Barnes v. Commissioner of Social Security

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ILLINOIS

SHARDAE B.,1 )

)

Plaintiff, )

)

vs. ) Case No. 3:24-CV-287-MAB2

)

COMMISSIONER OF SOCIAL )

SECURITY, )

)

Defendant. )

MEMORANDUM AND ORDER

BEATTY, Magistrate Judge:

In accordance with 42 U.S.C. § 405(g), Plaintiff Shardae B. is before the Court,

represented by counsel, seeking review of the final decision of the Commissioner of Social

Security denying her applications for Disability Insurance Benefits (DIB) and

Supplemental Security Income (SSI) under Titles II and XVI of the Social Security Act. For

the reasons set forth below, the Commissioner’s decision is REVERSED and this matter

is REMANDED for rehearing and reconsideration of the evidence pursuant to sentence

four of 42 U.S.C. § 405(g).

PROCEDURAL HISTORY

Plaintiff protectively filed a Title II application for a period of disability and DIB

on January 14, 2021 (Tr. 30, 126-127). Plaintiff also filed a Title XVI application for SSI on

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) (Doc. 26).

that date (Tr. 30, 126-127). Plaintiff’s applications both alleged disability beginning on

January 1, 2021, due to physical and mental conditions including multiple sclerosis

(“MS”), dizziness, balance issues, trouble walking, fatigue, and depression (see, e.g. Tr.

262, 305).

Plaintiff’s applications were initially denied in August 2021 (Tr. 30, 126-127). They

were then denied upon reconsideration in December 2021 (Tr. 30, 164-165). Plaintiff

requested a rehearing by an Administrative Law Judge (ALJ) (see Tr. 177-178), which

occurred on October 19, 2022 (Tr. 49-100). Following the hearing, ALJ Brian Battles issued

an unfavorable decision dated March 9, 2023 (Tr. 30-42). Thereafter, Plaintiff’s request for

review was denied by the Appeal’s Council and thus, the ALJ’s decision became the final

agency decision (Tr. 1-6). Accordingly, Plaintiff exhausted her administrative remedies

and filed a timely complaint in this Court seeking judicial review of the ALJ’s adverse

decision (Doc. 1).

APPLICABLE LEGAL STANDARDS

To qualify for DIB or SSI, a claimant must be disabled within the meaning of the

applicable statutes and regulations.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

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, of the DIB regulations. Most citations herein are to the DIB regulations out of convenience.

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 claimant is disabled, the ALJ conducts a five-step

sequential analysis. 20 C.F.R. § 416.920(a)(4). The first step is to determine whether the

claimant is presently engaged in substantial gainful activity. Id. at § 416.920(a)(4)(i). If the

answer is yes, then the claimant is not disabled regardless of their medical condition, age,

education, and work experience. Id. at § 416.920(a)(4)(i), (b). If the answer is no and the

individual is not engaged in substantial gainful activity, the analysis proceeds to the

second step. Id. at § 416.920(a)(4).

At step two, the ALJ considers whether the claimant has a medically determinable

physical or mental impairment, or a combination of impairments, that is “severe” and

expected to persist for at least twelve months. 20 C.F.R. § 416.920(a)(4)(ii), 416.909. If the

answer is no, then the claimant is not disabled. Id. at § 416.920(c). If the answer is yes, the

analysis proceeds to question three. Id. at § 416.920(a)(4).

At step three, the ALJ must determine whether the claimant’s severe impairments,

singly or in combination, meet the requirements of any of the “listed impairments”

enumerated in the regulations. 20 C.F.R. § 416.920(a)(4)(iii). See also 20 C.F.R. Pt. 404,

Subpt. P, Appendix 1 (list of impairments). A claimant who meets the requirements of a

“listed impairment” is deemed disabled. 20 C.F.R. § 416.920(d). For claimants who do not

meet the requirements of a “listed impairment,” the ALJ must then determine the

claimant’s residual functional capacity (“RFC”). Id. at § 416.920(e).

An individual’s RFC is his or her ability do work despite the individual’s

impairments. Id. at § 416.945; see also Craft v. Astrue, 539 F.3d 668, 675-76 (7th Cir. 2008)

(“RFC is the maximum that a claimant can still do despite his mental and physical

limitations.”). “In assessing a claimant’s RFC, the ALJ must consider all of the relevant

evidence in the record and provide a ‘narrative discussion’ that cites to specific evidence

and describes how that evidence supports the assessment. The ALJ’s analysis and

discussion should be thorough and ‘[s]et forth a logical explanation of the effects of the

symptoms, including pain, on the individual’s ability to work.’” Passig v. Colvin, 224 F.

Supp. 3d 672, 680 (S.D. Ill. 2016) (quoting SSR 96-8).

At step four, the ALJ must determine whether the claimant retains the RFC to

perform the requirements of their past relevant work. 20 C.F.R. § 416.920(a)(4)(iv). If the

answer is yes, then the claimant is not disabled. Id. at § 416.920(a)(4)(iv), (f). If the answer

is no, the analysis proceeds to the final step. Id. at § 416.920(a)(4).

At the fifth and final step, the ALJ must consider whether the claimant can make

an adjustment to perform any other work considering the claimant’s RFC, age, education,

and work experience. Id. at § 416.920(a)(4)(v). If the claimant can make an adjustment to

other work, then the claimant is not disabled. Id. at § 416.920(g). Conversely, if the

claimant cannot, then the claimant is disabled. Id.

Notably, the scope of judicial 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). This Court’s task is not to determine whether Plaintiff

was, in fact, disabled at the relevant time, but instead to determine 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). “[W]e cannot uphold an administrative decision that fails to mention highly

pertinent evidence, or that because of contradictions or missing premises fails to build a

logical bridge between the facts of the case and the outcome.” Id. (internal citations

omitted).

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

presented in mostly chronological order and directed to the points and factual allegations

raised by Plaintiff.

I. Relevant Medical Records:

Plaintiff alleges her disability began on January 1, 2021 (see, e.g., Tr. 255). Several

years earlier in late 2017, Plaintiff began experiencing dizziness (Tr. 491). As a result,

Plaintiff underwent an MRI in January 2018, which showed findings consistent with

multiple sclerosis (“MS”) (Tr. 491, 493). In March 2020, an MRI of Plaintiff’s brain showed

“at least 6 new areas of abnormal T2 FLAIR hyperintense supratentorial white matter

signal.” (Tr. 449). Additionally, in comparison to Plaintiff’s MRI from 2018, her 2020 MRI

showed “multiple new supratentorial, infratentorial, and spinal cord lesions” and the

“lesion at C2 demonstrated fairly faint gadolinium enhancement.” (Tr. 449). Thereafter,

Plaintiff had a telemedicine visit with Dr. Tullman in July 2020 (Tr. 449). Plaintiff reported

that her balance remained impaired, numbness in her right hand was persisting, and she

felt forgetful (Tr. 449). Plaintiff also stated that she was on the verge of losing her job

because of her MS (Tr. 449).

Medical records from January 29, 2021, indicate Plaintiff had not been taking MS

medications because she was concerned about side effects (Tr. 437). A neurological

examination at that time indicated that Plaintiff was awake, alert, oriented, could follow

commands, was able to walk heel and toe without difficulty, but had an abnormal tandem

gait (Tr. 434). On February 11, 2021, Plaintiff visited Dr. Tullman (Tr. 446-448). She

reported that her balance was worse, and she fell about once every two weeks (Tr. 447).

Plaintiff also stated that her right-hand numbness was without change, she struggled

with anxiety and depression, had trouble focusing, and relied on her mother and sister

for transportation, help around the home, and with her children (Tr. 447). Dr. Tullman’s

progress notes indicated generally normal examination results, other than a broad-based

gait that was mildly paretic and ataxic (Tr. 448).

Plaintiff visited Dr. Tullman again in March 2021, wherein he noted “no new

symptoms suggestive of MS exacerbation or gradual disease progression.” (Tr. 442). Dr.

Tullman also observed that Plaintiff was thirty weeks pregnant at that time and discussed

concerns related to an increased risk of MS relapse in the first three months postpartum

if MS is left untreated (Tr. 442). Plaintiff returned to Dr. Tullman in August 2021 (Tr. 480).

Dr. Tullman’s notes discuss Plaintiff’s then-recent pregnancy performed by emergency

C-section, as well as her postpartum course which was reportedly complicated by acute

psychosis with paranoia and auditory and visual hallucinations (Tr. 480). Plaintiff also

reported that she was suffering from urinary urgency and had episodes of incontinence

every other day (Tr. 480). Dr. Tullman’s examination indicated that Plaintiff’s immediate

recall was intact (Tr. 480). However, she recalled 1 out of 3 objects correctly at 10 minutes

and correctly named 11 out of the 12 months backwards, having confused February for

July (Tr. 480). Dr. Tullman also found Plaintiff’s vibratory sensation was absent at the

right hallux and moderately impaired at the left hallux (Tr. 480). Dr. Tullman again noted

that Plaintiff’s gait was mildly broad-based and mildly paretic and ataxic (Tr. 480).

Another MRI of Plaintiff’s brain and brainstem was conducted in September 2021

(Tr. 484). The MRI revealed multiple foci of hyperintensity but did not find new or

enhancing lesions (Tr. 485). Plaintiff had another appointment with Dr. Tullman on

November 1, 2021, which was documented by PA Wei (Tr. 529-533). At the appointment,

Plaintiff and her mother reported that Plaintiff was having additional trouble balancing,

was unable to walk straight, had fallen several times, was suffering from cognitive

dysfunction and memory problems, was experiencing intermittent dizziness, and

experienced numbness in both hands (Tr. 529). A physical examination found that

Plaintiff’s immediate recall was intact, but she again recalled 1 out of 3 objects at 10

minutes (Tr. 530). That report also noted Plaintiff’s gait was mildly broad-based, and

mildly paretic and ataxic (Tr. 530). In addition, the physical examination again found that

Plaintiff’s vibratory sensation was absent at the right hallux and moderately impaired at

the left hallux (Tr. 530).

Plaintiff visited Dr. Rukmangadachar on January 20, 2022 (Tr. 493). Physical

examination indicated that Plaintiff’s finger and foot taps were slow, and she had a mild

wide-based and unsteady gait (Tr. 497). Dr. Rukmangadachar also reported that Plaintiff

“has relapse of onset multiple sclerosis and extensive lesion burden and accumulated

significant disability.” (Tr. 497). Plaintiff had a telemedicine visit with Dr. Tullman in

February 2022 (Tr. 527). At that visit, Plaintiff complained of right lower extremity pain

and reported that she typically holds onto someone when walking (Tr. 527).

II. Disability Determinations and Opinion Evidence:

At the initial level in July 2021, state agency consultants Dr. Yondell Moore and

Disability Adjudicator Padeitra Moorer reviewed the medical records provided to them

and noted that Plaintiff had not been seen “in office for the past two years,” was never

on MS medication, and did not receive recommended injections (Tr. 106). They also found

that medical records demonstrated Plaintiff had normal strength in her extremities and

could walk heel and toe without difficulty, but she did have gait issues including

abnormal tandem station, and a broad based gait that was mildly paretic and ataxic (Tr.

106). Dr. Moore found that Plaintiff’s medically determinable impairment of MS could

produce her reported symptoms of pain, weakness, and fatigue, but Plaintiff’s statements

about intensity, persistence, and functionally limiting effects were not substantiated by

the objective medical evidence (Tr. 107). Dr. Moore opined that Plaintiff had exertional

limitations including: occasionally lifting and/or carrying 20 pounds, frequently lifting

and/or carrying 10 pounds, standing 6 hours in an 8 hour workday, and sitting 6 hours

in an 8 hour workday (Tr. 108). Dr. Moore also found the following postural limitations:

occasionally climbing ramps/stairs, ladders/ropes/scaffolds, and balancing, and

frequently kneeling, crouching, and crawling (Tr. 109). Dr. Moore did not impose any

manipulative, visual, communicative, or environmental limitations (Tr. 109). The initial

level state agency consultants ultimately found Plaintiff was not disabled and could

conduct light work, based upon the documented findings (Tr. 111, 124-125). Three

examples of light work that Plaintiff could perform were: addresser – 209.587-010, ticket

taker – 344.667-010, and surveillance system monitor – 379.367-010 (Tr. 112, 124).

At the reconsideration level, State agency consultants considered the medical

evidence in the record and opined that Plaintiff’s residual functional capacity allowed

for: occasional lifting and/or carrying 20 pounds, frequent lifting and/or carrying 10

pounds, standing and/or walking 4 hours in an 8 hour work day, sitting 6 hours in an 8

hour work day, occasional climbing ramps/stairs and balancing, frequent stooping,

kneeling, crouching, and crawling, and never climbing ladders/ropes/scaffolds (Tr. 139-

141, 157-159). They also found that Plaintiff’s MS warranted the environmental limitation

that she must avoid concentrated exposure to hazards, including avoiding commercial

driving, operating dangerous machinery, uneven terrain, and unprotected heights (Tr.

141-142, 159-160). State agency consultant Dr. Garon found that at the reconsideration

level, additional evidence did not demonstrate a change in Plaintiff’s physical condition,

but initial records and the totality of the evidence was only partially consistent with the

initial functional assessment (Tr. 142, 160). Accordingly, at the reconsideration level, state

agency consultants found Plaintiff could work at the sedentary level and therefore, was

not disabled (Tr. 144, 162).

On February 23, 2022, Plaintiff’s primary care doctor, Dr. Mazhar Lakho,

completed a physical residual functional capacity evaluation of Plaintiff (Tr. 513-524). Dr.

Lakho indicated that Plaintiff could lift and carry: negligible weight continuously, less

than 10 pounds occasionally, and negligibly lift any weight 10 pounds or over (Tr. 514).

Dr. Lakho then answered “No” to the question of whether Plaintiff could reliably sustain

performance for an 8-hour workday, 40-hour week without having to take unscheduled

breaks, by alternating between sitting, standing and walking (Tr. 515). Dr. Lakho found

that Plaintiff could only perform zero to less than 1 hour of sitting, standing, walking,

and resting/laying down (Tr. 515). Dr. Lakho determined Plaintiff could not ambulate

effectively and requires the use of an assistive device (Tr. 515). Regarding Plaintiff’s

hands, Dr. Lakho reported that Plaintiff could occasionally reach, and could frequently

handle, finger, feel, and push/pull with both hands (Tr. 516). Dr. Lakho indicated that

Plaintiff could occasionally use her feet to operate foot controls and he explained that this

limitation was due to Plaintiff’s altered gait related to her MS and her inability to walk

without a cane or walker (Tr. 516). Dr. Lakho also reported that Plaintiff had marked

limitations in physical functioning, understanding or remembering/applying

information, interacting with others, maintaining concentration, persistence or pace, and

adapting or managing oneself (Tr. 520). Due to her limitations, Dr. Lakho found that

Plaintiff met the criteria of listed impairment § 11.09, multiple sclerosis (Tr. 518-519).

On October 19, 2022, Plaintiff’s mother submitted an opinion letter wherein she

stated that she has to lift Plaintiff up off the couch and help her to the car while Plaintiff

puts most of her body weight on her (Tr. 399). She also stated that she must help Plaintiff

out of the car and walk with her into the doctor’s office in the same manner (Tr. 399).

Likewise, Plaintiff’s mother wrote that she takes the same steps to help Plaintiff with

using the bathtub (Tr. 399).

III. Administrative Hearing:

An administrative hearing was held before ALJ Battles on October 19, 2022 (Tr. 48-

100). Plaintiff was represented by Attorney Bradley Bauer and Plaintiff’s sister, Jessica

Hall, also appeared to assist in providing testimony (Tr. 48). In addition, Vocational

Expert Rebecca Kendrick provided testimony classifying Plaintiff’s past work (Tr. 95-97).

Plaintiff testified that she lived with her mother in a ground level apartment (Tr.

57-58). However, the apartment had some stairs which caused her trouble on a daily basis

(Tr. 58). Plaintiff also reported that she was no longer driving (Tr. 59). Plaintiff discussed

her past work as a home healthcare provider and an employee at the United States Postal

Service (Tr. 59-61). Plaintiff’s counsel then asked Plaintiff why she was sitting leaned

forward with her hand on her head and her eyes closed, to which Plaintiff explained that

she was tired (Tr. 63). Circling back to the question of stairs, Plaintiff said she had to walk

up stairs to both get into the apartment and to use the bathroom, which was on the upper

level of the apartment (Tr. 63). As a result, she indicated she often uses a bedside

commode so she does not have to climb the stairs to the bathroom (Tr. 64).

Plaintiff testified that her MS impacted her balance and ability to walk, which

caused her to rely upon a walker to get around (Tr. 64-65). She also stated that her

memory and ability to concentrate had been impacted by her MS, such that she

sometimes had no idea what was going on in conversations (Tr. 65). Plaintiff discussed

difficulties she faced in getting up, keeping her balance, and finding comfortable

positions in light of pain she experienced (Tr. 66-67). Plaintiff stated that she had lost

feeling in her right foot at that point in the hearing (Tr. 67). Plaintiff later testified that her

mother did the chores around the house, but she would try to accompany her on trips to

the grocery store (Tr. 68-69). Plaintiff said that she had difficulty using her hands, relied

upon her mother to do her hair, and needed help tying her shoes (Tr. 71).

While Plaintiff’s counsel directed several addition questions to Plaintiff, her

responses became less coherent and counsel became concerned that she was falling asleep

(Tr. 70). As a result, Plaintiff’s sister, Jessica Hall, was brought into counsel’s office to

assist in providing hearing testimony (Tr. 73-74). Ms. Hall stated that she did not live

with Plaintiff and typically visited her twice a week after the workday ended (Tr. 75). Ms.

Hall indicated that Plaintiff was not allowed to use the stove when their mother was not

home, and Plaintiff typically prepared microwave food that their mother had left in the

microwave for her (Tr. 76). Ms. Hall stated Plaintiff could not climb the stairs to the

bathroom by herself and had significant trouble holding objects (Tr. 76). She also stated

that Plaintiff had to have assistance with sponge baths, putting on clothes, and tying her

shoes (Tr. 76-77).

As to Plaintiff’s memory, Ms. Hall said Plaintiff had become very forgetful and

provided several examples of her memory issues and struggles to fully understand

conversations (Tr. 77-78). Ms. Hall also indicated that she thought Plaintiff would have

trouble holding a job because: (1) she would have transportation issues getting there; (2)

she lacked the mental capacity and concentration to work full shifts; (3) she suffers from

frequent fatigue, (4) she experiences incontinence and requires assistance in changing her

diapers; and (5) she deals with balance, dizziness, and vertigo issues (Tr. 78-83). The ALJ

then asked Ms. Hall why Plaintiff’s current presentation appeared substantially worse

than how she appeared to present herself on telehealth appointments (Tr. 85). Ms. Hall

responded that Plaintiff was appearing today as she usually does (Tr. 85). Likewise, the

ALJ asked Ms. Hall why the medical records did not discuss Plaintiff’s reliance on a

walker when her hearing testimony was that she always used it (Tr. 86). Ms. Hall

responded that Plaintiff always relied upon her walker when they were together, but Ms.

Hall admitted that Plaintiff’s mother was the one who typically took Plaintiff to her

doctors’ appointments (Tr. 86-89).

The ALJ then asked counsel to help him understand the “disconnect between

portions of the record” and “what has gone on in the last hour and 15 minutes.” (Tr. 91).

Counsel indicated additional records were forthcoming and that he personally observed

Plaintiff’s condition deteriorate over the last year and a half (Tr. 93). The ALJ then

discussed the question of how Plaintiff’s alleged onset date had been determined and

stated that:

If the claimant chooses not to [amend her alleged onset date], I’ve got no

problem with that. If it means that that results in a later onset versus a fully

favorable, versus an unfavorable, none of that really matters to me because

the end result is an additional three hours of work and I’m never going to

put – you know, I’m never going to call into question anything about these

hearings by trying to give the impression that there was almost like a quid

pro quo. Again, I know – I’m not suggesting you did that, but I just want to

make sure that I’m crystal clear about that.

(Tr. 94-95).

Thereafter, Vocational Expert Rebecca Kendrick was called to provide testimony

as to Plaintiff’s past work (Tr. 95). Based upon the testimony and record, Ms. Kendrick

classified Plaintiff’s past home health care job as a home health aide, DOT code 354.377-

014, which was medium work as generally performed and as Plaintiff had actually

performed (Tr. 97). Plaintiff’s post office job was classified as a mail clerk, DOT code

209.687-026, which was light work as generally performed but medium work as actually

performed by Plaintiff (Tr. 97). No questions regarding Plaintiff’s past work were posed

to Ms. Kendrick, so she was dismissed after the ALJ informed her that “there may or may

not be interrogatories in the next 30 to 45 days.” (Tr. 97). The ALJ concluded the hearing

shortly after (Tr. 99).

THE ALJ’S DECISION

The ALJ’s decision followed the five-step analytical framework described above

(Tr. 27-47). At step one, the ALJ determined that Plaintiff had not engaged in substantial

gainful activity since January 1, 2021, the alleged onset date (Tr. 33). At step two, the ALJ

found Plaintiff had the severe, medically determinable impairment of multiple sclerosis

(Tr. 33-34). The ALJ also considered Plaintiff’s medically determinable impairment of

depression but found that it was nonsevere because it did not cause more than a minimal

limitation in Plaintiff’s ability to perform basic mental work activities (Tr. 34). In reaching

this conclusion, the ALJ found Plaintiff had no limitation in interacting with others and

mild limitations in (1) understanding, remembering or applying information; (2)

concentrating, persisting or maintaining pace, and (3) adapting or managing oneself (Tr.

34). In making the above determinations, the ALJ reviewed various aspects of the record

including Plaintiff’s activities of daily living and her ability to dress, bathe, and feed

herself independently, to manage her own finances, and to handle stress and changes in

routine very well (Tr. 34). Finally, the ALJ also discussed the opinions in the record

related to Plaintiff’s mental functioning abilities and found that they support a finding

that Plaintiff does not have a severe mental medically determinable impairment (Tr. 35).

At step three, the ALJ held that Plaintiff’s physical impairments, considered singly

or in combination, did not meet or medically equal the criteria of any impairment listed

in 20 CFR Part 404, Subpart P, Appendix 1 (Tr. 35). The ALJ specifically indicated that he

considered listing 11.09 (multiple sclerosis) and found Plaintiff does not meet that listing

because:

[T]he record, consistent with the findings below, does not demonstrate that

the claimant has multiple sclerosis with: (A) disorganization of motor

function in two extremities resulting in an extreme limitation in the ability

to stand up from a seated position, balance while standing or walking, or

using the upper extremities; or (B) a marked limitation in physical

functioning and in one of the following: understanding, remembering, or

applying information; interacting with others; concentrating, persisting, or

maintaining pace; or adapting or managing oneself.

(Tr. 35).

Before reaching step four, the ALJ formulated Plaintiff’s RFC, finding:

After careful consideration of the entire record, the undersigned finds that

the claimant has the residual functional capacity to perform light work as

defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can

occasionally operate foot controls with the bilateral lower extremities. The

claimant can occasionally balance, stoop, kneel, crouch, and crawl. The

claimant can occasionally climb ramps and stairs and can never climb

ladders, ropes, or scaffolds. The claimant can frequently handle, finger, and

reach with the bilateral upper extremities. The claimant can never work in

hazardous environments, such as at unprotected heights or around moving

mechanical parts. The claimant can understand, remember, and carry out

simple instructions in the workplace.

(Tr. 35-36). In reaching this conclusion, the ALJ found Plaintiff’s medically determinable

impairments could be reasonably expected to cause the alleged symptoms (Tr. 36).

However, “the claimant’s statements concerning the intensity, persistence and limiting

effects of these symptoms are not entirely consistent with the medical evidence and other

evidence in the record for the reasons explained in this decision.” (Tr. 36).

The ALJ then summarized the medical evidence that was presented (Tr. 37-38). He

first acknowledged that examinations during the period at issue showed abnormal

tandem gait, mildly reduced strength, broad based, mildly paretic and ataxic gait, slow

finger and foot taps, unsteady gait, impaired recent memory, and poor attention (Tr. 37).

However, he then noted that “examinations also showed that the claimant was in no

distress; and exhibited normal strength in the bilateral upper and lower extremities; no

tremor; intact sensation; intact coordination; a normal and steady gait; and no facial

weakness.” (Tr. 37).

The ALJ then discussed Plaintiff’s January 2018 and March 2020 MRIs, which

presented findings consistent with MS (Tr. 37). And while the March 2020 MRI showed

areas of abnormal T2 FLAIR hyperintense supratentorial white matter signal and new

foci of cord signal abnormality, the ALJ emphasized that diagnostics of Plaintiff’s brain

in September 2021 “showed multiple intracranial white matter lesions compatible with

multiple sclerosis, but no new T2 or enhancing lesions compared to her March 2020

diagnostic imaging.” (Tr. 37). The ALJ also highlighted the fact that Plaintiff was not on

MS medication in either January 2021 or January 2022 (Tr. 37). He further pointed out

that the record did not include a prescription for a walker (Tr. 37). He also noted that

Plaintiff had no new symptoms suggestive of MS exacerbation in August 2021 (Tr. 37).

Consequently, the ALJ concluded that:

Considering the claimant’s abnormal diagnostic imaging of her

brain; her physical and mental examinations showing an abnormal tandem

gait, an unsteady gait, mildly reduced strength, a mildly paretic and ataxic

gait, slow finger taps and foot taps, impaired recent memory, and poor

attention; her subjective complaints regarding her symptoms and their

impact on her functioning; the testimony of her sister and the information

provided by her mother; and her activities of daily living, the undersigned

has limited the claimant to work at the light exertional level with the above

postural, manipulative, environmental, and mental limitations.

However, the claimant’s stable diagnostic imaging in September

2021; her examinations also showing that she was in no distress, normal

strength in her upper and lower extremities, no tremor, intact sensation,

intact coordination, a steady gait, and no facial weakness; and her

conservative treatment during the period at issue, and periods when she

was not adhering to her prescribed treatment, are not consistent with

greater or additional limitations. Additionally, while the claimant testified

that she requires the use of a walker, the record indicates that the claimant

was able to walk on her heels and toes without difficulty and she had a

steady gait in January 2021 (Exhibit 1F/17). In February, August, and

November 2021, the claimant’s gait was noted to be broad based and mildly

paretic and ataxic, but there was no mention of the use of an assistive device

being required to ambulate (Exhibit 2F/8; 4F/7; 8F/5). In January 2022, the

claimant’s gait was noted to be mildly wide based, but, again, there was no

mention of the use of or need for an assistive device, and the claimant’s

coordination was normal (Exhibit 5F/7). As such, the undersigned has not

allowed for the use of an assistive device.

(Tr. 37-38).

The ALJ also analyzed the opinion evidence in the record when formulating

Plaintiff’s RFC (Tr. 38-40). The ALJ found the opinions of the initial level state agency

consultants to be somewhat persuasive (Tr. 38). Specifically, he found their opinions were

supported by the medical records and Plaintiff’s subjective complaints, but he then

imposed greater postural, manipulative, environmental, and mental limitations,

explaining that:

The claimant’s abnormal diagnostic imaging of her brain, but stable

diagnostic imaging in September 2021; her physical and mental

examinations showing both an abnormal tandem gait, an unsteady gait,

mildly reduced strength, a mildly paretic and ataxic gait, slow finger taps

and foot taps, impaired recent memory, and poor attention, as well as that

she was in no distress, normal strength in her upper and lower extremities,

no tremor, intact sensation, intact coordination, a steady gait, and no facial

weakness; her conservative treatment and lack of adherence to her

prescribed treatment; the testimony of her sister and the information

provided by her mother; her subjective complaints; and her activities of

daily living are consistent with a limitation to light work with the above

postural, manipulative, environmental, and mental limitations (Hearing;

Exhibit 6E; 8E; 1F/16/17/20; 2F/2/4/7/8; 4F/7/11; 5F/1/3/7;

8F/4/5/10).

(Tr. 38). The ALJ then considered the opinions of the state agency consultants from the

reconsideration level, finding their opinion was not persuasive (Tr. 38-39). Most

prominently, the ALJ explained that the reconsideration level opinions were not

persuasive because they imposed additional limitations in Plaintiff’s ability to stand

and/or walk (Tr. 39).

The ALJ rejected Dr. Lakho’s February 2022 opinion, finding it was not persuasive

because Dr. Lakho failed to support such a significant degree of limitation. The ALJ

reiterated that Dr. Lakho’s opinion was not consistent with the longitudinal record

because, “[a]s discussed above, the claimant’s diagnostic imaging; her normal and

abnormal physical and mental examinations; her conservative treatment and lack of

adherence to her prescribed treatment; the reports of her sister and mother; her subjective

complaints; and her activities of daily living are consistent with a limitation to light work

with the above postural, manipulative, environmental, and mental limitations.” (Tr. 39).

The ALJ also considered the opinion letter submitted by Plaintiff’s mother, finding

the degree of limitation in her report was not “fully consistent with the objective medical

evidence during the period under review.” (TR. 39-40). The ALJ then stated, “As

discussed above, the claimant’s diagnostic imaging; her normal and abnormal physical

and mental examinations; her conservative treatment and lack of adherence to her

prescribed treatment; the reports of her sister and mother; her subjective complaints; and

her activities of daily living are consistent with a limitation to light work with the above

postural, manipulative, environmental, and mental limitations.” (Tr. 40).

Finally, the ALJ summarized his RFC findings by explaining that his assessment

was supported by the medical evidence of record and accommodated for Plaintiff’s

impairments by limiting her to light work with additional postural, manipulative,

environmental, and mental limitations (Tr. 40). However, “[b]ecause the claimant’s

allegations are not fully consistent with the evidence of record, no other limitations are

warranted.” (Tr. 40).

At step four, the ALJ relied upon the Vocational Expert’s testimony to conclude

that Plaintiff is unable to perform past relevant work as actually or generally performed

(Tr. 41). Lastly, at step five, the ALJ again relied upon Ms. Kendrick, the Vocational

Expert, stating, “[t]he Vocational Expert testified that given all of these factors the

individual would be able to perform the requirements of representative occupations such

as: Merchandise marker, 209.587-034[;] Cleaner, housekeeping, 323.687-014[;] Routing

clerk, 222.687-022[.]” (Tr. 41). The ALJ then confirmed that the Vocational Expert’s

testimony was consistent with the Dictionary of Occupational Titles and held that

“[b]ased on the testimony of the vocational expert, the undersigned concludes that,

considering the claimant’s age, education, work experience, and residual functional

capacity, the claimant is capable of making a successful adjustment to other work that

exists in significant numbers in the national economy.” (Tr. 41-42). For this reason, the

ALJ found Plaintiff was not under a disability, as defined by the Social Security Act, for

the period from January 1, 2021, through the date of the ALJ’s decision (March 9, 2023)

(Tr. 42).

ISSUES RAISED BY PLAINTIFF

Plaintiff raises the following issues (see Doc. 21):

1. The ALJ failed to fully and fairly develop the record and issued a decision

knowing there was outstanding medical evidence.

2. The ALJ did not properly consider opinion evidence in accordance with 20

C.F.R. § 404.1520c.

3. The ALJ did not properly evaluate Plaintiff’s complaints of pain in

accordance with SSR 96-3p.

4. The ALJ failed to properly consider Plaintiff’s non-compliance with

treatment in accordance with SSR 96-7p.

DISCUSSION

Plaintiff challenges the ALJ’s decision on several grounds. First, Plaintiff contends

the ALJ erred by failing to fully and fairly develop the record because the record was

missing key files related to Plaintiff’s mental health impairment and a motor vehicle

accident (Doc. 21 at p. 3). Second, Plaintiff contends the ALJ improperly weighed opinion

evidence and failed to explain his reasoning by frequently grouping numerous,

inconsistent factors together to support his RFC determination without any further

explanation or elaboration (Id. at pp. 3-9). Third, Plaintiff avers that the ALJ discredited

Plaintiff’s subjective complaints of pain and limited mobility by relying on evidence of

Plaintiff’s daily activities, without explaining how those activities undermined Plaintiff’s

credibility (Id. at pp. 9-13). And fourth, Plaintiff contends that the ALJ failed to properly

consider Plaintiff’s reasons for her noncompliance with treatment and/or lack of

treatment when relying upon that noncompliance to determine Plaintiff’s credibility and

RFC (Id. at pp. 13-15). Ultimately, while the Court will discuss several of the arguments

raised by Plaintiff, the Court finds that this matter must be remanded for a different

reason – that the record does not contain the testimony of the Vocational Expert which

was relied upon by the ALJ at Step Five of his decision.

Significantly, as far as the Court can discern, Vocational Expert Rebecca Kendrick

only testified at the October 19, 2022, hearing as to Plaintiff’s past work (see, e.g., Tr. 95-

97). However, in addition to inaccurately stating that Vocational Expert Roxanne Benoit

testified at the hearing (see Tr. 30), the ALJ’s decision acknowledged that Ms. Kendrick

was sent a vocational interrogatory that inquired as to Plaintiff’s ability to perform any

unskilled occupations that exist in the national economy considering Plaintiff’s

hypothetical RFC (see Tr. 401-405) (Exhibit 18E). Ms. Kendrick purportedly provided her

interrogatory answers in Exhibit 19E (see Tr. 407-411) (Exhibit 19E) and they were

provided to Mr. Peter Drummond, Plaintiff’s counsel at the time, who was given an

opportunity to submit written questions to Ms. Kendrick (Tr. 413-414) (Exhibit 20E).

While such an approach would be acceptable under normal circumstances, the

record currently before the Court does not demonstrate normal circumstances. In

addition to originally misidentifying the Vocational Expert (Tr. 30), the ALJ’s opinion

elaborates upon the process of sending a vocational interrogatory to Ms. Kendrick and

states that because Plaintiff did not respond to Exhibit 20E’s notice, “the evidence was

entered into the record as Exhibit 16E.” (Tr. 31). Unquestionably, however, Exhibit 16E

does not contain Ms. Kendrick’s vocational interrogatory answers. Instead, Exhibit 16E is

a one-page letter submitted by Plaintiff’s mother (Tr. 399).

Presumably, the ALJ intended to cite to Exhibit 19E, which is labeled, “Response

to Vocational Interrogatory, dated 12/06/2022, from VE: Rebecca Kendrick.” (Tr. 407-

411; see also Doc. 12-1 at p. 3). Yet, Exhibit 19E includes the same interrogatories found in

Exhibit 18E and does not contain any answers or other responses to those questions

(Compare Tr. 401-406 with Tr. 407-411). In fact, the only difference between Exhibit 18E

and Exhibit 19E is that the final page of Exhibit 19E includes Ms. Kendrick’s signature,

dated 12/6/2022 (see Tr. 411). Thus, while the Court presumes that there is a version of

the vocational interrogatories that contains Ms. Kendrick’s responses, neither the ALJ’s

citation to Exhibit 16E nor the filing found at Exhibit 19E provide a record of such.4

And critically, the ALJ indisputably relied upon Ms. Kendrick’s vocational

interrogatory responses when finding at Step Five that given Plaintiff’s RFC, other jobs

exist in significant numbers in the national economy (Tr. 41). As such, the Court has no

idea what Ms. Kendrick’s responses were and whether she considered and/or discussed

non-exertional limitations that would impact the range of work Plaintiff could perform.

See, e.g., Luna v. Shalala, 22 F.3d 687, 691 (7th Cir. 1994) (“[T]his court has said that in cases

where a non-exertional limitation might substantially reduce a range of work an

individual can perform, the ALJ must consult a vocational expert.”); Wirth v. Barnhart,

318 F. Supp. 2d 726, 745 (E.D. Wis. 2004) (“[T]his Court cannot conclude that the ALJ’s

decision to rely exclusively on the Grid Rule as opposed to also basing her decision on a

VE’s testimony is supported by substantial evidence because the record was not fully and

fairly developed, (specifically relevant here are: Dr. Kourakis’s diagnosis of chronic pain

syndrome, Tr. 318, and the plaintiff’s alleged mental disorder, depression, and side effects

from medications).”).

Furthermore, the Commissioner certified that the transcript provided to the Court

“constitute[d] a full and accurate transcript of the entire record of proceedings relating to

4 In fact, the ALJ included a footnote that corrected a DOT code that Ms. Kendrick purportedly provided

the wrong number for in her responses (Tr. 41 at fn. 1). Unfortunately, however, that footnote also fails to

include any citation to Ms. Kendrick’s interrogatory responses.

this case.” (Doc. 12).5 Thus, what the Court is left with is a certified record, wherein the

ALJ substantially relied upon Ms. Kendrick’s vocational interrogatory responses, but

those responses are blank as provided to the Court (Tr. 407-411). While the Court

presumes the ALJ had Ms. Kendrick’s responses before him when issuing his decision,

the ALJ’s failure to cite an exhibit containing those responses (Tr. 41) combined with the

Commissioner’s certification of a record that does not include those responses (Doc. 12)

leads the Court to the inescapable conclusion that, as proffered here, “the vocational

expert’s testimony does not provide substantial evidence to support the administrative

law judge’s conclusion at step five of the sequential evaluation process.” Holtz v. Astrue,

07-C-314-C, 2007 WL 5323758, at *6 (W.D. Wis. Nov. 8, 2007). “When a full and fair record

is lacking, however, the ALJ will not have sufficient facts on which to make an informed

decision, and thus his decision will not be supported by substantial evidence.” Clark v.

Berryhill, 402 F. Supp. 3d 541, 545 (W.D. Wis. 2019). See also McDaniel v. Astrue, 1:07-CV-

642-SEB-TAB, 2009 WL 211861, at *3 (S.D. Ind. Jan. 29, 2009) (“Absent the ALJ’s

consideration and evaluation of the vocational expert testimony which was favorable to

McDaniel’s claim, the court cannot be confident that the ALJ considered the important

evidence of record, nor can it trace the path of the ALJ’s reasoning.”). For this reason, the

5 42 U.S.C. § 405(g) provides, in pertinent part, that “As part of the Commissioner’s answer the

Commissioner of Social Security shall file a certified copy of the transcript of the record including the

evidence upon which the findings and decision complained of are based.” While the Court presumes

clerical errors are to blame for the apparent gap in the record, such that the Commissioner’s certification

was a mere oversight, other courts have approached this issue with additional skepticism and noted that

“in the appropriate case, the Commissioner may be exposed to sanctions if she certifies as complete a record

that plainly is not.” Acevedo v. Barnhart, 474 F. Supp. 2d 1001, 1005 (E.D. Wis. 2007).

Court finds that the ALJ’s decision at Step 5 is not supported by substantial evidence.

Therefore, this case must be remanded to the Commissioner for further proceedings.6

While the above issue merits remand on its own, the Court also briefly addresses

several of the arguments raised by Plaintiff related to how the ALJ weighed evidence and

determined Plaintiff’s RFC. Most notably, the ALJ rejected, or found non-persuasive,

opinion evidence (see Tr. 38-40), medical evidence (Tr. 37-38), and subjective complaints

(Tr. 36) that were contrary to his RFC determination by finding that the combination of

Plaintiff’s more limiting and less limiting evidence supported his RFC determination, but

not further limitations (see, e.g., Tr. 40).

RFC is an assessment of what work-related activities an individual can perform

6 In addition, the Court notes that the blank vocational interrogatories posed to Ms. Kendrick do not include

questions expressly inquiring as to available jobs when accounting for Plaintiff’s mild mental limitations

in: (1) understanding, remembering or applying information; (2) concentrating, persisting or maintaining

pace; and (3) adapting or managing oneself (see Tr. 34 -35). And pertinently, the ALJ found the opinions of

the reconsideration level state agency consultants to be persuasive as to Plaintiff’s mild mental limitations

(Tr. 35). Yet, the vocational interrogatories posed to Ms. Kendrick did not include a question that

incorporated those specific mental limitations which the ALJ found to be persuasive (see, e.g. Tr. 401-405).

Instead, at most, the ALJ’s hypothetical included a limitation related to understanding, remembering or

carrying out simple instructions in the workplace (Tr. 402).

Thus, the Court does not believe that the ALJ’s posed hypotheticals adequately accounted for all

of Plaintiff’s mental limitations. The Seventh Circuit has “repeatedly rejected the notion that a hypothetical

like the one here confining the claimant to simple, routine tasks and limited interactions with others

adequately captures temperamental deficiencies and limitations in concentration, persistence, and pace.”

Varga v. Colvin, 794 F.3d 809, 814 (7th Cir. 2015) (internal quotation marks and citation omitted). See also

Yurt v. Colvin, 758 F.3d 850, 859 (7th Cir. 2014) (Expressing the same concern and then holding that

“[b]eyond stating that Yurt could perform ‘unskilled task[s] without special considerations,’ the

hypothetical does nothing to ensure that the VE eliminated from her responses those positions that would

prove too difficult for someone with Yurt’s depression and psychotic disorder.”); Mischler v. Berryhill, 766

F. App’x 369, 376 (7th Cir. 2019); DeCamp v. Berryhill, 916 F.3d 671, 675 (7th Cir. 2019); Stewart v. Astrue, 561

F.3d 679, 685 (7th Cir. 2009); Craft v. Astrue, 539 F.3d 668, 677 (7th Cir. 2008); Young v. Barnhart, 362 F.3d 995,

1004 (7th Cir. 2004). Thus, even if the Court had been provided with Ms. Kendrick’s responses, it is not

clear that her responses would have accounted for the concentration and other mental limitations found to

be persuasive by the ALJ. See Stewart, 561 F.3d at 685 (“As a consequence, the vocational expert did not

address these limitations when he suggested vocations such as punch-board assembler, laundry worker,

or sorter.”).

despite his or her limitations. Young v. Barnhart, 362 F.3d 995, 1000–01 (7th Cir. 2004)

(citing 20 C.F.R. § 404.1545(a)). An individual’s RFC should be assessed based upon all

relevant evidence in the record. Id. However, the Seventh Circuit has “repeatedly held

that although an ALJ does not need to discuss every piece of evidence in the record, the

ALJ may not analyze only the evidence supporting her ultimate conclusion while

ignoring the evidence that undermines it.” Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir.

2014). In other words, an ALJ may not simply cherry-pick facts that support a finding of

non-disability while ignoring evidence that points to a contrary result. See Denton v.

Astrue, 596 F.3d 419, 425 (7th Cir. 2010).

Here, on no less than three occasions, the ALJ attempted to overcome evidence

that would have supported a more restrictive RFC by stating:

As discussed above, the claimant’s diagnostic imaging; her normal and

abnormal physical and mental examinations; her conservative treatment

and lack of adherence to her prescribed treatment; the reports of her sister

and mother; her subjective complaints; and her activities of daily living are

consistent with a limitation to light work with the above postural,

manipulative, environmental, and mental limitations (Hearing; Exhibit 6E;

8E; 1F/16/17/20; 2F/2/4/7/8; 4F/7/11; 5F/1/3/7; 8F/4/5/10).

(Tr. 39, 40). Quite simply, this lumping of evidence together provides the Court with no

way of determining how the ALJ arrived at the conclusion he did. See Minnick v. Colvin,

775 F.3d 929, 937 (7th Cir. 2015) (“Though an ALJ’s credibility determination may only

be overturned if it is ‘patently wrong,’ Craft v. Astrue, 539 F.3d 668, 678 (7th Cir. 2008), a

failure to adequately explain his or her credibility finding by discussing specific reasons

supported by the record is grounds for reversal.”); Sarchet v. Chater, 78 F.3d 305, 307 (7th

Cir. 1996) (“If the administrative law judge believed the medical reports that found that

Sarchet has enough strength to work and disbelieved Sarchet’s own testimony, this

would compel the denial of the application for benefits. We cannot say that this

combination of belief and disbelief would be unreasonable but we cannot uphold a

decision by an administrative agency, any more than we can uphold a decision by a

district court, if, while there is enough evidence in the record to support the decision, the

reasons given by the trier of fact do not build an accurate and logical bridge between the

evidence and the result.”); Mueller v. Astrue, 860 F. Supp. 2d 615, 619 (N.D. Ill. 2012) (“The

ALJ need not build the Pont Neuf. A simple trestle will suffice so long as it allows the

reviewing judge to traverse safely the divide between the evidence and the

conclusions.”).

In taking this approach, the ALJ did not actually explain why he did not find

evidence supporting a more restrictive RFC to be persuasive. “An ALJ does not have to

accept an opinion from a treating physician as long as the ALJ cites good reasons for

rejecting it.” Joe R. v. Berryhill, 363 F. Supp. 3d 876, 882 (N.D. Ill. 2019). Here, for example,

the ALJ rejected the opinion of Dr. Lakho by citing numerous pieces of favorable and

unfavorable evidence together (Tr. 39). But by taking this approach and generally

asserting that the “longitudinal record” does not support such severe restrictions, the ALJ

failed to provide specific reasons for rejecting that evidence. And confusingly, in doing

so, he even cited numerous pieces of evidence that support Dr. Lakho’s more-severe

limitations such as evidence of Plaintiff’s subjective complaints, reports from her mother

and sister, activities of her daily living that demonstrate she was reliant upon family to

help her with even the most basic of tasks, and the multitude of medical records

documenting her MS and the resulting balance and gait issues she experienced (Tr. 39).

See, e.g., Emanuele v. Astrue, 803 F. Supp. 2d 959, 973 (E.D. Wis. 2011) (“As Emanuele

argues, the same Exhibit is being used to show stability and worsening. The ALJ needed

to discuss more which records showed stability and how, rather than referencing sixty-

eight pages of records, some of which contradict a finding of stability.”). Therefore,

without further analysis or explanation, the ALJ has not built a logical bridge to explain

why the conflicting evidence – when considered together – supports his RFC

determination and not the more restrictive RFC determinations of the reconsideration

level state agency consultants or Dr. Lakho. See Craft v. Astrue, 539 F.3d 668, 678 (7th Cir.

2008) (“The finding must be supported by the evidence and must be specific enough to

enable the claimant and a reviewing body to understand the reasoning.”).

Relatedly, in citing Plaintiff’s daily activities, even if the Court were to assume the

ALJ found all of those activities demonstrated that additional limitations were not

warranted, the Court questions how the limited evidence of Plaintiff’s daily activities

could support the ALJ’s RFC determination and finding that Plaintiff could perform light

work, standing for up to 6 hours in a workday. “It is obvious – or should be – that mowing

the lawn one day out of a month with breaks over a two-hour period is not consistent

with standing and walking for up to six hours every workday. Neither, of course, are

sporadic chores around the house.” Michael C v. Saul, 408 F. Supp. 3d 919, 924 (N.D. Ill.

2019). Likewise, here the Court struggles to understand how Plaintiff’s daily activities,

such as microwaving food that her mother left in the microwave (Tr. 76) or doing laundry7

are consistent with the ALJ’s determination that Plaintiff could perform light work and

stand and walk for up to six hours every workday. See Id. Certainly, some of Plaintiff’s

daily activities may support the ALJ’s conclusion. However, instead of citing to those

specific examples – the ALJ merely provided generalized conclusions and citations

without further development.

Again, the Court will defer to the ALJ’s decision if it is supported by substantial

evidence, so long as the ALJ builds a logical bridge between that evidence and his

conclusion so Plaintiff and this Court can trace his line of reasoning. See Tracie H. v. Saul,

388 F. Supp. 3d 990, 994 (N.D. Ill. 2019). But here, the ALJ’s generalized citations and

grouping of both favorable and unfavorable exhibits into one conflicting string citation

do not provide a reasonable way for Plaintiff or the Court to understand the ALJ’s

reasoning. Accordingly, in addition to finding remand is required because of the issue

7 Furthermore, when discussing Plaintiff’s daily activities, the ALJ stated that Plaintiff was able to perform

household chores including laundry (Tr. 34). The ALJ did not include a citation at the end of that sentence,

but he did cite the entirety of the hearing testimony and Exhibits 6E and 8E at the end of that paragraph

(Tr. 34). Having reviewed those exhibits and the hearing transcript, the Court is unable to find statements

in those documents that support his assertion that Plaintiff can independently do laundry. No testimony

was provided on this point at the hearing (Tr. 48-100). Moreover, while Plaintiff’s answers in Exhibits 6E

and 8E state that she does laundry (Tr. 329, 360), that statement was limited by Plaintiff’s other responses

in those exhibits. For instance, in Exhibits 6E and 8E, just before Plaintiff answered that she does laundry,

Plaintiff answered that laundry was something she was able to do before her illness that she could no longer

do (Tr. 330, 359) (For reasons unclear to the Court, page 5 of 10 in Exhibit 6E (Tr. 329) was filed before page

4 of 10 in Exhibit 6E (Tr. 330). However, this change in page order does not alter the Court’s point).

Additionally, later on in Exhibits 6E and 8E, Plaintiff answered that laundry was an activity she did with

others (Tr. 332, 362). Thus, none of the exhibits or testimony the ALJ cited actually support his finding that

Plaintiff was able to independently perform the household chore of doing laundry (see Tr. 34).

Admittedly, the ALJ never specified that he was treating that evidence as evidence that she was

doing laundry on her own. Nevertheless, the Court assumes he made such an assumption because clearly,

a claim that Plaintiff can work a job on her own for 8 hours would not be supported by evidence that

Plaintiff can do some laundry at home when assisted by others.

related to the missing vocational interrogatory responses, the Court finds the ALJ’s

decision must also be remanded because it fails to build a logical bridge between the cited

evidence and his conclusions.8

In summary, the Court holds that: (1) the ALJ’s generalized citation of the evidence

was not sufficient to provide a logical bridge between the evidence and his conclusions,

and (2) in the absence of all of the Vocational Expert’s testimony or filings, the ALJ’s

decision at Step 5 was not supported by substantial evidence. See Terry v. Astrue, 580 F.3d

471, 475 (7th Cir. 2009). Accordingly, remand is proper so the ALJ can reconsider the

evidence, develop the record, and provide a logical bridge between that evidence and his

conclusions.

8 Finally, the Court points out two additional concerns – without reaching a determination on those

concerns - that it hopes the parties will consider on remand. First, the parties discussed (and disputed)

whether the records show that Plaintiff’s MS had progressed or exacerbated during the time period in

question. Upon remand, the parties should keep in mind that evidence of Plaintiff’s then-current level of

impairment is more important than evidence of MS progression or exacerbation. See Wilder v. Chater, 64

F.3d 335, 337 (7th Cir. 1995) (“The fact that, according to her daughters, Wilder got worse in 1988 and 1989

does not indicate how bad she was in 1986.”); Milliken v. Astrue, 397 Fed. Appx. 218, 225 (7th Cir. 2010)

(“We recognize that the fact that Milliken’s condition may have worsened at the time of the 2005 MS

exacerbation does not compel the finding that she was not disabled prior to her date last insured.”).

Second, the parties dispute the significance of Plaintiff’s failure to consistently take MS medication

and Plaintiff’s purportedly inconsistent and/or conservative treatment plan. Certainly, the medical record

contains several, potentially conflicting, explanations for why Plaintiff was not taking medication for her

MS at all times (e.g., health insurance concerns, concerns related to which pharmacies carried specialty

medications, side-effect concerns and issues regarding MS medication while pregnant and/or

breastfeeding) (see, e.g., Tr. 429, 437, 442, 447, 493). In considering this matter on remand, it would be

beneficial for the parties to elaborate upon the differing explanations offered for Plaintiff’s medication

regime and course of treatment because some of those explanations could weigh against Plaintiff’s claims

while others might not. See SSR 16-3p; see also Murphy v. Colvin, 759 F.3d 811, 816 (7th Cir. 2014) (“The ALJ

may deem an individual’s statements less credible if medical reports or records show that the individual is

not following the treatment as prescribed…. However, such evidence should not negatively affect an

individual’s credibility if there are good reasons for the failure to complete the plan.”); Craft v. Astrue, 539

F.3d 668, 679 (7th Cir. 2008) (“Here, although the ALJ drew a negative inference as to Craft’s credibility

from his lack of medical care, she neither questioned him about his lack of treatment or medicine

noncompliance during that period, nor did she note that a number of medical records reflected that Craft

had reported an inability to pay for regular treatment and medicine.”).

The Court wishes to stress that this Memorandum and Order should not be

construed as an indication that the Court believes Plaintiff was disabled or that she

should be awarded benefits. To 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 applications for DIB and SSI

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: September 26, 2025

s/ Mark A. Beatty

MARK A. BEATTY

United States Magistrate Judge