Moody v. Commissioner of Social Security, No. 4:2020cv00055 - Document 23 (N.D. Ind. 2022)
Court Description: OPINION AND ORDER: The Court GRANTS the relief sought in the Plaintiff's Brief ECF No. 1 and REVERSES the decision of the Commissioner. The Court REMANDS this matter for further proceedings consistent with this Opinion. The Court DENIES the Plaintiffs request to award benefits. Signed by Judge Theresa L Springmann on 3/28/22. (Attachment: # 1 Correct Opinion and Order). (nal).
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Moody v. Commissioner of Social Security Doc. 23 UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA HAMMOND DIVISION AT LAFAYETTE DAWN M. MOODY, Plaintiff, v. CAUSE NO.: 4:20-CV-55-TLS KILOLO KIJAKAZI, Acting Commissioner of the Social Security Administration, Defendant. OPINION AND ORDER The Plaintiff Dawn M. Moody seeks review of the final decision of the Commissioner of the Social Security Administration denying her applications for disability insurance benefits and supplemental security income. For the reasons set forth below, the Court reverses and remands for further proceedings. PROCEDURAL BACKGROUND On August 18 and August 29, 2016, the Plaintiff filed applications for disability insurance benefits and supplemental security income, respectively, alleging disability beginning on July 23, 2016. AR 267, 271, ECF No. 16. After the claims were denied initially and on reconsideration, the Plaintiff requested a hearing, which was held before the ALJ on February 21, 2019. Id. at 32. On May 24, 2019, the ALJ issued a written decision, finding the Plaintiff not disabled. Id. at 10–23. The Plaintiff sought review of the ALJ’s decision by the Appeals Council, and the Appeals Council subsequently denied review. Id. at 1. Thus, the ALJ’s decision is the final decision of the Commissioner. Jozefyk v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019). The Plaintiff now seeks judicial review under 42 U.S.C. § 405(g). On July 7, 2020, the Plaintiff filed her Complaint [ECF No. 1] in this Court, seeking reversal of the Commissioner’s final decision. Dockets.Justia.com The Plaintiff filed an opening brief, the Commissioner filed a response, and the Plaintiff filed a reply. See ECF Nos. 20–22. THE ALJ’S DECISION For purposes of disability insurance benefits and supplemental security income, a claimant is “disabled” if she is unable “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); see also 20 C.F.R. §§ 404.1505(a), 416.905(a). To be found disabled, a claimant must have a severe physical or mental impairment that prevents her from doing not only her previous work, but also any other kind of gainful employment that exists in the national economy, considering her age, education, and work experience. 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B); 20 C.F.R. §§ 404.1505(a), 416.905(a). An ALJ conducts a five-step inquiry to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920. The first step is to determine whether the claimant is no longer engaged in substantial gainful activity. Id. §§ 404.1520(a)(4)(i), (b), 416.920(a)(4)(i), (b). In this case, the ALJ found that the Plaintiff had not engaged in substantial gainful activity since July 23, 2016, the alleged onset date. AR 12. At step two, the ALJ determines whether the claimant has a “severe impairment.” 20 C.F.R. §§ 404.1520(a)(4)(ii), (c), 416.920(a)(4)(ii), (c). Here, the ALJ determined that the Plaintiff has the severe impairments of intrarticular bursitis of the right hip, obesity, degenerative disc disease of the lumbar spine, diabetes mellitus with neuropathy, fibromyalgia, obstructive sleep apnea, and affective disorder. AR 12. 2 Step three requires the ALJ to consider whether the claimant’s impairment(s) “meets or equals one of [the] listings in appendix 1 to subpart P of part 404 of this chapter.” 20 C.F.R. §§ 404.1520(a)(4)(iii), (d), 416.920(a)(4)(iii), (d). If a claimant’s impairment(s), considered singly or in combination with other impairments, meets or equals a listed impairment, the claimant will be found disabled without considering age, education, and work experience. Id. §§ 404.1520(a)(4)(iii), (d), 416.920(a)(4)(iii), (d). Here, the ALJ found that the Plaintiff does not have an impairment or combination of impairments that meets or medically equals a listing, indicating that she considered Listings 1.02, 1.04, 3.14, 12.04, and 14.09. AR 13. When a claimant’s impairment(s) does not meet or equal a listing, the ALJ determines the claimant’s “residual functional capacity” (RFC), which “is an administrative assessment of what work-related activities an individual can perform despite [the individual’s] limitations.” Dixon v. Massanari, 270 F.3d 1171, 1178 (7th Cir. 2001); see also 20 C.F.R. §§ 404.1520(e), 416.920(e). In this case, the ALJ assessed the following RFC: 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). Specifically, the claimant can lift and/or carry ten pounds frequently, twenty pounds occasionally; she can stand and/or walk for two hours out of an eight-hour workday; she can sit for six hours out of an eighthour workday; she can do postural activities on an occasional basis except she is never to climb ladders, ropes or scaffolds; she is to avoid concentrated exposure to hazardous conditions; she is never to walk on uneven ground; and she is limited to simple tasks. AR 16. The ALJ then moves to step four and determines whether the claimant can do her past relevant work in light of the RFC. 20 C.F.R. §§ 404.1520(a)(4)(iv), (f), 416.920(a)(4)(iv), (f). In this case, the ALJ found that the Plaintiff is unable to perform any relevant work. AR 21. 3 If the claimant is unable to perform past relevant work, the ALJ considers at step five whether the claimant can “make an adjustment to other work” given the RFC and the claimant’s age, education, and work experience. 20 C.F.R. §§ 404.1520(a)(4)(v), (g), 416.920(a)(4)(v), (g). Here, the ALJ found that the Plaintiff is not disabled because the Plaintiff can perform significant jobs in the national economy of addresser, callout operator, and tube operator. AR 22. The claimant bears the burden of proving steps one through four, whereas the burden at step five is on the ALJ. Zurawski v. Halter, 245 F.3d 881, 885–86 (7th Cir. 2001); see also 20 C.F.R. §§ 404.1512, 416.912. STANDARD OF REVIEW The Social Security Act authorizes judicial review of the agency’s final decision. 42 U.S.C. § 405(g). On review, a court considers whether the ALJ applied the correct legal standard and whether the decision is supported by substantial evidence. See Summers v. Berryhill, 864 F.3d 523, 526 (7th Cir. 2017); 42 U.S.C. § 405(g). A court will affirm the Commissioner’s findings of fact and denial of disability benefits if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019) (citations omitted). Even if “reasonable minds could differ” about the disability status of the claimant, the court must affirm the Commissioner’s decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008) (quoting Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007)). The court considers the entire administrative record but does not “reweigh evidence, resolve conflicts, decide questions of credibility, or substitute [the court’s] own judgment for that of the Commissioner.” McKinzey v. Astrue, 641 F.3d 884, 889 (7th Cir. 2011) (quoting Lopez ex 4 rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003)). Nevertheless, the court conducts a “critical review of the evidence,” and the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues. Lopez, 336 F.3d at 539 (citations omitted); see also Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014) (“A decision that lacks adequate discussion of the issues will be remanded.”). The ALJ is not required to address every piece of evidence or testimony presented, but the ALJ “has a basic obligation to develop a full and fair record and must build an accurate and logical bridge between the evidence and the result to afford the claimant meaningful judicial review of the administrative findings.” Beardsley v. Colvin, 758 F.3d 834, 837 (7th Cir. 2014) (internal citations omitted). However, “if the Commissioner commits an error of law,” remand is warranted “without regard to the volume of evidence in support of the factual findings.” White ex rel. Smith v. Apfel, 167 F.3d 369, 373 (7th Cir. 1999) (citing Binion v. Chater, 108 F.3d 780, 782 (7th Cir. 1997)). ANALYSIS The Plaintiff raises several arguments in this appeal, but the Court addresses only the argument that compels remand. Here, the ALJ failed to properly explain the weight given to the Plaintiff’s treating physician’s medical opinion, which is complicated by the ALJ’s incomplete discussion of the Plaintiff’s activities of daily living. The Plaintiff argues that the ALJ erred in evaluating the opinion of her treating physician, Dr. Ungar-Sargon. The treating physician rule, applicable in this case,1 provides that the opinion of a treating physician on the nature and severity of an impairment is given controlling weight if it “is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is 1 On January 18, 2017, the Commissioner published new regulations, “Revisions to Rules Regarding the Evaluation of Medical Evidence,” which addressed 20 C.F.R. § 416.927. However, the new regulations only apply to claims filed on or after March 27, 2017, and the claims in this case were filed in 2016. 5 not inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R. §§ 404.1527(c)(2); 416.927(c)(2); see Karr v. Saul, 989 F.3d 508, 511 (7th Cir. 2021) (citing 20 C.F.R. § 404.1527(c)(2); Reinaas v. Saul, 953 F.3d 461, 465 (7th Cir. 2020)). If the treating physician’s opinion is not given controlling weight, the Commissioner must apply the factors set forth in the regulations to determine what other weight to give the opinion. 20 C.F.R. §§ 404.1527(c)(2); 416.927(c)(2); see Karr, 989 F.3d at 512 (“[T]he ALJ failed to expressly analyze Dr. Canavati’s statement within the multifactor framework delineated in 20 C.F.R. § 404.1527(c)(2). The ALJ should have done so.” (citing Gerstner v. Berryhill, 879 F.3d 257, 263 (7th Cir. 2018))). The factors are whether there is an examining relationship; whether there is a treatment relationship, and if so, the length of the relationship, the frequency of examination, and the nature and extent of the relationship; whether the opinion is supported by relevant evidence and by explanations from the source; the consistency of the opinion with the record as a whole; whether the opinion was offered by a specialist about a medical issue related to his or her area of specialty; and any other factors that tend to support or contradict the opinion. 20 C.F.R. §§ 404.1527(c)(2)–(6), 416.927(c)(2)–(6). The Commissioner “must offer good reasons for discounting the opinion of a treating physician.” Israel v. Colvin, 840 F.3d 432, 437 (7th Cir. 2016) (citing Moore, 743 F.3d at 1127); Reinaas, 953 F.3d at 465 (noting that the ALJ concluded that the treating physician’s opinion did not deserve controlling weight because it was based only on the claimant’s subjective report of symptoms and because it was “inconsistent” with the record but finding that the ALJ failed to adequately support the conclusions (citing Meuser v. Colvin, 838 F.3d 905, 910 (7th Cir. 2016)); see also Smith v. Berryhill, No. 3:17-cv-261, 2018 6 WL 4357129, at *6 (N.D. Ind. Sept. 13, 2018) (stating that the Commissioner failed to “identify specific inconsistencies” to allow the court to determine how the opinion is inconsistent). Here, Dr. Ungar-Sargon completed a Medical Source Statement of Ability to Do WorkRelated Activities (Physical) in July 2018, opining as to the Plaintiff’s functional abilities. AR 1242–48. Dr. Ungar-Sargon opined that the Plaintiff was limited to occasionally lifting up to 10 pounds (never more), sitting for one hour, and standing/walking for a half hour. Id. at 1242–43. In support, he cited the Plaintiff’s insulin dependent diabetes mellitus and resulting neurological symptoms. Id. He further reported that the Plaintiff required a “medically necessary” cane to ambulate effectively and could walk only about a block without one. Id. at 1243. Dr. UngarSargon believe that the Plaintiff could occasionally reach overhead but she could not perform other reaching, handling, fingering, feeling, pushing/pulling, perform postural maneuvers, operate foot controls, or climb a few steps at a reasonable pace with the use of a single handrail due to neuropathy. Id. at 1244–45. Dr. Ungar-Sargon also indicated that the Plaintiff was able to perform many normal daily living activities such as shopping, traveling without a companion for assistance, preparing a simple meal, attending to her hygiene, and handling papers and files, but he advised that she should avoid environmental hazards and that she was not able to navigate rough or uneven surfaces, use public transportation, or climb stairs with use of a single handrail. Id. at 1246–47. Dr. Ungar-Sargon opined that the Plaintiff’s limitations were present since 2016 and had lasted or will last for 12 consecutive months. Id. at 1247. For some sections of the form, Dr. Ungar-Sargon provided the correlating medical or clinical findings that supported his answers such as right sciatica, neuropathy, insulin dependent diabetes mellitus, and numbness in legs; for other sections he left the explanation blank. Id. at 1242–48. 7 In assessing Dr. Ungar-Sargon’s opinion, the ALJ gave “little weight to this extreme opinion because it is not supported by objective evidence and it is inconsistent with the record as a whole.” Id. at 20. The ALJ then made one broad statement as to each of those two factors with no specific discussion of or citation to Dr. Ungar-Sargon’s opinion or the evidence that purportedly does not support or is inconsistent with the opinion. However, as argued by the Plaintiff, the medical evidence of record both supports and is consistent with Dr. Ungar-Sargon’s opinion. See Reinaas, 953 F.3d at 466 (explaining that the plaintiff could not “prevail by arguing that the ALJ improperly weighed the evidence” but that the plaintiff had “correctly note[d] that the ALJ overlooked entire swaths of it”); cf. Karr, 989 F.3d at 513 (finding that the plaintiff failed to carry her burden of proving that she is disabled by “not identifying any objective evidence in the record corroborating” the treating physician’s statement). First, as to supportability, the ALJ stated broadly, “Dr. Ungar-Sargon primarily summarized in the treatment notes the claimant’s subjective complaints, diagnoses, and treatment, but he did not provide objective clinical or diagnostic findings to support the functional assessment.” AR 20. Dr. Ungar-Sargon’s opinion of the Plaintiff’s functioning is based primarily on the effects of neuropathy caused by her diabetes. See id. at 1242–44. The Plaintiff notes several aspects of the medical records that support this finding, including Dr. Ungar-Sargon’s examination findings. See id. at 1200, 1220, 1655–56, 1660, 1667, 1676–77. At multiple examinations, Dr. Ungar-Sargon detected tenderness of the paracervical and thoracic and lumbar paravertebral muscles with spasms. He elicited a positive straight leg raise test response, tenderness in her sacroiliac joints, and positive Faber and Trendelenburg’s tests. The Plaintiff displayed muscle weakness in her lower extremities (4/5 strength on the MRC scale). Dr. Ungar-Sargon also detected loss of sensation and reflexes in the Plaintiff’s lower extremities. 8 He observed the Plaintiff to have an antalgic gait and a loss of normal curvature in her lumbar spine. The Plaintiff had restricted range of motion in her lumbar spine with flexion limited to 30 degrees and extension limited to 10 degrees due to pain. Dr. Ungar-Sargon observed swelling in the Plaintiff’s knees with tenderness to palpation. The Plaintiff had high glucose and A1C. Id. at 2196–97, 2391–92. CT scans of the pelvis, lumbar spine, and abdomen, ordered by Dr. Ungar-Sargon based on “low back pain, 1 year radiating to right hip,” showed abnormalities requiring further study. See id. at 1204–06. An SEP-Lower test conducted by Dr. Ungar-Sargon showed “[i]nconsistent response in right tibial nerve and no responses in right peroneal nerve” with an impression of “[t]ransmission deficits in right tibial and peroneal [systems] consistent with a primary end organ disease.” Id. at 1215–17. A nerve conduction study showed nerve damage consistent with carpal tunnel syndrome, and an EMG confirmed right carpal tunnel syndrome and revealed chronic changes in right leg and lumbar paraspinals consistent with right focal lumbar radiculopathy. Id. at 1224–26, 1232. All of this evidence of record identified by the Plaintiff appears to support neurological deficits in both the upper and lower extremities, consistent with Dr. Ungar-Sargon’s opinion. Yet, the ALJ did not engage with this evidence in relation to the opinion. Although the ALJ listed some of these findings earlier in the recitation of “positive findings,” which the ALJ generally described as “often mild and never more than moderate,” id. at 18–19, the ALJ offered no analysis of how these findings do not support Dr. Ungar-Sargon’s opinion. See, e.g., Lambert v. Berryhill, 896 F.3d 768, 774 (7th Cir. 2018) (“But no medical source opined that the imaging results were inconsistent with Lambert’s complaints of disabling pain.”); Akin v. Berryhill, 887 F.3d 314, 317–18 (7th Cir. 2018) (finding that, without an expert opinion interpreting the MRI 9 results in the record, the ALJ was not qualified to conclude that the MRI results were “consistent” with his RFC assessment (citing Goins v. Colvin, 764 F.3d 677, 680 (7th Cir. 2014); Moon v. Colvin, 763 F.3d 718, 722 (7th Cir. 2014))). Moreover, these treatment findings and objective tests undermine the ALJ’s suggestion that Dr. Ungar-Sargon’s opinion relies on little more than the Plaintiff’s subjective complaints. Second, as to consistency, the ALJ states generally: “This opinion is inconsistent with the objective findings already discussed above in this decision, which show many negative findings. This opinion is also inconsistent with the claimant’s admitted activities of daily living that have already been described above in this decision.” Id. at 20. Earlier in the opinion, the ALJ listed, without discussion, several “negative findings” but also listed “positive findings” that “were often mild and never more than moderate.” Again, the ALJ does not identify which, if any, objective findings, are inconsistent with Dr. Ungar-Sargon’s opinion. The Plaintiff has numerous health problems and has undergone numerous tests and examinations to treat her myriad conditions. As the Plaintiff argues, the fact that some of the test results were benign does not explain how Dr. Ungar-Sargon’s opinion is inconsistent with the bulk of the medical records related to his opinions. As for the Plaintiff’s activities of daily living, Dr. Ungar-Sargon opined that the Plaintiff could engage in a variety of day-to-day activities such as shopping, traveling without a companion, ambulating without a wheelchair or two crutches, preparing a simple meal and feeding herself, attending to her hygiene, and handling papers and files. Id. at 1247. Similarly, the ALJ found that that the Plaintiff lived with her boyfriend and two grown children, has a driver’s license, does housework, prepares meals, takes care of herself, vacuums, washes dishes, mops the floor, shops by herself, watches television, reads, uses the internet, and takes care of 10 four birds. AR 17. However, the ALJ’s characterization of these activities omits several qualifiers. For example, the Plaintiff stated that doing laundry takes a “long while” and that she needs someone to carry the basket for her. AR 310. The Plaintiff does housework, but she spreads it out over most of the day. AR 312. Her children and boyfriend helped with the pets. Id. at 311. The Plaintiff can care for herself, but her boyfriend reported that she has difficulty getting out of the tub and rising from the toilet because of her back. Id. at 311, 323. Although she can prepare meals, it takes her longer and, sometimes, she was unable to cook due to pain and would ask her children or boyfriend to cook instead. Id. at 312. The Plaintiff avoids going outside in bad weather, and when she drives, she can only remain seated for about a half hour. Id. at 313. Although the Plaintiff could shop for groceries, she used the electric scooter at the store. Id. at 313. The ALJ’s disregard for the Plaintiff’s difficulties with activities of daily living undermines the assertion that the Plaintiff’s activities are inconsistent with Dr. Ungar-Sargon’s opinion on the Plaintiff’s functional limitations, which Dr. Ungar-Sargon identified while also opining that the Plaintiff can perform basic activities of daily living. Because the ALJ ignored the limitations on how the Plaintiff carried out her activities of daily living, the ALJ failed to satisfactorily explain how those activities are inconsistent with the limitations in Dr. Ungar-Sargon’s opinion and the Court cannot trace the logic of the ALJ’s reasoning. See Lothridge v. Saul, 984 F.3d 1227, 1234 (7th Cir. 2021) (finding that, in emphasizing the activities of daily living that the plaintiff reported performing, “the ALJ overlooked, or at least did not acknowledge and engage with, the limitations with those tasks that Lothridge included in that same report—such as the pain and fatigue those activities caused her, her need for frequent breaks, and her dependence on her children for daily living activities (including shopping, personal hygiene, and caring for pets)” (citing Craft v. Astrue, 539 F.3d 11 668, 680 (7th Cir. 2008))). The Commissioner offers no response to this argument regarding the ALJ’s failure to consider the limited nature of the Plaintiff’s activities of daily living. Finally, because the ALJ determined that Dr. Ungar-Sargon’s opinion was not entitled to controlling weight, the ALJ was required to consider the relevant regulatory factors. See Gerstner, 879 F.3d at 263. While the ALJ does not need to explicitly address every factor, see Schreiber v. Colvin, 519 F. App’x 951, 959 (7th Cir. 2013), the ALJ should have addressed them in a way to enable review by this Court, see Scrogham v. Colvin, 765 F.3d 685, 697–98 (7th Cir. 2014). Here, the ALJ only considered supportability and consistency; the ALJ did not discuss any other factors or provide an analysis that would allow the Court to understand how the ALJ had considered the factors. For these reasons, remand is necessary for the ALJ to properly evaluate Dr. UngarSargon’s opinion in light of his treatment records and the objective evidence as well as the regulatory factors and to provide an adequate explanation for the weight that is ultimately assigned to the opinion. See Lothridge, 984 F.3d at 1233–34 (“It is not a court’s role to displace an ALJ’s judgment by making our own findings about the facts, but we cannot uphold an administrative determination that failed to explain the outcome adequately.” (citing Parker v. Astrue, 597 F.3d 920, 921 (7th Cir. 2010)). The Plaintiff makes several other arguments regarding the ALJ’s treatment of her subjective complaints and the formulation of the RFC. However, since remand is required due to the ALJ’s errors in weighing the opinion of the Plaintiff’s treating physician, the Court declines to address the issues on this appeal. The Plaintiff also asks the Court to reverse and remand for an award of benefits, or, in the alternative, for a new hearing and decision. “An award of benefits is appropriate . . . only if all factual issues involved in the entitlement determination have been 12 resolved and the resulting record supports only one conclusion—that the applicant qualifies for disability benefits.” Allord v. Astrue, 631 F.3d 411, 415 (7th Cir. 2011) (citing Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 355 (7th Cir. 2005)). Based on the discussion above, an immediate award of benefits is not appropriate in this case. CONCLUSION For the reasons stated above, the Court GRANTS the relief sought in the Plaintiff’s Brief [ECF No. 1] and REVERSES the decision of the Commissioner. The Court REMANDS this matter for further proceedings consistent with this Opinion. The Court DENIES the Plaintiff’s request to award benefits. SO ORDERED on March 28, 2022. s/ Theresa L. Springmann JUDGE THERESA L. SPRINGMANN UNITED STATES DISTRICT COURT 13
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