Lauster

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ILLINOIS

TODD L.,1 )

)

Plaintiff, )

)

vs. ) Case No. 3:25-CV-106-MAB2

)

COMMISSIONER OF SOCIAL )

SECURITY, )

)

Defendant. )

MEMORANDUM AND ORDER

BEATTY, Magistrate Judge:

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

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

Security denying his 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 HISTORY3

Plaintiff applied for DIB and SSI in April 2007, alleging disability beginning on

September 15, 2006 (Tr. 386-390). Plaintiff’s DIB and SSI applications were denied at the

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. 21).

3 The Court has attempted to summarize the lengthy procedural history of this case as succinctly as

possible. As such, many aspects of this case’s procedural history that are not directly relevant to Plaintiff’s

initial and reconsideration levels, and then by ALJ Don Harper in April 2010 (Tr. 130-142)

after a hearing was held one month earlier (Tr. 552-577). Meanwhile, Plaintiff filed

another claim for disability insurance benefits in June 2010 which was granted at the

reconsideration level (Tr. 144-147). Due to the inconsistent rulings, in August 2011 the

Appeals Council vacated and consolidated both the unfavorable decision from April 2010

and the favorable decision on Plaintiff’s subsequent June 2010 application (Tr. 144-147).

Thereafter, another hearing on Plaintiff’s applications was held in 2013 (Tr. 578-

616), which resulted in ALJ Anne Pritchett issuing an unfavorable decision in July 2013

(Tr. 154-172). However, that decision was vacated and remanded by the Appeals Council

in February 2014 (Tr. 173-175). On remand, ALJ Stuart T. Janney held a third hearing in

May 2014, wherein Vocational Expert Matthew Sprong appeared and testified (Tr. 617-

668). ALJ Janney issued an unfavorable decision on July 9, 2014 (Tr. 176-198). Plaintiff

appealed the decision to the Appeals Council, but on that occasion the Appeals Council

denied his request for review (Tr. 199-201). Accordingly, Plaintiff appealed the July 2014

decision to this Court, which ultimately reversed the Commissioner’s final decision and

remanded this case back to the Commissioner for rehearing and reconsideration of the

evidence on February 8, 2017 (Tr. 203-223). See also Lauster v. Berryhill, 15-CV-1134-JPG-

CJP, 2017 WL 513663 (S.D. Ill. Feb. 8, 2017).

claims have been omitted. For a detailed recollection of this case’s procedural history, see the administrative

transcript found at Doc. 23 (Tr. 1-697), as well as this Court’s prior opinion, Lauster v. Berryhill, 15-CV-1134-

JPG-CJP, 2017 WL 513663 (S.D. Ill. Feb. 8, 2017).

Pursuant to this Court’s Order, ALJ Janney held another hearing on November 20,

2017 (Tr. 93-129). At that hearing, Plaintiff appeared with counsel and Vocational Expert

James Bordieri also appeared (Tr. 93-129). On February 16, 2018, ALJ Janney issued an

unfavorable decision (Tr. 28-77). Thereafter, Plaintiff filed exceptions to the ALJ’s

decision (Tr. 239-240). Ultimately, on December 4, 2024, the Appeals Council declined

Plaintiff’s exceptions, leaving the ALJ’s 2018 decision as the final decision of the

Commissioner and providing Plaintiff with 60 days to file a civil action seeking judicial

review (Tr. 1-4). This appeal followed on January 24, 2025 (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.4 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

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,

4 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.

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 focuses

on the specific medical records and opinions cited in the ALJ’s 2018 decision that are the

subject of Plaintiff’s challenges on appeal (see Doc. 29).

I. Selected Medical Records and Opinions:

a. Relevant Records/Opinions of Plaintiff’s Physical Injuries

Plaintiff injured his left shoulder during a work-related fall in 2001, which resulted

in him undergoing left shoulder surgery in September 2001 (Tr. 841, 1014-1015). In July

2003, Plaintiff injured his right shoulder in another fall at work (Tr. 836). Plaintiff

underwent surgery on his right shoulder in February 2004 (Tr. 830-835) and surgery on

his right elbow in August 2004 (Tr. 813). Plaintiff also underwent left shoulder surgeries

in June and October 2004 (Tr. 902-905). Numerous additional medical records document

Plaintiff’s prolonged record of physical injuries, pain, and abnormalities (see generally Tr.

433-1966).

For instance, the record contains an MRI of Plaintiff’s cervical spine that was taken

in May 2011 (Tr. 1328-1329). Pertinently, while many of the May 2011 MRI’s findings

indicated mild or minimal abnormalities, that MRI also found “marked right” foraminal

stenoses at C3-4, mild to moderate right foraminal narrowing at C4-5, and mild to

moderate right foraminal stenoses at C5-6 (Tr. 1328-29). Consequently, the May 2011 MRI

included the impression that Plaintiff had multilevel foraminal stenosis, especially at

right C3-4, C4-5, and C5-6 (Tr. 1329).

Notably, in June 2012, Dr. Randall Pass, Plaintiff’s family physician, wrote an

opinion letter as to Plaintiff’s ability to work (Tr. 1500; see also 73-74). In that letter, Dr.

Pass stated that he had been caring for Plaintiff since 2007 and Plaintiff had been seen for

numerous medical problems including chronic pain in the shoulder, neck, and back,

depression, low testosterone, hyperlipidemia, and gastric reflux (Tr. 1500). Dr. Pass then

stated:

[Plaintiff] has required the use of narcotic pain medication since at

least 2007, and this use is not likely to diminish. He experiences a lot of

ongoing pain, and after only an hour or two household chores or similar

work, he needs to lie down and rest. Frequent position changes are

necessary. Frequent absences of work due to his condition and his need for

medical care would be expected. Besides pain medications, he has been to

various specialists, as well as a pain management clinic, and no

improvement in his condition has been forthcoming.

While many of [Plaintiff]’s complaints are subjective, and difficult to

objectively verify, he has had imaging studies which confirm significant

disease. For example, an MRI of the cervical spine in 2011 showed

multilevel foraminal stenosis.

Due to this ongoing neck and back pain, it is my medical opinion

that [Plaintiff] cannot maintain employment in a competitive workplace

environment. Therefore, I would ask this his application for permanent

disability be granted.

(Tr. 1500).

Additionally, office treatment notes from the date Dr. Pass prepared that opinion

letter further document the circumstances surrounding the letter’s preparation (Tr. 1658).

In that treatment note, Dr. Pass indicated that Plaintiff visited him for the purpose of

obtaining an opinion letter (Tr. 1658). At that time, Plaintiff reiterated his medical

concerns to Dr. Pass and explained why he believed he could not work (Tr. 1658). The

note also indicated that Plaintiff had a diagnosis of chronic pain, and it further specified

that Plaintiff requested a pain medication refill, but that issue was going to be addressed

at Plaintiff’s upcoming appointment on July 9, 2012 (Tr. 1658). The treatment notes form

was otherwise largely left blank, other than one marking under “General” which

indicated Plaintiff was “WNL,” presumably meaning “within normal limits.” (Tr. 1658).

b. Relevant Mental Health Records/Opinions

The record also contains numerous records documenting Plaintiff’s mental health

struggles. Most notably for purposes of this case, the record includes a few reports on

Plaintiff’s mental health prepared in 2009 by Plaintiff’s treating therapist, Gabriel Martin,

and treating psychologist, Dr. Naeem Quereshi (Tr. 1059-1068). Those mental health

professionals began treating Plaintiff in July 2007 (Tr. 1063). Specifically, their 2009

reports found that Plaintiff had an Anxiety Related Disorder (12.06) that caused marked

restriction of activities of daily living; marked difficulties in maintaining social

functioning; and repeated episodes of decompensation (Tr. 1060, 1065). They also found

that Plaintiff had a Personality Disorder (12.08) that caused marked restriction of

activities of daily living; marked difficulties in maintaining social functioning; and

repeated episodes of decompensation (Tr. 1060, 1065). Similarly, their report found

Plaintiff had an Affective Disorder (12.04) of depressive syndrome that caused marked

restriction of activities of daily living; marked difficulties in maintaining a social

functioning; and marked difficulties in maintaining a concentration persistence or pace

(Tr. 1061, 1066).

II. 2017 Administrative Hearing:

After this matter was remanded to the Commissioner in 2017, a fourth

administrative hearing was held before ALJ Janney on November 20, 2017 (Tr. 93-129).5

At that hearing, Plaintiff was represented by Attorney Jim Brown (Tr. 93).6 Vocational

Expert Dr. James Bordieri was also present (Tr. 93).

After beginning by discussing some evidentiary matters with Plaintiff’s counsel,

ALJ Janney indicated his intent to rely on Vocational Expert Matthew Sprong’s

classification of Plaintiff’s past work from the 2014 hearing (Tr. 104). Plaintiff did not

object, so those classifications were read into the record as follows:

It was heating and air conditioning installer/servicer, 637.261-014, medium

per the DOT, SVP 7, very heavy as actually performed. And general laborer,

509.687-026, heavy per the DOT, semi-skilled, SVP 3, very heavy as

performed. And that precluded the past -- or concludes the past work.

(Tr. 104).

Plaintiff first testified that he had not worked since the prior hearing in 2014 (Tr.

104-105). Plaintiff next described the right shoulder pain he was then experiencing as

5 As previously noted supra, this was the second hearing before ALJ Janney (see Tr. 93-129, 617-668).

6 Plaintiff’s counsel, Jim Brown, has represented Plaintiff at all four hearings (Tr. 93, 552, 578, 617).

similar to the other pains he was suffering, but occasionally worse (Tr. 105). Plaintiff also

discussed the pain he experienced in other parts of his body including his neck and his

middle and lower back (Tr. 106-107).

When asked about being prescribed pain medication, Plaintiff testified that he had

been taken off the pain medication he was previously prescribed because his doctor left

the practice and the new providers refused to provide Plaintiff and other similarly

situated patients with refills of their prescription pain medications (Tr. 107-108). Plaintiff

indicated his frustration with the situation and stated that he thought the prescription

pain medications had worked pretty well, such that he would have continued to take

them if he was able to (Tr. 108-109). He also specified that he was taking Aleve every day

for his pain (Tr. 108). Plaintiff then stated that he was still being prescribed and taking

Prozac for his depression (Tr. 109). Plaintiff’s counsel then asked Plaintiff if he believed

the pain he was experiencing contributed to his depression, which Plaintiff answered,

“without a doubt.” (Tr. 110). Plaintiff testified that he had low energy because he

frequently wakes up due to the pain he experiences (Tr. 110). As a result of those sleep

issues, he wrecked his truck when he fell asleep while driving (Tr. 110).

When asked about his interests, Plaintiff indicated he still was interested in the

same things he used to be interested in, but he could no longer do those activities due to

his circumstances (Tr. 111). Plaintiff stated he had problems with his mood and anger,

and he attributed some of those problems to no longer having the ability to work and

make money like he used to (Tr. 111-112). Plaintiff testified that he could no longer work

an eight-hour day due to his pain (Tr. 112). Plaintiff also explained that in the past when

he was still working on light duty, he would have to take work breaks so he could lie

down, and he similarly takes breaks to lie down every day even though he is no longer

working (Tr. 112).

The ALJ then asked Plaintiff if he used alcohol on a regular basis (Tr. 113). Plaintiff

answered that he occasionally drinks and does so to the point of intoxication

approximately ten times per year (Tr. 113-114). Plaintiff further explained that alcohol

use helped with certain symptoms, such as his mood, but it did not alleviate any of his

physical symptoms (Tr. 114). And he admitted that he had learned the hard way that

alcohol did not help his nerve pain (Tr. 114). In describing that pain, Plaintiff said,

“unfortunately you do get used to nerve pain. It becomes not as sharp and lightning

effect. It becomes more of a dull, just a horrible ache.” (Tr. 115).

Plaintiff also testified that he stopped going to mental health a few months ago

because his doctor had quit and he was frustrated with the idea of having to explain his

situation to another doctor and start from scratch (Tr. 116). However, Plaintiff then

acknowledged, “I really need to get more meds because I just ran out of them and I’m

going to go back. I need to go back. I can tell when I’m not doing too good without them.”

(Tr. 116). Regarding outdoor chores, Plaintiff stated he still occasionally cut the grass for

up to 40 minutes using a riding lawn mower, but he then detailed how he had also

crashed his mower that summer when he fell asleep while operating it (Tr. 117). As for

indoor chores, Plaintiff said he sometimes helps his wife do dishes but, “hardly ever.”

(Tr. 119).

Plaintiff then discussed his hobbies (Tr. 117-118). He said he had not fished in a

long time, other than one recent attempt that he had to abandon after 20 minutes because

he couldn’t stand it (Tr. 117). As for hunting, he couldn’t use a deer stand, was unable to

find a combination of sitting and standing that worked, and he had to constantly fidget

or move due to pain, tiredness, and frustration (Tr. 117-118). Plaintiff did note, however,

that he had an active hunting license and he thought he killed a deer last year, but he

relied on his friend to do the field dressing (Tr. 118).

Plaintiff then explained the various ways his symptoms impact his ability to use

his arms, from nerves pinching in his arm while driving, to his inability to reach across

his body or touch his back, to the difficulty in putting his arms into his sleeves when

trying to get dressed (Tr. 119). He also said he was told he had carpal tunnel in both

hands, and he dropped things as a result (Tr. 120).

Returning to questions of mental health medication, Plaintiff said he stopped

taking Xanax because he thought it was messing with his memory, which was something

he was already concerned about because he was taking morphine at that time (Tr. 121).

Plaintiff testified that it was pain that prevented him from being able to complete tasks

(Tr. 121-122). Consequently, he would try to lie down, stretch, or squat to take breaks

when pain prevented him from continuing with a task (Tr. 122). In the first instance of

taking such a break, he would usually need 20 to 30 minutes for that break (Tr. 122).

However, each time he returned to the task he was attempting, the pain would build up

faster, he would need a longer break, and each respective break was less helpful (Tr. 122).

As a result, he would give up and save that task for another day (Tr. 122). Plaintiff also

indicated that he could reach out in front of him or to the sides with both arms and he

only experienced “a little” pain in doing so, though that pain was different in each arm

(Tr. 122-123). Plaintiff’s counsel then asked him if he could perform tasks that involved

reaching like that for an entire workday, to which Plaintiff definitively answered he could

not (Tr. 123).

At that point, Plaintiff’s testimony concluded and the ALJ indicated he did not

have any questions for Vocational Expert Dr. Bordieri because the hypothetical questions

he asked Vocational Expert Sprong in 2014 were the same as the questions he would ask

Dr. Bordieri at that time (Tr. 123-124). After Plaintiff’s counsel indicated he had no

questions for the Vocational Expert, Dr. Bordieri was disconnected from the hearing (Tr.

124). Plaintiff’s counsel then provided closing remarks and the hearing concluded (Tr.

124-129).

THE ALJ’S DECISION

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

(see Tr. 28-77). At step one, the ALJ determined that Plaintiff had not engaged in

substantial gainful activity since September 15, 2006 (Tr. 34). At step two, the ALJ found

Plaintiff had the following severe medical impairments:

[D]egenerative disc disease of the cervical spine; degenerative disc disease

of the lumbar spine with a spontaneously resolved annular tear; left

shoulder impingement and AC separation status post acromioclavicular

reconstruction with grafting and a partial left claviculectomy; right lateral

epicondylitis and olecranon bursitis; right shoulder internal derangement

treated with arthroscopic surgery; right shoulder SLAP and superior

glenoid labrum lesions on the right; right shoulder impingement; moderate

left ulnar neuropathy; right lateral epicondylitis; right ankle

tendinitis/right ankle avulsion fracture; level one obesity; late onset

dysthymic disorder; depression; major depressive disorder, recurrent;

adjustment disorder with mixed emotional features; anxiety disorder, not

otherwise specified; generalized anxiety disorder; social phobia; chronic

pain syndrome; personality disorder, not otherwise specified; and history

of alcohol abuse.

(Tr. 34-35).

The ALJ also found that the medical evidence established valid diagnoses for low

testosterone, hyperlipidemia, gastric reflux/GERD, and foot dermatitis (Tr. 35).

However, the ALJ found the medical evidence as to those conditions did not establish

more than a slight abnormality or combination of abnormalities, which would have a

more than minimal effect on Plaintiff’s ability to perform basic work activities (Tr. 35).

Additionally, the ALJ found that the medical evidence established valid diagnoses for a

finger wound, brachial plexopathy, left great toe pain, and bilateral hand pain (Tr. 35).

However, those abnormalities or combination of abnormalities did not last for a period

of twelve months and had no more than a minimal effect on Plaintiff’s ability to perform

basic work activities (Tr. 35-36). The ALJ then explained that Plaintiff had not satisfied all

the criteria required to determine that a claimant has the medically determinable

impairment of fibromyalgia (Tr. 36-37).

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

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. 37-41). Specifically, regarding Plaintiff’s

degenerative disc disease, the ALJ determined it did not meet listing 1.04 because the

record does not demonstrate compromise of a nerve root or the spinal cord with

additional required findings (Tr. 38). Likewise, as to Plaintiff’s mental impairments, the

ALJ found they do not meet or medically equal the criteria of any listings because they

do not result in at least one extreme limitation or two marked limitations in a broad area

of functioning (Tr. 39-41). Namely, the ALJ found Plaintiff had only moderate limitations

in (1) understanding, remembering, or applying information; (2) interacting with others;

(3) concentrating, persisting or maintaining pace (Tr. 39-40); and a mild limitation in

adapting or managing oneself (Tr. 40).

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

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

frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl

and occasionally climb ladders, ropes, or scaffolding. He cannot reach

overhead with the bilateral upper extremities, but can occasionally reach

bilaterally in other directions, and can frequently handle, finger, and feel

with the bilateral upper extremities. He can understand, remember, and

carry out rote or routine instructions that require the exercise of little

independent judgment or decision making for the two hour work segments

that make up an 8 hour workday at a consistent pace, but not if the tasks

are complex or detailed. He should work in a task or object oriented setting

as opposed to a service oriented setting. He may have frequent work related

interaction with co-workers, supervisors, but no more than occasional

interaction with the public.

(Tr. 41).

The ALJ then proceeded to devote the next 34 single-spaced pages of his decision

to discussing the evidence he relied upon in reaching that RFC determination (Tr. 41-75).

Rather than summarizing that extensive analysis, the Court instead focuses its discussion

on the evidence related to the arguments Plaintiff has raised here.

Significantly, the ALJ’s decision summarized the results of the MRI of Plaintiff’s

cervical spine that was taken in May 2011 (Tr. 47). Specifically, the ALJ stated that “MRI

of the cervical spine showed mild cervical levoscoliosis, mild facet arthropathy, and

multilevel degenerative disc disease, multilevel foramina stenosis especially at right C3-

4, C4-5, and C5-6, but no cervical cord compression or central canal stenosis.” (Tr. 47).

After the ALJ proceeded to discuss many other pieces of evidence in the record,

the ALJ moved on to assign weight to the medical findings and opinions contained within

the record, including those of Dr. Pass and Dr. Quereshi/Therapist Martin (Tr. 62-75). In

considering Dr. Pass’s opinion letter, the ALJ found that Dr. Pass had incorrectly

described the May 2011 MRI (Tr. 74). Specifically, the ALJ reasoned that the MRI in

question “was not described as showing significant disease” and rather, “it described

only mild abnormal findings[.]” (Tr. 74). Accordingly, the ALJ determined that Dr. Pass’s

suggested restrictions to frequent absences and frequent position changes were

“incorrect” because they relied on a misinterpretation of the May 2011 MRI (Tr. 74). The

ALJ also considered the office treatment note from that same date which included a

finding of within normal limits, and reasoned that, “if indeed the claimant was this

limited, the corresponding examination should contain abnormal findings that support

this extreme degree of limitations.” (Tr. 74). The ALJ further took issue with Dr. Pass’s

limitations because they “directly corresponded” to “the claimant’s subjective reporting

rather than Dr. Pass opining based upon his examinations of the claimant or other

objective evidence.” (Tr. 74).

The ALJ also spent a significant amount of time discussing the mental health

opinions of Dr. Quereshi and Therapist Martin (Tr. 68-70). Pertinently, the ALJ found that

“portions of this opinion were clearly contradictory.” (Tr. 68). Most notably, the ALJ

found that the “frequency of [Plaintiff’s] treatment did not support marked restrictions

in areas of mental health functioning” because Plaintiff typically only saw a mental health

professional once, or occasionally twice, a month (Tr. 69). Thus, the ALJ reasoned that

Plaintiff “saw his treating mental health professionals infrequently enough that a marked

limitation due to mental systems did not appear supported. It would appear he would

require mental health treatment from a psychological professional at least weekly if his

mental impairments were so pervasive and having such an effect on his life that he had

marked limitations in all areas of his mental functioning.” (Tr. 69). The ALJ also

discredited the mental health professionals’ opinions because Plaintiff’s “regular treating

physicians” generally described Plaintiff’s mental functioning as normal on their mini

mental status examinations (Tr. 69-70).

The ALJ then challenged Dr. Quereshi and Therapist Martin’s treating opinions

because they conflicted with their own treatment notes of Plaintiff, which generally

described him as cooperative and without any described social difficulties, “despite

sometimes appearing irritable or depressed.” (Tr. 70). The ALJ further analyzed Dr.

Quereshi and Therapist Martin’s treatment records, generally explaining that any

records/findings which supported their determinations were infrequent or otherwise

“intermittently normal.” (Tr. 70). As such, the ALJ assigned little weight to their opinions

“due to the contradictory nature of the opinion itself and the complete inconstancy” with

Plaintiff’s other mental functioning and treatment records (Tr. 70).

The ALJ assigned various weights to the opinions of numerous other medical

providers and examiners (Tr. 62-75). Thereafter, he summarized his findings as follows:

In sum, although the claimant described disabling symptoms as a result of

medical impairments, the record is not consistent with those allegations.

The above residual functional capacity assessment is supported by the

objective medical evidence, the medical opinions when afforded

appropriate weight, and the claimant’s subjective complaints during the

relevant period when taken in proper context. In view of all of the factors

discussed above, the limitations on the claimant’s capacities which were

described earlier in this decision are considered warranted, but no greater

or additional limitations are justified.

(Tr. 75).

At step four, the ALJ relied upon the 2014 testimony of Vocational Expert Sprong

to find that Plaintiff was unable to perform past relevant work as actually or generally

performed (Tr. 75, 104; see also Tr. 657-658). Lastly, at step five, the ALJ again relied on

the 2014 testimony of Vocational Expert Sprong to find that an individual with Plaintiff’s

RFC could perform the requirements of representative occupations such as laminating

machine off-bearer, scaling machine operator, and fruit distributor (Tr. 76; see also Tr. 658-

661). The ALJ then confirmed that the 2014 testimony from Vocational Expert Sprong was

consistent with the Dictionary of Occupational Titles and therefore, given Plaintiff’s age,

education, work experience, and RFC, he “is capable of making a successful adjustment

to other work that exists in significant numbers in the national economy.” (Tr. 77). For

this reason, the ALJ found Plaintiff was not under a disability, as defined by the Social

Security Act, from September 15, 2006, through the date of the decision (Tr. 77).

ISSUES RAISED BY PLAINTIFF

Plaintiff raises the following issues (see Doc. 29):

1. The ALJ did not give good reasons for discounting the opinions of treating

doctors Pass and Quereshi/Martin.

2. The ALJ’s finding that Plaintiff could “frequently” interact with coworkers

and supervisors is not supported by substantial evidence.

3. The Commissioner did not adequately carry his step five burden because

the three-and-a-half-year-old Vocational Expert testimony he was relying

on was not clearly articulated.

DISCUSSION

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

that the ALJ erred by failing to provide “good reasons” for discounting the opinions of

treating physicians Dr. Pass and Dr. Quereshi/Therapist Martin (Doc. 29 at pp. 9-13).

Second, Plaintiff argues that the ALJ’s finding that he could “frequently” interact with

coworkers and supervisors is not supported by substantial evidence (Id. at pp. 13-14).

And third, Plaintiff avers that the Commissioner failed to meet his burden at step five

because the three-and-a-half-year-old vocational expert testimony relied upon by the

Commissioner was not clearly articulated (Id. at pp. 14-15). Ultimately, the Court focuses

its analysis on Plaintiff’s first contention because that point is dispositive and requires

this matter be remanded.

I. The ALJ’s Discounting of Favorable Treating Physician Opinions

Plaintiff argues that the ALJ failed to provide good reasons for discounting the

opinions of several treating physicians including Dr. Pass and Dr. Quereshi/P.A. Martin

(Doc. 29 at p. 9). Consequently, Plaintiff contends that this failure requires reversal (Id. at

p. 13). The Court finds these arguments to be persuasive.

Generally speaking, a “treating doctor’s opinion receives controlling weight if it is

‘well-supported’ and ‘not inconsistent with the other substantial evidence’ in the record.”

Scott v. Astrue, 647 F.3d 734, 739 (7th Cir. 2011) (quoting 20 C.F.R. § 404.1527(d)(2)).

Additionally, pursuant to 20 C.F.R. § 404.1527(d)(2) (2009), an ALJ must offer “good

reasons” in his decision for the weight given to a treating source’s medical opinion. Thus,

when an ALJ discounts a treating source’s medical opinion, the “ALJ must offer ‘good

reasons’ for discounting the opinion of [that] treating physician.” Scott, 647 F.3d at 739.

Moreover, “[i]f an ALJ does not give a treating physician’s opinion controlling weight,

the regulations require the ALJ to consider the length, nature, and extent of the treatment

relationship, frequency of examination, the physician’s specialty, the types of tests

performed, and the consistency and supportability of the physician’s opinion.” Moss v.

Astrue, 555 F.3d 556, 561 (7th Cir. 2009).

a. Dr. Pass’s Opinion

As explained above, the ALJ provided several reasons for affording little weight

to Dr. Pass’s treating physician opinion (see Tr. 73-74). However, for the reasons discussed

below, the Court finds the ALJ’s proffered reasons, when viewed individually or in

combination, do not justify the ALJ’s decision to afford little to no weight to Dr. Pass’s

treating physician opinion.

Most significantly, the ALJ premised a portion of his decision to discredit Dr.

Pass’s opinion on his belief that the May 2011 MRI “described only mild abnormal

findings” and Dr. Pass’s interpretation of that MRI “was incorrect.” (Tr. 74). The ALJ

further explained that “this MRI of the cervical spine was not described as showing

significant disease.” (Id.). However, that May 2011 MRI is not as unfavorable to Plaintiff

and Dr. Pass’s opinions as the ALJ claims. To the contrary, while many of the May 2011

MRI’s findings noted only mild or minimal abnormalities, that MRI also found “marked

right” foraminal stenoses at C3-4, mild to moderate right foraminal narrowing at C4-5,

and mild to moderate right foraminal stenoses at C5-6 (Tr. 1328-29). Consequently, the

May 2011 MRI included the impression that Plaintiff had multilevel foraminal stenosis,

especially at right C3-4, C4-5, and C5-6 (Tr. 1329). This is almost exactly what Dr. Pass

noted in his opinion, which leaves the Court scratching its head as to why the ALJ found

Dr. Pass’s interpretation was inaccurate and instead determined that the MRI showed no

significant disease7 and “only mild abnormal findings.” (Tr. 74) (citing Tr. 1658).

Furthermore, because the ALJ specifically highlighted the MRI’s “mild” findings both in

his own recounting of that MRI (Tr. 47) and in his criticism of Dr. Pass’s analysis (Tr. 74),

it was not permissible for him to simply ignore the “marked” finding from that same MRI

which was adverse to his decision. Newman v. Colvin, 211 F. Supp. 3d 1126, 1131 (N.D.

Ind. 2016) (“The ALJ’s reliance on certain evidence that supports his decision while failing

to address, and potentially failing to even consider, contrary evidence strikes me a classic

case of ‘cherry-picking’ that the Seventh Circuit has denounced time and time again.”).

The ALJ provided several other reasons for his decision to afford Dr. Pass’s

opinion little weight, but none of them salvage his determination. First, the ALJ noted

that the office visit treatment note associated with this medical source statement

7 To the extent the ALJ believed that a finding of “multilevel foraminal stenosis” does not constitute a

“significant disease,” such a determination goes beyond the bounds permitted of an ALJ and into the realm

of a doctor. Furthermore, in summarizing the May 2011 MRI, the ALJ expressly stated that “MRI of the

cervical spine showed mild cervical levoscoliosis, mild facet arthropathy, and multilevel degenerative disc

disease, multilevel foramina stenosis especially at right C3-4, C4-5, and C5-6, but no cervical cord

compression or central canal stenosis.” (Tr. 47) (emphasis added). Put simply, the Court does not know

whether multilevel degenerative disc disease or multilevel foramina stenosis constitutes significant disease,

and “the ALJ does not know either.” Liskowitz v. Astrue, 559 F.3d 736, 741 (7th Cir. 2009) (criticizing an ALJ

for playing doctor by making a medical determination that, while potentially correct, was something

reserved for doctors to determine).

described Plaintiff’s physical examination as within normal limits (Tr. 74). However, that

treatment note from June 12, 2012 (i.e., over a year after Plaintiff’s May 2011 MRI),

indicated that Plaintiff was specifically visiting Dr. Pass for a letter for federal disability

(Tr. 1658). Furthermore, in that note, Plaintiff indicated he was suffering from chronic

pain on a scale of 7 out of 10 (Tr. 1658). The examination portion of that treatment note is

left almost entirely blank, other than containing just one check mark indicating “WNL”

(presumably, “within normal limits”) as to “General.” (Id.). Pertinently, however, in

addition to leaving 19 out of the 20 sections of that portion of the form blank, Dr. Pass’s

treatment note specifically indicated that he would address Plaintiff’s request for pain

medication at his next appointment on July 9, 2012 (Id.). In other words, that treatment

note made it very clear that Dr. Pass was not examining or treating Plaintiff as he would

at a normal appointment, and the ALJ’s failure to acknowledge such is concerning.

In essence, the ALJ’s interpretation of this “appointment” clearly overstates the

significance of its lack of findings and ignores the obvious explanation for why no such

findings were made at that time. In fact, if the ALJ were to have considered Dr. Pass’s

treatment notes from Plaintiff’s next appointment in July 2012, he would have discovered

that at that time Dr. Pass diagnosed Plaintiff with chronic pain, depression, decreased

testosterone, increased lipids, refilled his prescription for morphine, and noted that they

should consider another scan of Plaintiff’s lower back (Tr. 1657).

Moreover, the ALJ also found Dr. Pass’s opinion to be lacking value because it

relied on Plaintiff’s subjective complaints rather than on examinations or other objective

evidence. Undoubtedly, Dr. Pass’s medical notes document Plaintiff’s self-reported

complaints of pain (see, e.g., Tr. 1657-1658). However, “an ALJ cannot disregard subjective

complaints of disabling pain just because a determinable basis for pain of that intensity

does not stand out in the medical record.” Moss, 555 F.3d at 561. Furthermore, Dr. Pass’s

opinion letter makes it quite clear that he was also relying on: (1) his years of treating

Plaintiff; (2) Plaintiff’s extensive medical history for chronic pain; and “imaging studies

which confirm significant disease” such as Plaintiff’s “MRI of the cervical spine in 2011

[that] showed multilevel foraminal stenosis.” (Tr. 1500).

Finally, the ALJ offered one additional – arguably more understandable –

explanation as to why he was affording little to no weight to Dr. Pass’s opinion. Namely,

the fact that Dr. Pass’s opinion stated that Plaintiff had been using narcotic pain

medication since 2007 and “this use of narcotics was not likely to diminish.” (Tr. 73)

(citing Tr. 1500). Conversely, as the ALJ noted, Plaintiff testified at the 2017 hearing that

he had not been taking narcotics for two years, took Aleve instead, and had “built up a

tolerance to the pain.” (Tr. 73). Pertinently, however, the ALJ did not explain the reasons

Plaintiff provided at the hearing as to why he was no longer taking narcotic pain

medication. Most notable of which is the fact that Plaintiff indicated he was no longer

taking prescription pain medication because his doctor left the practice, but he thought it

had worked and he would have continued to take it if he was able to (Tr. 108). Moreover,

the ALJ relied upon Plaintiff’s testimony about how his chronic pain had evolved from a

“sharp and lightning effect” to a “horrible ache” (Tr. 115) as evidence that Plaintiff “had

built up a tolerance to the pain” (Tr. 73), which apparently also discredited Dr. Pass’s

opinion about Plaintiff’s chronic pain. To put it bluntly, even though Plaintiff did admit

that he “got used to” the nerve pain (Tr. 115), the ALJ’s interpretation of that admission,

which could be interpreted in many ways, clearly goes too far by construing it as an

admission that he had built up a tolerance to the pain (Tr. 73). See Moss, 555 F.3d at 560

(“An ALJ’s conjecture is never a permitted basis for ignoring a treating physician’s

views[.]”); Collins v. Astrue, 324 Fed. Appx. 516, 522 (7th Cir. 2009) (“Dr. Schneider’s

testimony points equally in opposite directions and therefore cannot serve as substantial

evidence to support the ALJ’s conclusions.”).

Additionally, the ALJ failed to explain how or why Dr. Pass incorrectly predicted

Plaintiff’s ability to obtain pain medication in the future equated to the conclusion that

Dr. Pass’s findings as to Plaintiff’s disability should be afforded little weight. To be clear,

this is not a situation in which Dr. Pass predicted Plaintiff would suffer from chronic pain

for the rest of his life, only to have subsequent evidence demonstrate that Plaintiff no

longer suffered from pain. Instead, it is a situation wherein the method of treating

Plaintiff’s pain was altered, to what Plaintiff considered to be a less effective method (Tr.

107-108), for reasons the ALJ did not even mention (Tr. 74).

In summary, none of the explanations offered by the ALJ for affording little to no

weight to Dr. Pass’s opinion has any merit. Therefore, because the ALJ “failed to

articulate any good reason for significantly discounting [Dr. Pass’s] medical opinion, his

decision is not supported by substantial evidence.” Collins, 324 Fed. Appx. at 521.

Accordingly, reversal is warranted due to this error.

b. Dr. Quereshi & Therapist Martin’s Opinion

As previously discussed, the ALJ also provided numerous reasons for affording

little weight to the opinions of Plaintiff’s treating mental health professionals, Dr.

Quereshi and Therapist Martin. While the Court need not analyze these points in detail

due to the Court’s holding above, the Court nevertheless makes the following

observations regarding the ALJ’s weighing of Dr. Quereshi and Therapist Martin’s

opinions.

First, the Court takes issue with the ALJ’s decision to, at least in part, discredit Dr.

Quereshi and Therapist Martin’s “marked” restrictions in mental functioning because

Plaintiff only saw a mental health professional once, or occasionally twice a month, which

the ALJ believed was not frequent enough to support such findings. Pertinently, the ALJ

did not cite any medical opinions, evidence, or caselaw, to support his questionable belief

that marked mental health restrictions could only be supported in instances where a

claimant has been receiving weekly mental health treatment. Such a belief appears to be

nothing more than conjecture, and an “ALJ’s conjecture is never a permitted basis for

ignoring a treating physician’s views.” Moss v. Astrue, 555 F.3d at 560.

Likewise, the Court questions the ALJ’s reliance upon the generally normal mental

health findings of Plaintiff’s general physicians as evidence that the mental health

opinions of Plaintiff’s mental health providers, Dr. Quereshi and Therapist Martin,

should be given little weight (Tr. 69-70). To be clear, the general physician treatment notes

the ALJ cited were made by general care providers, surgeons, and orthopedic

providers―not mental health physicians (see Tr. 1737-1966). As such, the Court questions:

(1) whether those providers were even truly analyzing Plaintiff’s mental health at those

visits, and (2) why those “mini mental status examinations” made by general providers

would outweigh the findings of mental health professionals who were specifically

meeting with Plaintiff to evaluate and treat his mental health concerns.

In addition, the ALJ discredited Dr. Quereshi and Therapist Martin’s opinions

because they were contradictory to their own medical findings. While the Court agrees

that such a contradiction would be an adequate reason to discredit Dr. Quereshi and

Therapist Martin’s opinions, the ALJ did not cite specific records to demonstrate their

purportedly inconsistent findings (Tr. 70). In fact, that paragraph of the ALJ’s decision

contains no citations to the record whatsoever (Tr. 70). Not only is that failure concerning,

but the ALJ’s own statements indicate that some of Dr. Quereshi and Therapist Martin’s

records did support their findings such as a “few records over a period of years showing

any decreased concentration at all” and that “his most frequent abnormal findings were

of a decrease in mood and effect.” (Tr. 70). As such, if the ALJ meant to appropriately

discredit those findings as outliers, he should have explained why that was the case and

cited specific records to make his point, instead of vaguely stating “even these appeared

intermittently normal.” (Tr. 70). See Campbell v. Astrue, 627 F.3d 299, 306 (7th Cir. 2010)

(“An ALJ may not selectively discuss portions of a physician’s report that support a

finding of non-disability while ignoring other portions that suggest a disability.”). By

failing to adequately explain his reasoning for crediting some records but not others, the

Court is unable to draw a logical bridge from the evidence to the ALJ’s conclusions.

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 he 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: March 26, 2026

s/ Mark A. Beatty

MARK A. BEATTY

United States Magistrate Judge