“[The ALJ] thought the medical witnesses had contradicted themselves when they said the plaintiff’s mental illness was severe yet observed that she was behaving pretty normally during her office visits. There was no contradiction.”
How later courts described this case
- “[The ALJ] thought the medical witnesses had contradicted themselves when they said the plaintiff’s mental illness was severe yet observed that she was behaving pretty normally during her office visits. There was no contradiction.”
- when considering subjective complaints, the ALJ needs to “explain[] the inconsistencies” between the complaints and the medical evidence
- “[T]here is no reason to expect a doctor asked about an eye problem, or a back pain, or an infection of the urinary tract to diagnose depression. He is not looking for it, and may not even be competent to diagnose it.”
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
SOUTH BEND DIVISION
CINDY L. SCHULER, )
Plaintiff, )
)
v. ) CAUSE NO.: 3:21-CV-65-JPK
)
KILOLO KIJAKAZI, Acting Commissioner of )
Social Security, )
Defendant. )
OPINION AND ORDER
This matter is before the Court on a Complaint [DE 1], and Plaintiff’s Opening Brief [DE
18], requesting that the May 19, 2020 decision of the Administrative Law Judge (ALJ) denying
her claim for disability insurance benefits be reversed and benefits awarded. For the following
reasons, the Court grants Plaintiff’s request for remand, but declines to award benefits.
PROCEDURAL BACKGROUND
On January 6, 2019, Plaintiff Cindy L. Schuler filed an application for disability insurance
benefits, alleging disability beginning February 1, 2017. Plaintiff’s application was denied initially
and on reconsideration. (AR 86-111).1 Plaintiff requested a hearing, which was held before an
Administrative Law Judge (ALJ) on May 5, 2020. (AR 52-85). On May 19, 2020, the ALJ issued
an unfavorable decision, making the following findings:2
1. The claimant meets the insured status requirements of the Social Security
Act through June 30, 2022.
2. The claimant has not engaged in substantial gainful activity since February
1, 2017, the alleged onset date.
1 Page numbers in the Administrative Record (AR) refer to the page numbers assigned by the filer, which are found
on the lower right corner of the page, and not the page numbers assigned by the Court’s CM/ECF system.
2 These findings quote the bolded findings throughout the ALJ’s decision. Internal citations to the Code of Federal
Regulations are omitted.
3. The claimant has the following severe impairments: fibromyalgia,
headaches/migraines, cervicalgia, and bilateral mild ulnar variance/carpal tunnel
syndrome/De Quervain’s.
4. The claimant does not have an impairment or combination of impairments
that meets or medically equals the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1.
5. … [T]he claimant has the residual functional capacity to perform sedentary
work as defined in 20 CFR 404.1567(a) except that the claimant can occasionally
climb ramps and stairs, she can never climb ladders, ropes or scaffolds, she can
occasionally balance, stoop, kneel, crouch and crawl, she can frequently handle and
finger with the bilateral upper extremities, and she should avoid concentrated
exposure to unprotected heights and unguarded moving machinery.
6. The claimant is capable of performing past relevant work as a Maintenance
Service Dispatcher, DOT# 239.367-014, semi-skilled, SVP 3, sedentary per DOT,
performed at sedentary by the claimant. This work does not require the performance
of work-related activities precluded by the claimant’s residual functional capacity.
7. The claimant has not been under a disability, as defined in the Social
Security Act, from February 1, 2017, through the date of this decision.
(AR 12-23).
Plaintiff appealed, but the Appeals Council denied review. (AR 1-3). Plaintiff then filed
this civil action seeking review of the Agency’s decision pursuant to 42 U.S.C. § 405(g).
STANDARD OF REVIEW
The Social Security Act authorizes judicial review of the agency’s final decision. 42 U.S.C.
§ 405(g). The question before the Court is not whether the claimant is in fact disabled, but whether
the ALJ’s decision “applies the correct legal standard and is supported by substantial evidence.”
Summers v. Berryhill, 864 F.3d 523, 526 (7th Cir. 2017); 42 U.S.C. § 405(g). Under § 405(g), the
Court must accept the Commissioner’s factual findings as conclusive if they are supported by
substantial evidence, which is “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Moore v. Colvin, 743 F.3d 1118, 1120-21 (7th Cir. 2014)
(quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)).
The Court reviews the entire administrative record but does not re-weigh the evidence,
resolve conflicts in evidence, or substitute its judgment for that of the ALJ. See McKinzey v. Astrue,
641 F.3d 884, 890 (7th Cir. 2011) (citing Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th
Cir. 2003)). However, “if the Commissioner commits an error of law,” the Court may reverse the
decision “without regard to the volume of evidence in support of the factual findings.” White v.
Apfel, 167 F.3d 369, 373 (7th Cir. 1999) (citing Binion v. Chater, 108 F.3d 780, 782 (7th Cir.
1997)). At a minimum, an ALJ must articulate her analysis of the evidence in order to allow the
reviewing court to trace the path of his reasoning and to be assured that the ALJ considered the
important evidence. See Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002). The ALJ also has a
basic obligation to develop a full and fair record and “must build an accurate and logical bridge
between the evidence and the result to afford the claimant meaningful judicial review of the
administrative findings.” Beardsley v. Colvin, 758 F.3d 834, 837 (7th Cir. 2014).
DISABILITY STANDARD
To be eligible for benefits, a claimant must establish that she suffers from a “disability,”
defined as an inability to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment that can be expected to result in death or that 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). The ALJ follows a five-step inquiry to determine whether a claimant is disabled:
(1) whether the claimant has engaged in substantial gainful activity since the alleged onset of
disability, (2) whether the claimant has a medically determinable impairment or combination of
impairments that is severe, (3) whether the claimant’s impairment or combination of impairments
meets or medically equals the criteria of any presumptively disabling impairment listed in the
regulations, (4) if the claimant does not meet a listing, whether she is unable to perform her past
relevant work, and (5) if the claimant is unable to perform past relevant work, whether she is
unable to perform any work in the national economy. See 20 C.F.R. §§ 404.1520(a)(4)(i)-(v),
416.920(a)(4)(i)-(v).
Prior to step four, the ALJ determines the claimant’s residual functional capacity (RFC),
which “is an administrative assessment of what work-related activities an individual can perform
despite her limitations.” Dixon v. Massanari, 270 F.3d 1171, 1178 (7th Cir. 2001). An affirmative
answer at either step three or step five leads to a finding of disability. Briscoe ex rel. Taylor v.
Barnhart, 524 F.3d 345, 352 (7th Cir. 2005); 20 C.F.R. § 404.1520(a)(4). The claimant bears the
burden of proving steps one through four, whereas the burden at step five is on the ALJ. Zurawski
v. Halter, 245 F.3d 881, 885-86 (7th Cir. 2001).
ANALYSIS
Plaintiff asserts five grounds for reversal of the ALJ’s decision: that the ALJ erred in
assessing Plaintiff’s mental impairments, failed to properly evaluate her migraines, misconstrued
the opinion evidence, made a flawed assessment of her credibility, and that the appointment of a
previous Commissioner renders the ALJ’s decision constitutionally defective. Although the issues
overlap somewhat, the Court finds that the first two issues justify remand, and will not attempt to
resolve the remaining arguments.
I. Plaintiff’s Mental Impairments.
Plaintiff first argues that the ALJ failed to properly account for her mental impairments. At
the outset, the Court notes that the ALJ was faced with inconsistent and at times confusing
evidence on this issue. During the application process, Plaintiff reported that she was having panic
attacks and was so depressed that she was unable to complete activities of daily living. (AR 257,
262). Plaintiff said she became more depressed and anxious because of her declining physical
health. She also reported poor memory and concentration and difficulty following instructions.
(See, e.g., AR 239-40). At the hearing, she testified that on a bad day she would “lay [all day] and
just think [w]hat my life used to be, where it is now, and get scared that – my [physical] pain gets
so bad sometimes, I feel like I’m dying.” (AR 68-69). She rated her depression as a seven or eight
out of ten. (AR 68).
Her medical records show that during the period at issue, she complained inconsistently of
depression, and was trying different medications. In August 2017, her primary care doctor,
William Rauh, reported that she “does well on her current meds.” (AR 324-25 (referring to
citalopram)). In August 2018, he reported she “does well with her herb combination,” including
omega 3 fish oil. (AR 336, 338-39). In February 2019, her depression was “stable,” but in April
2019, she complained of “ongoing” panic attacks (AR 518-24). In February 2020, her neurologist
suggested a psychiatry consultation but Plaintiff wanted “to wait.” (AR 551). In short, the medical
records did not necessarily demonstrate that Plaintiff was unable to complete daily activities
because of depression.
In April 2019, Plaintiff underwent a consultative examination by Dr. Russell Coulter-Kern.
Plaintiff was tested on her memory, judgment, and insight, and showed logical and consistent
thought, but was “tearful at times.” (AR 496-498). The doctor concluded: “[I]t appears that
[Plaintiff] will not have difficulty understanding, remembering, and carrying out instructions.
[Plaintiff] will not have difficulty maintaining attention and concentration. [Plaintiff] will not have
difficulty responding appropriately to supervision and coworkers in a work setting. [Plaintiff] may
have difficulty coping appropriately to work pressures.” (AR 499) (emphasis added). At the
bottom of his report, Dr. Coulter-Kern wrote “Diagnostic impression is: 296.22 Major Depressive
Disorder, Single Episode, Moderate.” (Id.).
At step two, the ALJ found that Plaintiff’s mental impairments were “non-severe” (AR 15),
which means they did “not significantly limit [her] physical or mental ability to do basic work
activities.” 20 C.F.R. § 404.1522(a). Specifically, Plaintiff had no more than mild limitations in
the areas of understanding, remembering, or applying information; interacting with others;
concentrating, persisting, or maintaining pace; and adapting or managing oneself. (AR 15). The
ALJ concluded: “[Plaintiff] functioned fairly well without outpatient psychiatric treatment such as
therapy or counseling, and her mental status did not appear to significantly deteriorate when she
did not take her prescription medication.” (AR 17). The ALJ further found that her “statements
concerning the intensity, persistence and limiting effects of these symptoms” – including testimony
about her worsening memory and focus – were “not entirely consistent with the medical evidence
and other evidence in the record.”3 (AR 18). Accordingly, there were no mental limitations of any
kind in the RFC. (See AR 17).
Plaintiff objects to the ALJ’s treatment of Dr. Coulter-Kern’s opinion. First, she argues that
the diagnosis of “296.22 Major Depressive Disorder, Single Episode, Moderate” contradicts the
finding of only “mild” limitations at step two. In the social security context, “mild” and “moderate”
have distinct meanings. See 20 C.F.R. 404, Subpt. P, App. 1, § 12.00(F)(2) (“mild” means “slightly
limited” functioning, while “moderate” means “fair” functioning). The Court’s research suggests
3 Plaintiff objects that the ALJ used the wrong standard in stating that her testimony was “not entirely consistent” with
the other evidence. The correct standard is less rigorous: whether the allegations “can reasonably be accepted as
consistent with the objective medical evidence and other evidence.” 20 C.F.R. §§ 404.1529(a), 404.1529(c)(4),
416.929(a), 416.929(c)(4); see, e.g., Minger v. Berryhill, 307 F. Supp. 3d 865, 871 (N.D. Ill. 2018). Nonetheless, this
boilerplate language is problematic only “when the ALJ substitutes it for a proper, full-bodied explanation of why
credibility is lacking.” Hammerslough v. Berryhill, 758 F. App’x 534, 539 (7th Cir. 2019). Although this case is
remanded on other grounds, the Court notes that the ALJ discussed her findings with reference to medical evidence
(see AR 16-20), and it does not appear that the ALJ imposed a “not entirely consistent” standard.
that the diagnosis of moderate major depressive disorder, with the number 296.22, refers to the
ICD-9-CM diagnosis code, used for billing and classifying illnesses.4 That does not necessarily
contradict a finding of “mild” limitations, because it is not clear that “moderate” means the same
in ICD-9-CM as in the social security context. And as the Commissioner points out, a diagnosis
of “moderate” depression does not necessarily imply “moderate” work-related limitations. (Resp.
Br. 17-18); see, e.g., Amy A. v. Kijakazi, No. 1:21-CV-240, 2022 WL 1963641, at *4 (N.D. Ind.
June 6, 2022) (“Dr. Ray and Dr. Fawver both diagnosed Plaintiff with Recurrent Major Depression
. . . [b]ut a diagnosis alone does not establish the existence of an impairment.”) (citing Weaver v.
Berryhill, 746 F. App’x 574, 579 (7th Cir. 2018) (“It was Weaver’s burden to establish not just the
existence of the conditions, but to provide evidence that they support specific limitations affecting
her capacity to work.”)).
Nonetheless, the ALJ’s analysis of the opinion was incomplete. The ALJ found the opinion
“persuasive,” because it reflected “generally normal status findings” consistent with the record.
(AR 16). But among those normal findings, the doctor stated that Plaintiff “may have difficulty
coping appropriately to work pressures.” (AR 499).5 The ALJ recited that statement as one of the
doctor’s “persuasive” findings (AR 16), but did not reconcile it with the conclusion that Plaintiff’s
mental impairments created no significant limitations in work or in “adapting or managing
4 See http://www.icd9data.com/2015/Volume1/290-319/295-299/296/296.22.htm (“ICD-9-CM codes are used in
medical billing and coding to describe diseases, injuries, symptoms and conditions.”) (last visited July 7, 2022);
https://www.cdc.gov/nchs/icd/icd9cm.htm (“The International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) . . . is the official system of assigning codes to diagnoses and procedures associated with
hospital utilization in the United States.”) (last visited July 7, 2022).
5 The doctor’s findings closely aligned with the criteria for mental impairments to be considered at step two. Compare
(AR 499) with 20 C.F.R. 404, Subpt. P, App. 1, § 12.00(F)(2) (the criteria) and (AR 16) (the ALJ’s findings). The
criteria are: understand, remember, or apply information; interact with others; concentrate, persist, or maintain pace;
and adapt or manage oneself. The doctor found that she could “understand[], remember[], and carry[] out instructions”;
“maintain[] attention and concentration”; and “respond[] appropriately to supervision and coworkers in a work
setting”; but she “may have difficulty coping appropriately to work pressures.”
[her]self.” (AR 15). While “an ALJ does not need to discuss every piece of evidence in the record,”
she “must confront the evidence that does not support her conclusion and explain why that
evidence was rejected.” Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014) (citing Indoranto v.
Barnhart, 374 F.3d 470, 474 (7th Cir. 2004)).
The ALJ’s discussion did not explain this contradiction. For example, the ALJ cited Dr.
Rauh’s notes indicating that at various points Plaintiff’s depression was “do[ing] well” and
“stable.” (AR 16 citing, e.g., AR 324, 336, 518). Plaintiff was not working at the time (see AR 71),
and there is no apparent evidence that the doctor meant (or believed) that she could adapt to
pressure or changing circumstances. The notes do not discuss her mental health in depth or explain
what “doing well” or “stable” means, and most of them were made in the context of treatment for
other ailments. They are certainly evidence of some level of mental health, but by themselves they
do not preclude work-related limitations.6
The ALJ also cited these notes from other doctors and examiners about Plaintiff’s mental
health:
• “In July 2017, August 2017, September 2017, January 2019, April 2019, August
2019, and February 2020, [rehabilitation physician] David J. Lutz, M.D., described
the claimant as pleasant, cooperative, and not in apparent distress” (citing, e.g., AR
351, 355, 358, 360, 551, 578, 605);
6 See Derek N. v. Kijakazi, No. 121CV00737SEBMJD, 2022 WL 1558432, at *5 (S.D. Ind. Apr. 27, 2022) (“Critically,
none of the providers in question were treating Claimant for mental health issues; the notations about Claimant’s
mental health status are therefore highly unlikely to reflect any actual examination or consideration by the health care
provider.”); Donley v. Berryhill, No. 1:17-CV-00430-SLC, 2018 WL 5839856, at *8 (N.D. Ind. Nov. 8, 2018); Conner
v. Apfel, No. 98 C 7625, 1999 WL 495646, at *5 (N.D. Ill. June 28, 1999) (“Dr. Mutua is a family practitioner, not a
psychiatrist. . . . [h]is description of Conner’s mental state consists of one word, “good,” and the report indicates that
Dr. Mutua performed no tests of Conner’s mental condition.”).
• “[I]n January 2019 Madhav H. Bhat, M.D., a neurologist, recorded the claimant
was awake, oriented, followed simple commands, had an adequate fund of
knowledge, normal speech, and a normal mood and affect” (citing AR 363);
• “[I]n March 2019, physical consultative examiner Jason Childress, M.D., noted she
answered all questions, made eye contact with the examiner, was well-groomed,
alert, and oriented to person/place/time” (citing AR 484-495);
• “[I]n May 2019, [orthopedic physician] Mitchell Oetken, D.O., described her as
alert, oriented x3, and not in acute distress” (citing AR 507);
• “In January 2020, when she sought emergency department treatment for foot pain,
her speech, mood, behavior, thought content, and judgment were normal” (citing
AR 562);
• “During February 2020 neurological follow-ups with Pamela McMaster, FNP-C,
the claimant was alert and oriented x4” (citing AR 548, 569)7.
(AR 16-17). As with Dr. Rauh’s records, these notes suggest a basic level of mental health, but not
much else. See James W. v. Saul, No. 19 C 1758, 2021 WL 197426, at *5 (N.D. Ill. Jan. 20, 2021)
(ALJ failed to explain why physician’s observation of “cooperative, appropriate mood and affect”
undermined evidence of mental illness). And the doctors seeing her for other purposes – such as
the emergency room doctor and physical consultative examiner – were probably not attempting to
diagnose mental illness. Wilder v. Chater, 64 F.3d 335, 337 (7th Cir. 1995) (“[T]here is no reason
to expect a doctor asked about an eye problem, or a back pain, or an infection of the urinary tract
to diagnose depression. He is not looking for it, and may not even be competent to diagnose it.”)
7 The ALJ omitted that, at these two visits, Plaintiff was recorded as “Alert, oriented x4, mildly depressed affect” (AR
548), and “alert, oriented x4, tearful, depressed affect.” (AR 569) (emphases added).
(citations omitted). There is no “logical bridge” from this evidence to the conclusion that Plaintiff
could adapt to pressures in the workplace, especially when the only doctor who examined8 Plaintiff
suggested that she may have difficulty in that area. For that reason, remand is required.
Generally, the ALJ seemed to view these instances of Plaintiff appearing “pleasant,” or not
in “acute distress,” as undermining the existence of any mental impairment. Those observations
are relevant, but being pleasant to a doctor for a few minutes is not dispositive of mental illness.
Kangail v. Barnhart, 454 F.3d 627, 629 (7th Cir. 2006) (“[The ALJ] thought the medical witnesses
had contradicted themselves when they said the plaintiff’s mental illness was severe yet observed
that she was behaving pretty normally during her office visits. There was no contradiction.”);
Rosalyn L. v. Saul, No. 3:19-CV-345, 2020 WL 614648, at *11 (N.D. Ind. Feb. 10, 2020) (“[T]here
is a vast difference between the doctor’s office and the workplace and remaining calm for 20-40
minutes in a therapeutic environment is not the same as tolerating an 8-hour workday.”). On
remand, the ALJ must consider that “a person who suffers from a mental illness will have better
days and worse days, so a snapshot of any single moment says little about her overall condition.”
8 Two state agency doctors reviewed Plaintiff’s records, including Dr. Coulter-Kern’s examination, and opined that
she had no more than “mild” restrictions in mental functioning. (See AR 90-93, 104-07). However, the ALJ did not
rely on those reports in her analysis of mental impairments. (See AR 15-17). The Commissioner attempts to impute
reliance on these opinions (Resp. Br. 17), but she cannot defend the ALJ’s decision based on reasons the ALJ did not
provide. See Parker v. Astrue, 597 F.3d 920, 922 (7th Cir. 2010) (“[T]he only thing that cast doubt on [the claimant’s]
complaints were reports by two nonexamining physicians that the administrative law judge did not see fit even to
mention. The [Commissioner] relied heavily on those reports in her brief and at argument . . . but in doing so she
violated the Chenery doctrine which forbids an agency’s lawyers to defend the agency’s decision on grounds that the
agency itself had not embraced.”) (citing SEC v. Chenery Corp., 318 U.S. 80, 87–88, (1943)).
Further, the opinions are internally inconsistent in that they acknowledge Plaintiff’s depression as a “severe”
impairment, which “significantly limits [a person’s] physical or mental ability to do basic work activities.” 20 C.F.R.
§ 404.1522(c). The opinions suffer the same issue as the ALJ’s decision: they do not explain how the doctors went
from the evidence of plaintiff’s difficulty responding to work pressures to the conclusion that those issues were no
worse than “mild.” (See AR 92-93, 105-07).
Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011); see also Phillips v. Astrue, 413 F. App’x 878,
886 (7th Cir. 2010); Larson v. Astrue, 615 F.3d 744, 751 (7th Cir. 2010).
II. Plaintiff’s Migraines.
The case is remanded based on Plaintiff’s mental impairments, but the ALJ’s treatment of
Plaintiff’s migraines would also require remand. Plaintiff complained inconsistently about
migraines until January 2019, when she began care with neurologist Madhav Bhat. (See AR 19).
Plaintiff told Dr. Bhat that she was suffering moderate to severe throbbing headaches daily, which
worsened six or seven times per month. (AR 362). From that point, she saw his assistant, nurse
practitioner Pamela McMaster, at least four times over the following twelve months. In April 2019,
the nurse noted Plaintiff’s report of severe migraines occurred twice per week for 12 hours, with
nausea and sensitivity to light. (AR 592). In May 2019, migraines were “occurring 3/4x per week
and last[ing] 8-12 hrs” with nausea and sensitivity to light. (AR 588). In August 2019 the
headaches were “occurring 4x/wk but they seem to be less severe and are shorter in duration.” (AR
573). In February 2020, the nurse reported that headache “severity has lessened but frequency has
not.” (AR 568). At the May 5, 2020 hearing, Plaintiff testified she had migraines four to five times
a week for twelve hours each, and stayed in bed on those days. (AR 63-64).
The ALJ remarked that Plaintiff’s migraine complaints “could suggest her headache
limitations resulted in off-task behavior or absenteeism, at times, but not for a continuous 12-
month period.” (AR 19). An impairment does not sustain a finding of disability unless it “lasted
or [is] expected to last for a continuous period of at least 12 months,” 20 C.F.R. § 404.1509, and
the ALJ must explain “clearly in the denial rationale” if a claim is denied for that reason. McKinley
v. Colvin, No. 2:13-CV-485-PRC, 2015 WL 404565, at *7 (N.D. Ind. Jan. 28, 2015) (quoting SSR
82–52, 1982 WL 31376, at *3 (Jan. 1, 1982)). The ALJ’s remark was confusing, because it was
immediately followed by a discussion of the medical records cited above, demonstrating that
Plaintiff was consistently treated for migraines between January 2019 and February 2020. (See AR
19). Toward the end of the year, the migraines seemed to be improving (see AR 568, 573), but
there was no record (or explanation from the ALJ) explaining why they would not still cause work
limitations. To the extent the ALJ found that Plaintiff’s headaches did not meet the 12-month
requirement, that finding was not adequately explained nor supported by substantial evidence.
The ALJ did ultimately find that Plaintiff’s migraines were a severe impairment (AR 14),
but how they factored into the RFC is unclear. A “severe impairment,” by definition, “significantly
limit[ed] [Plaintiff’s] physical or mental ability to do basic work activities.” 20 C.F.R.
§ 404.1522(c). In the RFC, Plaintiff was limited to sedentary work with further “restrictions that
limit physical stressors that would aggravate the claimant’s symptoms” (AR 20), such as avoiding
heights. The ALJ stated that these limitations were “supported by” Plaintiff’s “headaches[] and
related dizziness,” among other ailments. (AR 21). It appears the restriction on heights was
intended to prevent injury or additional dizziness from the migraines. Even so, there was no
limitation relating to Plaintiff’s alleged need to lie down for extended periods. The ALJ needed to
at least “consider” the need to lie down in crafting the RFC and explain why a corresponding
limitation was not included. See Denton v. Astrue, 596 F.3d 419, 423-24 (7th Cir. 2010).
The ALJ also found that Plaintiff’s “statements concerning the intensity, persistence and
limiting effects” of her symptoms, including migraines, were “not entirely consistent with the
medical evidence and other evidence in the record.” (AR 18). The ALJ stated that evidence of
Plaintiff’s physical strength undermined her claims of migraines: “[T]he generally normal strength
findings over multiple examinations do not lend support to the claimant’s testimony that she has
migraines four to five days per week that last eight to 12 hours [or] that she is in bed when she has
migraines.” (AR 20). The ALJ seemed to think Plaintiff claimed she was lying in bed purely
because the migraine sapped her strength. But Plaintiff did not report that or testify to that (see AR
54-84, 232-240, 266-273), nor did the ALJ point to a medical opinion suggesting that, so any
negative inference was not warranted. Zurawski, 245 F.3d at 887 (when considering subjective
complaints, the ALJ needs to “explain[] the inconsistencies” between the complaints and the
medical evidence). It seems equally plausible, if not more so, that she lies down to minimize the
discomfort of the migraine.
The ALJ also noted that in August 2017, results of a brain MRI were unremarkable9, and
“it does not appear that limitations from migraines resulted in significant Cranial Nerve
abnormalities or focal neural deficits.” (AR 19-20, citing, e.g., AR 363). Plaintiff reported that the
migraines caused vision issues (AR 240, 273), so the ALJ was justified in saying that evidence of
no “focal neural deficits” was inconsistent. But there was no basis to conclude that this discredited
Plaintiff’s reported symptoms of migraine pain and fatigue. In fact, the nurse who made most of
those findings was the one who opined that Plaintiff’s migraines would prevent her from working.
(See AR 548). Even leaving aside Plaintiff’s testimony, the ALJ did not build the required “logical
bridge” from the record to the conclusion that her severe migraines created no work limitations.
Beardsley, 758 F.3d at 837. On remand, the ALJ must account for Plaintiff’s migraines in the RFC,
or clearly explain why they do not need to be accounted for.
III. Award of Benefits.
Plaintiff requests remand for an award of benefits. “Courts have the statutory power to
affirm, reverse, or modify the Social Security Administration’s decision, with or without
9 Reliance on an “‘unremarkable’ [] MRI as evidence that [] migraines were not a significant problem is not
supportable. . . . Doctors use MRIs to rule out other possible causes of headache—such as a tumor—meaning that an
unremarkable MRI is completely consistent with a migraine diagnosis.” Moon v. Colvin, 763 F.3d 718, 722 (7th Cir.
2014).
remanding the case for further proceedings.” Allord v. Astrue, 631 F.3d 411, 415 (7th Cir. 2011)
(citing 42 U.S.C. § 405(g)). Nonetheless, “[a]n award of benefits is appropriate . . . only if all
factual issues involved in the entitlement determination have been resolved and the resulting record
supports only one conclusion—that the applicant qualifies for disability benefits.” Id. at 415.
Although the ALJ made errors in evaluating the evidence, the record does not clearly show that
Plaintiff is disabled as defined in the Social Security Act, so the Court declines Plaintiff’s request
to award benefits and remands the case for further proceedings.
CONCLUSION
Based on the foregoing, the Court hereby GRANTS the relief sought in Plaintiff’s Opening
Brief [DE 18] and REMANDS the decision of the Commissioner of the Social Security
Administration. The Court DIRECTS the Clerk of Court to ENTER JUDGMENT in favor of
Plaintiff and against Defendant.
So ORDERED this 26th day of August, 2022.
s/ Joshua P. Kolar
MAGISTRATE JUDGE JOSHUA P. KOLAR
UNITED STATES DISTRICT COURT