United States District Court, S.D. Indiana, Indianapolis Division
JOHN I. FELDHAKE, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.
ORDER ON PLAINTIFF'S BRIEF IN SUPPORT OF APPEAL
TIM A. BAKER, District Judge.
Plaintiff John Feldhake appeals the Administrative Law Judge's denial of his period of disability and disability insurance benefits application. Feldhake's alleged impairments include: multilevel cervical spondylosis with congenitally small canal; lumbar spine dysfunction described as multiple level changes with degenerative disc disease at T10-11 and throughout the lumbar spine resulting in mild spinal stenosis; and mental impairments variously assessed as mood disorder, cognitive disorder, and antisocial behavior. On appeal, Feldhake raises four issues: (1) whether the ALJ erroneously assessed Feldhake's migraine headaches; (2) whether the ALJ adequately addressed Feldhake's impairments under the listings without summoning a medical advisor; (3) whether the ALJ failed to articulate Feldhake's residual functional capacity and logically bridge the evidence to her conclusion; and (4) whether the ALJ's credibility determination was erroneous. For the reasons set forth below, Plaintiff's brief in support of appeal [Filing No. 21] is denied and the Commissioner's decision affirmed.
A. Standard of review
The Social Security regulations provide a five-step sequential inquiry to determine whether a plaintiff is disabled: whether the plaintiff (1) is currently unemployed; (2) has a severe impairment; (3) has an impairment that meets or equals one of the impairments listed as disabling in the Commissioner's regulations; (4) is unable to perform his past relevant work; and (5) is unable to perform any other work in the national economy. 20 C.F.R. § 404.1520; Simila v. Astrue, 573 F.3d 503, 512-13 (7th Cir. 2009). "An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled." Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000) (quoting Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985)). "A negative answer at any point, other than Step 3, ends the inquiry and leads to a determination that a claimant is not disabled." Id.
The Court must uphold the ALJ's decision if substantial evidence supports her findings. Pepper v. Colvin, 712 F.3d 351, 361-62 (7th Cir. 2013). "Although a mere scintilla of proof will not suffice to uphold an ALJ's findings, the substantial evidence standard requires no more than such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. The ALJ is obligated to consider all relevant medical evidence and cannot simply cherry-pick facts that support a finding of nondisability while ignoring evidence that points to a disability finding . Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010). If evidence contradicts the ALJ's conclusions, the ALJ must confront that evidence and explain why it was rejected. Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014). The ALJ, however, need not mention every piece of evidence, so long as she builds a logical bridge from the evidence to his conclusion. Pepper, 712 F.3d at 362.
B. Migraine headaches
At step two, the ALJ found that Feldhake's headache syndrome was not severe given that there was very little in Feldhake's treatment notes regarding his headaches and no abnormal findings. Feldhake argues that the ALJ's discussion of his headaches was erroneous as she incorrectly dismissed Feldhake's complaints. The ALJ allegedly ignored Feldhake's statement that some of his headaches caused him to vomit, and Feldhake argues that this error warrants remand. However, the Court is not convinced that remand on this issue is appropriate. For one, the ALJ found Feldhake had other severe impairments that obligated her to proceed to steps three, four, and five, where she had to consider all relevant medical evidence in making her final determination, including Feldhake's headaches. See Arnett v. Astrue, 676 F.3d 586, 591 (7th Cir. 2012) (finding that as long as the ALJ determined that the claimant has one severe impairment, the error at step two is harmless as she is obligated to consider all relevant medical evidence in steps three, four, and five); Golembiewski v. Barnhart, 322 F.3d 912, 918 (7th Cir. 2003) ("Having found that one or more of [appellant's] impairments was severe, ' the ALJ needed to consider the aggregate effect of the entire constellation of ailments-including those impairments that in isolation are not severe.").
Moreover, the ALJ's decision discussed other evidence of Feldhake's headaches. The ALJ noted that Feldhake was assessed with headache syndrome and post-concussive syndrome in December 2009 and was prescribed pain medication. She indicated that his January 2010 and February 2010 exams were unremarkable, despite the fact that Feldhake's doctor assessed him with headaches secondary to trauma. [Filing No. 16-2, at ECF p. 26; Filing No. 16-9, at ECF p. 79-80; Filing No. 16-12, at ECF p. 42.] The ALJ relied on consultative examiner Mahmoud Kassab's evaluation during which Feldhake complained of headaches. However, Dr. Kassab found that Feldhake's head was atraumatic and normocephalic. [Filing No. 16-9, at ECF p. 75.]
Nevertheless, vomiting due to head pain certainly could affect Feldhake's capabilities in the workplace. In his May 11, 2010, psychological evaluation with Suzanne Leiphart, Feldhake stated, "I cannot get rid of the headaches. I get where I throw up they're so bad." [Filing No. 16-9, at ECF p. 97.] The ALJ mentioned Dr. Leiphart's psychological evaluation where Feldhake stated he had head pain, but the ALJ failed to include Feldhake's specific statement. The ALJ should have mentioned Feldhake's specific complaint as it contradicts her conclusion that his headaches were not severe. See Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014) ("The ALJ must confront the evidence that does not support her conclusion and explain why that evidence was rejected.")
However, any error in failing to specifically address Feldhake's statement about vomiting is harmless as his statement was inconsistent with the medical evidence. At Dr. Kassab's exam, Feldhake denied having a history of blurry vision, nausea, or vomiting. [Filing No. 16-9, at 75.] Dr. Kassab found Feldhake's head to be atraumatic and normocelphic. There was no treatment prescribed for his headaches other than pain medication for his general back, neck, and head pain in the record. Moreover, there was no evidence of light or sound sensitivity, or any other symptoms associated with severe headaches. See e.g. , Keller v. Colvin, No. 1:13-cv-00104-TWP-MJD, 2014 WL 948889 (Mar. 10, 2014) (noting that severe headaches under the Social Security's Program Operations Manual System include nausea, photophobia, and throbbing as symptoms); Crowder v. Massanari, No.00C5645, 2001 WL 649529 (N.D. Ill. June 8, 2001) (remanding the case because the ALJ failed to discuss the symptoms associated with claimant's severe headaches, including dizziness, light sensitivity, sound sensitivity, visual spots, slurring of speech, and numb hands). Thus, remand is not appropriate on this issue. See McKinzey v. Astrue, 641 F.3d 884, 892 (7th Cir. 2011) ("[The Court] will not remand a case to the ALJ for further specification where we are convinced that the ALJ will reach the same result.").
C. Summoning a medical advisor
Feldhake next argues that the ALJ failed to adequately address whether he met or equaled a listing because the ALJ did not summon a medical advisor. The Court should defer to an ALJ's decision whether to summon a medical advisor if she adequately explained how she reached her decision and she did not disregard medical evidence contrary to her conclusion. See Clifford v. Apfel, 227 F.3d 863, 873 (7th Cir. 2000); Thomas v. Astrue, No. 1:09-cv-808-SEB-JMS, 2010 WL 2485556, at *5 (S.D. Ind. June 11, 2010). In the case at hand, the ALJ considered the relevant medical evidence, including reports contrary to her conclusion. The ALJ reviewed evidence of Feldhake's cognitive limitations. She noted that Feldhake had moderate difficulty in social, occupational, or school ...