The opinion
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
MARIA P.,
Plaintiff,
No. 24 CV 3530
v.
Magistrate Judge McShain
FRANK BISIGNANO,
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
MEMORANDUM OPINION AND ORDER
Plaintiff Maria P. appeals the Commissioner of Social Security’s decision
denying her application for benefits. For the following reasons, plaintiff’s motion to
reverse the Commissioner’s decision [17] is granted, the Commissioner’s motion for
summary judgment [20] is denied, and the case is remanded for further
administrative proceedings.1
Background
In March 2016, plaintiff applied for a period of Title II disability and disability
insurance benefits as well as Title XVI supplemental security income, alleging an
onset date of February 17, 2016. [12-1] 15. The claims were denied initially, on
reconsideration, and after a hearing before an administrative law judge. [Id.] 15, 26.
The Appeals Council denied review in March 2019, [Id.] 1–3, and plaintiff appealed
to this Court. In May of 2022 the Court granted plaintiff’s motion to reverse the SSA's
decision and remand this case for further proceedings. Maria P. v. Kijakazi, No. 19
CV 3477, 2022 WL 1523639, at *7 (N.D. Ill. May 13, 2022). On remand, the ALJ held
a hearing and again denied plaintiff's application for benefits. [12-2] 1299. Plaintiff
did not file written exceptions with the Appeals Council and the Appeals Council did
not review plaintiff's case on its own within sixty days after the date of the ALJ's
decision, making the ALJ's decision the agency's final decision. [Id.] 1284–86; [17] 2;
See 20 C.F.R. §§ 404.955, 404.981. Plaintiff has again appealed to this Court, and the
Court has subject-matter jurisdiction under 42 U.S.C. § 405(g).2
1 Bracketed numbers refer to entries on the district court docket. Referenced page numbers are taken
from the CM/ECF header placed at the top of filings, except for citations to the administrative record,
[12-1]; [12-2]; [12-5], which refer to the page numbers in the bottom right corner of each page.
2 The parties have consented to the exercise of jurisdiction by a United States Magistrate Judge. [8].
The ALJ reviewed plaintiff’s claim in accordance with the Social Security
Administration’s five-step evaluation process. At step one, the ALJ found that
plaintiff had not engaged in substantial gainful activity since the alleged onset date.
[12-2] 1289–90. At step two, the ALJ determined that plaintiff has the following
severe impairments: “left shoulder impingement status-post arthroscopy and
revision; right shoulder impingement status-post arthroscopy; myofascial pain
syndrome; Chiari I malformation with cervical degenerative disc disease; and obesity”
[Id.] 1290. At step three, the ALJ concluded that plaintiff’s impairments did not meet
or equal the severity of a listed impairment. [Id.] 1292. Before turning to step four,
the ALJ ruled that plaintiff had the residual functional capacity (RFC) to perform
light work except that she (1) cannot climb ladders, ropes, or scaffolds; (2) only
occasionally crawl, but frequently crouch, kneel and stoop; and (3) cannot have
concentrated exposure to hazards, defined as working at heights. [Id.] 1292–97. At
step four, the ALJ held that plaintiff could not perform her past relevant work. [Id.]
1297. At step five, the ALJ found that jobs existed in significant numbers in the
national economy that plaintiff could perform: maker (131,100 jobs), housekeeper
cleaner (193,200 jobs), and laundry folder (19,500 jobs). [Id.] 1298. Accordingly, the
ALJ ruled that plaintiff was not disabled for the relevant time period.3
Legal Standard
The Court reviews the ALJ’s decision deferentially to determine if it is
supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is “not a
high threshold: it means only ‘such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.’ ” Karr v. Saul, 989 F.3d 508, 511 (7th
Cir. 2021) (quoting Biestek v. Berryhill, 587 U.S. 97, 103 (2019)). “When reviewing a
disability decision for substantial evidence, we will not reweigh the evidence, resolve
debatable evidentiary conflicts, determine credibility, or substitute our judgment for
the ALJ’s determination so long as substantial evidence supports it.” Warnell v.
O’Malley, 97 F.4th 1050, 1052-53 (7th Cir. 2024) (internal quotation marks and
brackets omitted).
Discussion
Plaintiff argues that the denial of benefits should be reversed because the ALJ
(1) failed to properly evaluate the opinion of Dr. Evans, her treating orthopedic
surgeon, and (2) failed to properly evaluate plaintiff’s subjective allegations of her
symptoms or limitations. [17] 6–16. The Court agrees that the ALJ’s discussion of Dr.
Evans’s opinion did not give “good reasons” for assigning less than controlling weight
to his opinion, as required by the Seventh Circuit. Brown v. Colvin, 845 F.3d 247, 252
3 Claimant filed a subsequent claim for Title II and Title XVI benefits on 04/25/2019 and the State
agency found the claimant disabled for Title XVI disability benefits as of that date [12-2] 1287. The
Appeals Council reviewed and affirmed the determination. [Id.]. Accordingly, the period under review
is 02/17/2016-04/24/2019. [Id.].
(7th Cir. 2016). The Court finds that the ALJ also failed to adequately discuss the
factors required by 20 C.F.R. § 404.1527(c) when weighing Dr. Evans’s opinion.
Accordingly, the Court finds that another remand is warranted to correct these
errors.
A. Treating Physician Rule
Because plaintiff applied for benefits before March 27, 2017, the ALJ was
required to apply the “Treating Physician Rule[.]” See e.g., Marcus W. v. Bisignano,
No. 23 CV 1936, 2025 WL 2299601, at *2 (N.D. Ill. Aug. 8, 2025). This rule entitles a
treating physician's opinion controlling weight if the opinion is both well supported
by medical findings and not inconsistent with other substantial evidence in the
record. Brown, 845 F.3d at 252 (7th Cir. 2016); Gerstner v. Berryhill, 879 F.3d 257,
261 (7th Cir. 2019). “When controlling weight is not given, an ALJ must offer ‘good
reasons’ for doing so, after having considered: (1) whether the physician examined
the claimant, (2) whether the physician treated the claimant, and if so, the duration
of overall treatment and the thoroughness and frequency of examinations, (3)
whether other medical evidence supports the physician's opinion, (4) whether the
physician's opinion is consistent with the record, and (5) whether the opinion relates
to the physician's specialty.” Brown, 845 F.3d at 252; see also 20 C.F.R. §
404.1527(c)(2).
Dr. Evans, an orthopedic surgeon, saw plaintiff from 2010 through 2015. [12-
1] 689; [12-2] 1175. As part of his treatment of plaintiff, he performed multiple
surgeries. [12-1] 613–15, 1068–70. On 10/19/2015, Dr. Evans opined, in a medical
source statement, that plaintiff could return to work, but had permanent restrictions
in her ability to lift and carry:
Maria [P.] has been examined by me on 3/3/2015 and is able to return to
work on 3/3/2015 with the following limitations per her FCE [i.e.,
functional capacity evaluation] on 5/20/2014:
Restrictions per FCE:
Floor lift no more than 10 lbs occasionally
Lifting up to level of shoulder no more than 5 lbs occasionally
Carrying no more than 10 lbs occasionally
Pull no more than 10 lbs occasionally
No overhead reaching
No ladder climbing
These are permanent restrictions
[12-2] 1175 (emphasis in original)
The ALJ explained her decision to give less than controlling weight to Dr.
Evans’s opinion as follows:
In accordance with the District Court remand order and subsequent
Appeals Council direction, I further considered the opinion of Dr. Evans
(Exhibits 14F; 15F). Dr. Evans offered permanent restrictions on
October 19, 2015, apparently based on a May 2014 functional capacities
evaluation, which is not in the file. The claimant representative stated
at the June 2023 hearing that she was unable to locate this actual
Functional Capacity Evaluation (FCE) given how old it is. Specifically,
Dr. Evans provided a statement that he examined the claimant on
March 3, 2015, at which time she was able to return to work based on
the limitations identified at the FCE on May 20, 2014. This included
permanent restrictions of floor lift no more than 10 pounds occasionally,
lifting up to level of shoulder no more than 5 pounds occasionally, carry
no more than 10 pounds occasionally, pull no more than 10 pounds
occasionally, no overhead reaching, and no ladder climbing (Exhibits
14F/2; 15F/2). I note that the opinion of Dr. Evans is from before the
claimant’s alleged onset date, and they were permanent restrictions.
This is not given controlling or any significant weight. While Dr. Evans
was a treating doctor, his extreme findings are not supported by later
examination findings which document few abnormalities (Exhibits
26F/4; 28F/1, 12, 15, 21; 31F/8).
I did not provide articulation about the evidence that is inherently
neither valuable nor persuasive in accordance with 20 CFR 404.1520b(c)
and 416.920b(c).
[12-2] 1296.
In the prior remand, this Court explained that the ALJ’s decision regarding
Dr. Evans’s opinion was inadequate under the treating physician rule because the
ALJ failed to provide a “good reason” for affording less than controlling weight to Dr.
Evans’s opinion and the ALJ “did not adequately discuss the factors that determine
what weight should be afforded to his opinion.” Maria P., 2022 WL 1523639, at *4–6.
The Commissioner argues that the ALJ’s most recent decision remedied these errors.
The Court disagrees.
B. Good reasons
The Commissioner argues that the ALJ’s discussion of other doctors’ treatment
notes, which she found to be inconsistent with Dr. Evans’s opinion, serves as a
“sufficient reason for rejecting a treating source opinion.” [21] 3–4. The ALJ’s does
discuss a treatment record from Dr. Kevin Orr, [12-2] 1169–72, as an example of a
record that she finds inconsistent with Dr. Evans’s opinion. [21] 3; [12-2] 1294. But
this discussion is not new, the ALJ also cited Dr. Orr’s treatment note in her 2018
decision. [12-1] 21. And this Court already gave several reasons for why that note was
insufficient to support the conclusion that Dr. Evans’s opinion was outdated:
The ALJ cited to a treatment note prepared by Dr. Kevin Orr, who
evaluated plaintiff at the Loyola Pain Medicine Clinic on May 19, 2015–
barely two-and-a-half months after plaintiff's last appointment with Dr.
Evans. Dr. Orr found that plaintiff retained flexion and abduction in
both arms to 120 degrees. Plaintiff also told Orr that her pain was
“better” when she took Aleve. Yet Dr. Orr's treatment note also
documented that plaintiff still experienced pain when performing the
flexion and abduction exercises; it also recorded plaintiff's statement
that her “pain has been getting worse steadily.” Unlike Dr. Evans,
moreover, Dr. Orr did not translate his findings into work-related
limitations. It is therefore unclear how this treatment note could
support a finding that plaintiff's condition had materially improved,
such that the ALJ could plausibly conclude that Dr. Evans's opinion
about plaintiff's ability to lift and carry was outdated.
Maria P., 2022 WL 1523639, at *5 (internal citations omitted). The ALJ’s discussion
of Dr. Orr’s note in her 2024 opinion is substantially similar to her 2018 opinion, [12-
2] 1294; [12-1] 21, and does not change the Court’s stated conclusion from the prior
remand.
The ALJ also cited, but did not discuss, treatment notes in support of her
statement that Dr. Evans’s “extreme findings are not supported by later examination
findings which document few abnormalities[.]” [12-2] 1296. Because the ALJ did not
discuss these notes, the Court is left to review them for itself and try and understand
the basis for the ALJ’s statement.
The first citation is a page from a February 2018 visit where the doctor
recorded that plaintiff “is here because she now has insurance and wants to catch up
with her health.” [12-2] 1274. The doctor also recorded that plaintiff “states she had
been diagnosed with Lupis and pre-diabetes. . . . Feeling weak, forgetful and very
disoriented.” [Id.]. While this note does not mention pain, it also records that plaintiff
is feeling weak, and does not appear to contradict Dr. Evans’s opinion that plaintiff’s
limitations regarding lifting were permanent.
The ALJ also cites several specific treatment records from an exhibit which
contains records of plaintiff’s eighteen visits to Premium Healthcare PC from
December 2018 to December 2019. [12-2] 1296. The ALJ cites four of these visits: (1)
an appointment made because of “[p]ossible bronchitis,” [Id.] 1557; (2) a follow up
appointment after plaintiff had an allergic reaction to medicine, [Id.] 1568; (3)
another follow up appointment regarding plaintiff’s allergic reaction, [Id.] 1571; and
(4) a visit after another allergic reaction to a different medicine and UTI symptoms,
[Id.] 1577. Another citation is to an AdventHealth emergency room record after
plaintiff was admitted due to epigastric pain following an endoscopy. [Id.] 1865. The
treater in an AdventHealth emergency room wrote “[n]ormal strength . . . [and] pain-
free after medications here, plan is discharge home[.]” [Id.]. While none of these
treatment notes indicate that plaintiff would have difficulty lifting, the reasons for
the visits were discrete issues unrelated to the restrictions discussed in Dr. Evans’s
opinion.
The Commissioner argues that the ALJ’s reliance on records made after visits
unrelated to plaintiff’s alleged disability were justified because “there were no other
physical examinations to consider[] . . . [and d]espite seeing her primary care
physician regularly for complaints unrelated to her alleged disability, she did not
report ongoing problems with her shoulders, and examiners did not document the
presence of functional deficits related to her shoulders.” [21] 4. After a review of the
administrative record, the Court disagrees that the ALJ had no records related to
plaintiff’s alleged lifting limitation to analyze. For example, among the treatment
notes from Premium Healthcare PC are several relevant findings. One such
appointment was a follow up after plaintiff received an MRI. [12-2] 1583. At that visit
plaintiff was assessed with “[c]ervical disc disorder with radiculopathy[.]” [Id.]. “
‘Cervical radiculopathy’ is defined as ‘radiculopathy of cervical nerve roots, often
manifesting as neck or shoulder pain.’ ” Corcoran v. Peake, No. 06-2893, 2008 WL
5101020, at *2 n.2 (Vet. App. Nov. 26, 2008) (citing DORLAND’S at 1595 (31st ed.
2007)); see also Jeanette D. v. Saul, No. CV CBD-18-2664, 2020 WL 1043264, at *5
(D. Md. Mar. 3, 2020) (“Radiculopathy . . . ‘typically causes pain, numbness, or
weakness in the part of the body which is supplied with nerves from that root.’ ”).
After another visit, the treatment record noted that plaintiff had an appointment set
with a pain specialist for treatment of her cervical disc disorder with radiculopathy.
[12-2] 1587. Finally, a 2019 treatment note from AdventHealth (found in the same
exhibit as the emergency room record cited by the ALJ) recorded that plaintiff
complained of “pain entire neck with pain, numbness and tingling in both arms to
hands for 1 year.” [12-5] 2098. “Although a written evaluation of each piece of
evidence or testimony is not required, . . . neither may the ALJ select and discuss only
that evidence that favors h[er] ultimate conclusion.” Herron v. Shalala, 19 F.3d 329,
333 (7th Cir. 1994) (citation modified); see also, Seruya v. Berryhill, No. 16 C 10896,
2017 WL 4650886, at *4 (N.D. Ill. Oct. 17, 2017) (ALJ cannot “cherry-pick[] . . . [by]
citing only to treatment notes which reflected improvement or stability.”).
For the reasons stated above, the Court finds that the ALJ did not provide a
“good reason” as required by the Seventh Circuit when assigning the opinion of
plaintiff’s treating physician less than controlling weight.
C. Consideration of the regulatory factors of 20 C.F.R. § 404.1527.
When this Court first remanded this case, it explained that, in addition to
failing to provide a good reason for affording less than controlling weight to Dr.
Evans’s opinion, the ALJ also failed to adequately discuss the factors required by §
404.1527(c)(2) to determine what weight should be afforded to his opinion. Maria P.,
2022 WL 1523639, at *6. Specifically, the Court identified that the ALJ failed to
discuss “the length and nature of the treatment relationship,” whether Dr. Evans’s
specialty of orthopedic surgery gave him “specialized knowledge regarding Plaintiff's
conditions and their effect on her functional capacity[,]” or the supportability of his
opinion. Id. (citation modified).
In the ALJ’s paragraph assigning less than controlling, or even significant,
weight to Dr. Evans’s opinion, she again fails to discuss the factors identified by the
Court in the initial remand. [12-2] 1296. The Commissioner argues that the Court
could infer that these factors were considered from the portion of the ALJ’s decision
where she discusses plaintiff’s medical history. [21] 7 (citing Paul M. v. Saul, No. 19
C 4581, 2021 WL 794981, at *4 (N.D. Ill. Mar. 2, 2021)). In discussing plaintiff’s
medical history, the ALJ did write that plaintiff “testified that Dr. Evans performed
two left shoulder surgeries,” [12-2] 1293, plaintiff “had left shoulder surgery in 2010”,
[Id.], and plaintiff received treatment from Dr. Evans though March 2015. [Id.] 1293–
94. While it is possible to infer from these statements that Dr. Evans’s is an
orthopedic surgeon who saw plaintiff for at least five years, the ALJ never explicitly
states that. [Id.]. More importantly, the ALJ does not give any indication that those
facts were considered when discounting Dr. Evans’s opinion. [12-2] 1296
It is also unclear to the Court the extent to which the ALJ considered the
supportability of Dr. Evans's opinion. The ALJ again did not undertake any detailed
review of Dr. Evans's treatment notes. [12-2] 1296. The ALJ did not even discuss the
specific treatment note identified by the Court in the prior remand. In that note “Dr.
Evans expressly opined in a July 22, 2014 treatment note that ‘the functional capacity
evaluation [was] valid,’ and he imposed corresponding restrictions on that basis.”
Maria P., 2022 WL 1523639, at *6; [12-1] 1090; see also [12-1] 678 (imposing similar
restrictions based on an earlier “valid” FCE). As this Court previously stated, “[t]his
was significant evidence of the supportability of Dr. Evans's opinion, which the ALJ
needed to address.” Maria P., 2022 WL 1523639, at *6. Despite the Court’s specific
instruction to address the supportability of Dr. Evans’s opinion and this note in
particular, the ALJ failed to do so.4 In the 2024 decision, the ALJ did note that the
functional capacities evaluation used by Dr. Evans’s was not in the file and that “[t]he
claimant representative stated at the June 2023 hearing that she was unable to locate
4 The Court notes that the ALJ did actually cite this treatment note in her decision. [12-2] 1293.
However, rather than discuss the issues raised by the Court in its prior remand, the citation was only
used to support the proposition that “it was unlikely that all her pains were related to her shoulder[.]”
[Id.].
[it]... given how old it is.” [12-2] 1296. But, again, if the ALJ thought it was necessary
to see this evaluation, the ALJ “should have contacted Dr. Evans or made an effort to
obtain the evaluation.” Maria P., 2022 WL 1523639, at *6.
For the reasons stated above, the Court finds that the ALJ did not adequately
discuss the factors that must be analyzed to determine the proper weight to be
afforded to Dr. Evans’s opinion. This error was not harmless. “Had the ALJ credited
Dr. Evans's opinion and incorporated these restrictions into plaintiff's RFC, plaintiff
would have been limited to performing sedentary work, see 20 C.F.R. § 404.1567(a) .
.. and the ALJ would have been required to find that she was disabled as of her
fiftieth birthday. See 20 C.F.R. Pt. 404, Subpt. P, App. 2, Table 1, Rule 201.14.” Maria
P., 2022 WL 15236389, at *2.
Because the ALJ misapplied the treating physician rule when she evaluated
Dr. Evans's opinion respecting plaintiff's permanent lifting and carrying restrictions,
this case must be remanded for further proceedings. Having found that the ALJ's
misapplication of the treating physician rule constitutes a reversible error requiring
remand, the Court need not address plaintiff's remaining contentions as to how the
ALJ erred.
Conclusion
Plaintiffs motion to reverse and remand [17] is granted and defendant's
motion for summary judgment [20] is denied. The decision of the Social Security
Administration is reversed, and, in accordance with the fourth sentence of 42 U.S.C.
§ 405(g), this case is remanded for further proceedings consistent with this
Memorandum Opinion and Order.
Wath AC Nun
HEATHER K. McSHAIN
United States Magistrate Judge
DATE: March 3, 2026