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Steinborn v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

March 30, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Sr. Michael G. Gotsch, Sr. United States Magistrate Judge

         Plaintiff, Teri L. Steinborn, appeals the Social Security Administration's (“SSA's”) decision to deny her application for Social Security disability benefits. An administrative law judge (“ALJ”) found that Steinborn was not disabled within the meaning of the Social Security Act. The ALJ specifically found that no disability listing had been met and that Steinborn was capable of performing light work as defined in 20 C.F.R. § 404.1567(b). This Court may enter a ruling on this matter based upon the parties' consent. 28 U.S.C. § 636(c); 42 U.S.C. § 405(g); [DE 11]. For the reasons set forth below, the decision of the Commissioner is REVERSED and this case is REMANDED to the Social Security Administration for further proceedings consistent with this opinion.

         I. Procedure

         On October 29, 2012, Steinborn filed an application for Disability Insurance Benefits (“DIB”) with the SSA pursuant to 42 U.S.C. § 423. Steinborn alleges a disability date of February 20, 2012. The SSA denied Steinborn's claims initially and on reconsideration. Steinborn then testified at an administrative hearing before an ALJ in November 2014. Steinborn was represented by an attorney at the hearing. In March 2015, the ALJ issued a finding that Steinborn had not been disabled since her alleged onset date of February 20, 2012. On June 24, 2016, the ALJ's decision became the final decision of the Commissioner when the Appeals Council denied Steinborn's request for review. See Fast v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005); 20 C.F.R. § 404.981. With all administrative remedies exhausted, Steinborn seeks judicial review under 42 U.S.C. §405(g).

         II. Facts

         Steinborn was born on December 13, 1961, making her over the age of fifty at the time of her benefit application. Steinborn has a limited education and has a demonstrated past work history that included employment as a paralegal, credit analyst, and a supervisor for loans and credit. The ALJ also found that despite a short attempt at waitressing during the relevant period, Steinborn had not engaged in any substantial gainful activity since the alleged onset date.

         A. Relevant Medical Evidence

         1. Physical Impairments

         As part of her application for disability benefits, Steinborn alleged several physical impairments including cervical spine issues that caused lower back pain, tingling in her hands, and ongoing migraine headaches. Dr. David Miller treated Steinborn for her lower back pain and prescribed both physical therapy and OxyContin. An MRI conducted in 2011 revealed a small central disc protrusion, and by September of that year she sought treatment from orthopedist, Dr. Henry DeLeeuw. Initially, Dr. DeLeeuw scheduled Steinborn for an anterior lumbar interbody fusion that was cancelled when her insurance company later denied coverage for the procedure.

         During this time, Steinborn was also treated with Toradol[1] injections for her migraines after various other medications failed.

         Steinborn was also placed into a physical therapy program. By April 2012, however, Steinborn stopped going to physical therapy due to her pain. Steinborn reported to Dr. Miller that she was in constant pain, and that she had trouble sleeping and remaining in one position. Another MRI, in December 2012, showed slight progressing disc disease, and further leg raise testing demonstrated that she had a restricted range of motion.

         After her DIB application was filed on October 29, 2012, Steinborn underwent an SSA consultative examination by Dr. Mutena Kormun in January 2013. Dr. Kormun found range of motion loss to Steinborn's upper extremities and a grip strength reading of 4/5, as well as a reduced range of motion to her thoracic and lumbar spine. Steinborn reported to Dr. Kormun that she suffered migraine headaches between two and three times per week.

         Throughout 2013, Steinborn complained to Dr. Miller of ongoing radicular and sacroiliac joint pain-and a sacroiliac joint injection provided limited relief. Steinborn also continued to see Dr. DeLeeuw for treatment of ongoing back and left shoulder pain. Another MRI conducted in February 2014 showed a labral tear in the shoulder and a disc protrusion. In April 2014, Steinborn underwent an anterior lumbar interbody fusion at discs L4-5. After the procedure, Steinborn still complained of left shoulder pain and continued to see Dr. DeLeeuw for her ongoing chronic back pain. She reported to Dr. DeLeeuw that she had difficulty standing up and walking, and reported an episode of falling down. Another MRI revealed disc protrusions and hypertrophy at discs L3-S1. Dr. DeLeeuw submitted a Residual Function Capacity (“RFC”) as part of the record before the ALJ opining that Steinborn could sit more than six hours, stand/walk about an hour before needing to sit, and stand three hours collectively in an eight-hour work day.

         2. Mental Impairments

         In addition to her physical impairments, Steinborn also alleged several mental impairments in her DIB application. Steinborn was treated by psychiatrist Dr. Anand Popli as early as 2010. In 2012, she reported to Dr. Popli that she generally felt down with decreased energy. Dr. Popli found that Steinborn was suffering from bipolar disorder and attention deficit disorder (“ADD”). Dr. Popli's records then show Steinborn underwent several ups and downs during treatment of her bipolar disorder. In June 2012 she was reported as being stable, yet by September she once again had decreased motivation and did not even want to leave bed. At this time her Patient Health Questionaire-9 (“PHQ-9”) score[2] was an 18, prompting Dr. Popli to increase her medication dosage. During the months that followed, Steinborn continued to report a lack of motivation, depression, and that she did not want to leave the house.

         Overlapping with Dr. Popli's treatment, Steinborn also sought treatment from Dr. Thomas Allen, Psy. D for family and marriage counseling. Dr. Allen reported that Steinborn was suffering from major depressive disorder (“depression”) and post-traumatic stress disorder (“PTSD”). In early 2013, Steinborn reported gaining 22 pounds, and her PHQ-9 score was now a 10-an improvement. In April 2013, however, her score worsened, moving up to a 14. Steinborn once again reported decreased motivation. During this time, Steinborn also reported that she remained in bed most days and did not cook, clean, or shower. She continued to report regular migraine headaches. Dr. Allen, in June, continued to treat Steinborn for depression and PTSD. In July, he reported that Steinborn had pressured speech, tangential thoughts, and grandiose ideas regarding building a jewelry shop and a boys and girls club. Dr. Allen also reported that she had difficulty maintaining focus at this appointment and appeared hyperactive and fidgety. At this time, she had a Global Assessment of Functioning (“GAF”) score of 70.[3] Two weeks after this appointment, she again had pressured speech, difficulty focusing, and tangential thoughts-as well as expansive affect. Again the following week she exhibited these symptoms, as well as anxiety. These symptoms continued, and in September, she was late to her appointment and reported being sad all the time. Additionally, Dr. Allen noted that Steinborn was anxious, had a tense affect, and was depressed and tearful during the examination. In an October session she was at first cheerful and then became angry. During this session she reported worsening marital problems.

         In November 2014, both Dr. Popli and Dr. Allen completed Medical Source Statements opining that Steinborn was disabled due to her mental impairments.

         B. Relevant Hearing Testimony

         On November 26, 2014, Steinborn appeared and testified before the ALJ at a hearing. At the time of the hearing, Steinborn was separated from her husband. Steinborn testified that she had attempted to work as a waitress at a country club, but that she could not carry trays, leading to her hours being cut back. She further testified that she had a dispute with her manager after a country club member complained about her service, and she was subsequently fired.

         In terms of pain, Steinborn testified that it hurt both to sit up, sit down, and walk. Steinborn contended that her surgery had done little to relieve this pain. Steinborn testified that her pain was continuous in her lower back, hips, and buttocks. Steinborn testified that she could probably walk about a block-and-a-half before needing to rest due to pain. Steinborn could stand, but not for long, and she would need to slouch and keep shifting due to the pain. She testified that the most comfortable position for her was on the edge of a chair. Additionally, she testified that her migraines occurred two to three times per week and that when one occurred she would need to lie down for the duration of the episode. According to Steinborn, each migraine would last six or seven hours. At the time of the hearing, Steinborn no longer had any issue with left shoulder pain. Steinborn also testified that while she was able to lift a gallon of milk and walk it across a room, doing so was very uncomfortable.

         Steinborn further testified as to other aspects of her daily life. Steinborn contended that she had no energy, had problems with focus and attention, and that she cried every day. She also testified that she did not have many friends and that she rarely went anywhere due to her pain and lack of energy. Additionally, Steinborn reported that she frequently would not leave bed or change her clothes. She also testified that she frequently felt a tingling in her neck that “spider-webbed” pain into her arms. Steinborn further testified that for over a year she was having childhood flashbacks stemming from her PTSD.

         Steinborn testified that she was on a combination of Methadone[4], Adderall[5], Lexapro[6], and Topamax[7] for her varied ailments. The current medications were helping, but she testified that in the past, dosages did nothing to fully alleviate her pain and symptoms. Steinborn reported that she had good and bad days and that her goal was to get off the medication and “get her life back.” The ALJ noted no problems in concentration at the hearing. On the day of the hearing, Steinborn testified that she was having a good day because her husband had put a “jewelry shop” in her basement. However, Steinborn reported that she had not been able to use the shop due to concentration issues. Her testimony then indicated that her husband had set up this basement “jewelry shop” for Steinborn six months earlier. Steinborn testified that the shop remained unused, despite her initial excitement when her husband installed it.

         C. The ALJ's Opinion

         Using its authority granted by the Social Security Act, the SSA has established a five-step sequential process for determining whether an applicant for disability benefits is disabled within the meaning of the Act. See 20 C.F.R. § 404.1520(a)(4)(i)-(v). The claimant bears the burden at steps one through four, whereas the burden at step five shifts to the ALJ. Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001). The ALJ's analysis is sequential and therefore if he determines at any step, other than step three, that the plaintiff is not disabled the analysis ends without proceeding to the next step. See Smith v. Berryhill, 2017 WL 4005935 at *2 (S.D. Ill. Sept. 12, 2017). The ALJ in his March 9, 2015, decision, followed this sequential evaluation process and concluded that Steinborn was not disabled.

         At step one, the ALJ concluded that Steinborn's work activity during the relevant period was not “substantial gainful activity.” The ALJ at step two found that Steinborn's status-post lumbar fusion with residual, status-post left shoulder arthroscopy with residuals, major depressive disorder, bipolar disorder, PTSD, and ADD constituted severe impairments. However, the ALJ found that Steinborn's history of cervical fusion, neck pain, and headaches did not constitute severe impairments. At step three, the ALJ took into account Steinborn's testimony and her medical records when determining that none of her physical impairments- either singularly or in combination-met or equalled a Listing after applying the “Paragraph B” criteria or the Special Technique.

         After determining that no Listing was met, the ALJ determined that Steinborn had a residual functional capacity (“RFC”) to perform light work with some additional limitations. Based on a vocational expert's testimony, the ALJ then found that Steinborn could not return to any past relevant work. Looking at Steinborn's age, education, RFC, and work experience, the ALJ determined that she would be able to adjust to other light work. The ALJ then found that significant jobs exist in the national economy that Steinborn could perform, taking into account her limitations. Accordingly, the ALJ found Steinborn to be not disabled.

         D. Appeals Council Decision

         After receiving an unfavorable determination from the ALJ, Steinborn filed a timely appeal to the SSA's Appeals Council. On June 24, 2016, the Appeals Council denied Steinborn's request to review the ALJ's decision. The Appeals Council's decision indicated that “additional evidence, ” identified as an RFC form dated November 25, 2014, and authored by Dr. DeLeeuw was considered in reaching its decision to deny Steinborn's appeal. [DE 8 at 15, 17]. With the Council's denial of Steinborn's appeal, the ALJ's determination became the final decision of the Commissioner.

         III. Analysis

         A. Standard of Review

         The Social Security Act authorizes judicial review of the final decision of the Commissioner and indicates that her factual findings must be accepted as conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an erroneous legal standard. SeeBriscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial evidence is more than a mere scintilla but may be less than the weight of the evidence. Scheck v. Barnhart, 357 F.3d 697, 699 (7th Cir. 2004). Thus, substantial evidence is simply ‚Äúsuch relevant evidence as a ...

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