. Standard for Disability

Disability benefits are available only to those individuals who can establish disability

under the terms of the Social Security Act. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998).

Specifically, the claimant must be unable “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). The Social Security regulations create a five-step process to

determine whether the claimant qualifies as disabled. 20 C.F.R. § 404.1520(a)(4)(i)–(v). The

steps are to be used in the following order:

1. Whether the claimant is currently engaged in substantial gainful activity;

2. Whether the claimant has a medically severe impairment;

3. Whether the claimant’s impairment meets or equals one listed in the regulations;

4. Whether the claimant can still perform relevant past work; and

5. Whether the claimant can perform other work in the community.

See Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001).

At step two, an impairment is severe if it significantly limits a claimant’s ability to do

basic work activities. 20 C.F.R. §§ 404.1522(a), 416.922(a). At step three, a claimant is deemed

disabled if the ALJ determines that the claimant’s impairment or combination of impairments

meets or equals an impairment listed in the regulations. 20 C.F.R. §§ 404.1520(a)(4)(iii),

416.920(a)(4)(iii). If not, the ALJ must then assess the claimant’s residual functional capacity,

which is defined as the most a person can do despite any physical and mental limitations that

may affect what can be done in a work setting. 20 C.F.R. §§ 404.1545, 416.945. The ALJ uses

the residual functional capacity to determine whether the claimant can perform other work in

society at step five. 20 C.F.R. §§ 404.1520(e), 416.920(e). A claimant qualifies as disabled if he

or she cannot perform such work. The claimant has the initial burden of proof at steps one

through four, but the burden shifts to the Commissioner at step five to show that there are a

significant number of jobs in the national economy that the claimant can perform. Young v.

Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004).

D. Discussion

Mr. Willis argues that the ALJ’s decision should be remanded for several reasons. He

argues that: (1) the ALJ erred in evaluating his subjective symptoms; (2) the ALJ erred in

evaluating the medical opinion evidence; and (3) the ALJ’s reliance on the vocational expert’s

testimony was improper because part of her testimony conflicted with the Dictionary of

Occupational Titles. (DE 19 at 5–14.) The Court agrees that the ALJ erred in evaluating the

medical opinion evidence, which led her to fail to form a logical bridge justifying the RFC that

she ultimately reached. The Court finds remand necessary for that reason. The parties can

address any remaining arguments on remand.

The ALJ considered four medical opinions in her written decision: the opinions of two

agency consultants, Dr. Sands and Dr. Brill, who reviewed Mr. Willis’s medical records; the

opinion of Mr. Willis’s treating pain management specialist, Dr. Quadri; and the opinion of Mr.

Willis’s treating cardiologist, Dr. Esper. (R. 33–34.) The ALJ found all of the opinions except for

Dr. Espar’s “not persuasive” because they were “not consistent with the available medical

evidence.” (R. 33–34.) The ALJ found Dr. Espar’s opinion only marginally better, finding it

“somewhat persuasive” because it was “somewhat consistent with the available medical

evidence.” (R. 33–34.)

Under the regulations, an ALJ does “not defer or give any specific evidentiary weight,

including controlling weight, to any medical opinion(s) or prior administrative medical

finding(s), including those from [a claimant’s] medical sources.” 20 C.F.R. § 404.1520c(a). The

ALJ must explain “how persuasive [she] find[s] all of the medical opinions and all of the prior

administrative medical findings in [a claimant’s] case record.” 20 C.F.R. § 404.1520c(b). When

considering the persuasiveness of any medical opinion, an ALJ must consider the following

factors: supportability; consistency; relationship with the claimant, including the length of the

treatment relationship, frequency of examination, purpose of the treatment relationship, extent of

the treatment relationship, and examining relations; specialization; and any other factors that

tend to support the medical opinion, including evidence that the medical source is familiar with

other medical evidence or has an understanding of social security policies. 20 C.F.R. §§

404.1520(c), 416.920c(c). Supportability and consistency are the two most important factors. 20

C.F.R. § 404.1520c(a). These are the factors the ALJ must explicitly discuss, whereas the ALJ

need only consider the other factors. 20 C.F.R. § 404.1520c(b). Failure to adequately discuss

supportability and consistency requires remand. See Tammy M. v. Saul, 2021 WL 2451907, at

*7–8 (N.D. Ind. June 16, 2021). The more consistent the medical opinion is “with the evidence

from other medical sources and nonmedical sources in the claim, the more persuasive” the

medical opinion will be. 20 C.F.R. § 404.1520c(c)(2). For a provider’s opinion to be supportable,

it must be based on “objective medical evidence and supporting explanations.” 20 C.F.R. §

404.1520c(c)(1). “The more relevant the objective medical evidence and supporting explanations

presented by a medical source are to support his or her medical opinion(s) or prior administrative

medical finding(s), the more persuasive the medical opinions or prior administrative medical

finding(s) will be.” 20 C.F.R. § 404.1520c(c)(1).

The Court finds two issues with the ALJ’s medical opinion analysis that ultimately

require remand. First, the ALJ failed to provide any detail in explaining why she found the

various medical opinions either wholly or somewhat inconsistent with the medical evidence. And

second, her failure to adopt any medical opinion left an evidentiary gap that prevented her from

building a logical bridge between her evidentiary analysis and the ultimate RFC.

The Court starts with the ALJ’s lack of detail in explaining why she found the various

medical opinions either wholly or partially inconsistent with the medical evidence. Dr. Quadri,

Mr. Willis’s treating pain management specialist, opined that Mr. Willis could stand up to one

hour and sit up to two hours per eight-hour workday as well as that Mr. Willis had limitations

with lifting, pulling, holding objects, bending, and stooping. (R. 282–83.) The ALJ found Dr.

Quadri’s opinions “not persuasive because despite the provider’s specialty and treating

relationship with the claimant, they are vague, greatly overstate the claimant’s limitations and are

not consistent with the available medical evidence summarized above.” (R. 33.) The ALJ did not

elaborate on that statement, and her lack of elaboration leaves the Court to guess as to what

portions of the “medical evidence summarized above” the ALJ specifically thought undermined

Dr. Quadri’s medical opinion about Mr. Willis’s capabilities. Dr. Espar, Mr. Willis’s treating

cardiologist, opined that Mr. Willis could not stand for six to eight hours per day but could sit for

six to eight hours per day. (R. 285.) The ALJ found Dr. Espar’s opinion “somewhat persuasive

because while the standing limitations are vague, the opinions overall are still somewhat

consistent with the available medical evidence summarized above and are supported by [Dr.

Espar’s] specialty and treating relationship with the claimant.” (R. 33.) The ALJ again failed to

elaborate on that generalized statement or explain how the record evidence is only somewhat

consistent with Dr. Espar’s opinions. Finally, the ALJ considered the agency medical opinions

from Dr. Sands and Dr. Brill. Those doctors each opined that Mr. Willis was capable of light

work, could both stand and sit for six hours in an eight-hour workday, could occasionally climb

ramps, stairs, ladders, ropes, scaffolds, balance, stoop, kneel crouch and crawl, and had to avoid

concentrated exposure to extreme temperatures, humidity, and pulmonary irritants. (R. 34, 93–

94, 106–07.) The ALJ found these opinions “not persuasive because, despite the consultants’

specialties and programmatic knowledge, they are not consistent with the available medical

evidence summarized above.” (R. 34.) Again, the ALJ failed to provide any actual explanation

for why she reached that conclusion about inconsistency with the available evidence.

The ALJ’s general statements about consistency of the medical opinions when compared

to the medical evidence that was before her are not enough. The regulations direct that an ALJ

must explain how he or she considered the consistency factors for a medical opinion. 20 C.F.R. §

404.1520c(b). Here, the ALJ simply provided her end result, that each opinion was either “not

consistent with the available medical evidence summarized above” or was “somewhat consistent

with the available evidence summarized above,” without giving any indication of which specific

evidence she considered in coming to those conclusions. (R. 33–34.) As other judges in this

district have recognized, such general statements without any further explanation are insufficient

under the new regulations and require remand because they create no logical bridge between the

medical evidence and the ALJ’s conclusion. See Tammy M. v. Saul, 2021 WL 2451907, at *8

(N.D. Ind. June 16, 2021) (“As this Court has set forth, the ALJ decision cannot stand under the

new regulations when the ALJ finds the opinion not persuasive because it is inconsistent with

medical evidence but does not explain why that evidence is inconsistent with the opinion.”);

Michael v. Saul, 2021 WL 1811736, at *11 (N.D. Ind. May 6, 2021) (citing Moore v. Colvin, 743

F.3d 1118, 1121 (7th Cir. 2014)) (“[T]he ALJ cannot merely summarize the evidence, as a

whole, and then conclude that [the doctor’s] opinions are not consistent with the evidence as a

whole. Rather, the ALJ must build a logical analytical bridge explaining what particular evidence

undermined [the doctor’s] opinions and why.”) Left with only the ALJ’s end result and no

explanation of how the ALJ arrived there, the Court can only guess as to what evidence the ALJ

relied on to determine the consistency of the medical opinions and therefore cannot find that the

ALJ properly evaluated the medical opinion evidence.

Even if the ALJ had offered some explanation of her conclusions about the consistency of

each medical opinion, however, she would still face the problem of having adopted an RFC after

discounting all of the medical opinions either in whole or in part. In doing that, the Court finds

the ALJ created an “evidentiary deficit” and then impermissibly created her own RFC in a way

that required her to play doctor. See Suide v. Astrue, 371 F. Appx. 684, 689–90 (7th Cir. 2010);

Tammy M., 2021 WL 2451907, at *8 (“Although the ALJ is not required to adopt a specific

physician opinion, by not adopting any medical opinion, the ALJ faced an evidentiary deficit.”).

The RFC that the ALJ ultimately adopted explained that Mr. Willis could perform “sedentary

work,”1 with the further limitations that Mr. Willis could occasionally climb ramps and stairs and

balance and stoop, as well as frequently reach in all directions except for overhead with his left

upper extremity, and could tolerate occasional exposure to extreme cold, extreme heat, humidity,

and pulmonary irritants. (R. 31.) The only limitation in that RFC that could be connected to any

1 Sedentary work “involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like

docket files, ledgers, and small tools.” 20 C.F.R. § 404.1567. Further, “[a]lthough a sedentary job is defined as one

which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties.” “Jobs

are sedentary if walking and standing are required occasionally and other sedentary criteria are met.” Id.

medical opinion that the ALJ did not fully discount is the limitation, given by Dr. Espar, that Mr.

Willis could sit for six hours in an eight-hour workday as part of a sedentary role. (R. 30–31,

285.) But even then, the Court must guess that the six-hour sitting limitation is within the portion

of Dr. Espar’s opinion that the ALJ found persuasive because the ALJ never made clear in her

decision that the sitting limitation contained in the opinion was something she found consistent

with the available evidence. (R. 33) (ALJ only stating that Dr. Espar’s opinions overall are

somewhat consistent with the available evidence) (emphasis added).

When looking at the rest of the RFC, it is even less clear how, after discounting the other

medical opinions completely, the ALJ reached the remaining limitations, unless she played

doctor or hedged between the opinions she had discounted. For example, the only medical

opinions that discussed Mr. Willis being able to tolerate occasional exposure to certain

temperature and breathing irritants, as the RFC references, were the agency consultants’

opinions, which the ALJ wholly discounted and thus had no reason to adopt. (DE 34, 93–94,

106–07.) Additionally, there was no medical opinion adopted about how long Mr. Willis could

stand during a workday, whether Mr. Willis could actually lift, pull, hold, bend, and stoop, or

reach in all directions with his left hand except for overhead, as the RFC states. (R. 33–34.)

Thus, the inclusion of each of these specific abilities or limitations in the RFC without medical

opinion support suggests that the ALJ either impermissibly played doctor in interpreting the

medical evidence for herself, see McHenry v. Berryhill, 911 F.3d 866, 871 (7th Cir. 2018);

Rohan v. Chater, 98 F.3d 966, 980 (7th Cir. 1995), or impermissibly attempted to construct a

middle ground between the various discounted opinions, Adelina M. v. Kijakazi, 2022 WL

375554, at *8 (N.D. Ill. Feb. 8, 2022). In either case, it is clear that the ALJ created an

evidentiary deficit, made her own medical determinations to overcome that deficit, and thus

failed to develop an adequate logical bridge between the available medical evidence and her

ultimate RFC. The Court believes that remand is required under those circumstances. See Suide,

371 F. Appx. at 689–90.

The Acting Commissioner’s briefing did not help to allay the Court’s concerns about the

need for remand. First, the Acting Commissioner did not provide any substantive defense of the

fact that the ALJ simply offered broad conclusions about the consistency of each medical

opinion without any actual explanation of which specific portions of the considered evidence led

her to those conclusions. (DE 24 at 13–15). The Acting Commissioner acknowledged that

“[p]erhaps the ALJ could have been more explicit” in her medical opinion analysis but argued

that the relevant standard only requires ALJs to “‘minimally articulate’ their justification for

accepting or rejecting specific evidence.” (DE 24 at 16) (citing Rice v. Barnhart, 384 F.3d 363,

371 (7th Cir. 2004)). While the Acting Commissioner provided a correct recitation of the

caselaw in making that argument, the ALJ’s decision did not meet the caselaw requirements. The

caselaw requires the ALJ to reference “specific evidence” whereas the ALJ here simply referred

broadly to “the available medical evidence summarized above” as the basis for her conclusion.

Courts have clearly held that such a general statement without further explanation is not

sufficient under the prior caselaw or the relevant updated regulations. See Tammy M., 2021 WL

2451907, at *8; Michael, 2021 WL 1811736, at *11. The Court thus maintains its finding that the

ALJ erred in evaluating the medical opinions.

Second, the Acting Commissioner did not explain away the evidentiary deficit the ALJ

created. The Acting Commissioner once again looked to relevant caselaw to construct an

argument, pointing out that “an ALJ ‘need not adopt any one doctor’s opinion’” when arriving at

an RFC. (DE 24 at 15) (citing Fanta v. Saul, 848 F. Appx. 655, 658 (7th Cir. 2021)). But while it

is true that an ALJ does not need to adopt one doctor’s opinion in particular, the failure to adopt

any medical opinion problematically forces an ALJ to face an evidentiary deficit. See Tammy M.,

2021 WL 2451907, at *8; Pamela B. v. Saul, 2021 WL 2411391, at *7 (N.D. Ind. June 14, 2021)

(citing Suide, 371 F. App’x at 690 (remanding because after rejecting all relevant medical

opinions and plaintiff’s testimony, the ALJ created a situation where the RFC could only be

supported by her interpretation of medical findings)). The ALJ failed to adopt any medical

opinion here. The Court therefore maintains its finding that the ALJ created an evidentiary

deficit by discounting the medical opinions and subsequently failed to build a logical bridge

between the available evidence and the RFC because of that deficit.

On remand, the ALJ should first analyze, in greater depth, whether each medical expert’s

opinion on Mr. Willis’s physical limitations is persuasive or unpersuasive. Specifically, the ALJ

should look to the factors set forth under 20 C.F.R. § 404.1520c and explain in the required

detail how the other portions of the record either conflict with or support each expert’s opinion.

After doing this, if the ALJ still concludes that these medical expert’s opinions are all generally

unpersuasive, the ALJ must fill in the “evidentiary deficit either by seeking further information

from [the medical experts] or [by] obtaining the opinions of [another] independent examining

physician or medical expert.” Daniels v. Astrue, 854 F. Supp. 2d 513, 523 (N.D. Ill. 2012).

E. Conclusion

For the foregoing reasons, the Court REVERSES the Commissioner’s decision and

REMANDS this matter to the Commissioner for further proceedings consistent with this opinion.

The Clerk is DIRECTED to prepare a judgment for the Court’s approval.

SO ORDERED.

ENTERED: June 30, 2022

/s/ JON E. DEGUILIO

Chief Judge

United States District Court