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Alexis H. v. Berryhill

United States District Court, S.D. Indiana, Terre Haute Division

August 2, 2018

ALEXIS H., Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner for Operations, Social Security Administration, Defendant.



         Plaintiff Alexis H.[1] requests judicial review of the denial by the Commissioner of the Social Security Administration (“Commissioner”) of her application for Social Security Disability Insurance (“DIB”) under Title II of the Social Security Act (“the Act”) and of her application for Supplemental Security Income (“SSI”) under Title XVI of the Act. See 42 U.S.C. §§ 301, 416(i), 423(d), 1382c(a)(3). For the reasons set forth below, this Court hereby REVERSES the ALJ's decision denying Plaintiff benefits and REMANDS this matter for further consideration.

         I. Procedural Background

         On October 18, 2013, the Plaintiff filed for disability insurance benefits under Title II and supplemental security income under Title XVI of the Social Security Act, alleging her disability began on October 25, 2012. The claims were denied initially and upon reconsideration. The Plaintiff then filed a written request for a hearing on June 12, 2014, which was granted.

         On January 25, 2016, Administrative Law Judge Shane McGovern conducted the hearing, where the Plaintiff and a vocational expert testified. On February 22, 2016, the ALJ issued an unfavorable decision finding that the Plaintiff was not disabled as defined in the Act. The Appeals Council denied the Plaintiff's request for review of this decision on February 28, 2017, making the ALJ's decision final. Plaintiff now seeks judicial review of the Commissioner's decision. See 42 U.S.C. § 1383(c)(3).

         II. Standard of Review

         To prove disability, a claimant must show 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). To meet this definition, Plaintiff's impairments must be of such severity that she is not able to perform the work she previously engaged in and, based on her age, education, and work experience, she cannot engage in any other kind of substantial gainful work that exists in significant numbers in the national economy. 42 U.S.C. § 423(d)(2)(A). The Social Security Administration (“SSA”) has implemented these statutory standards by, in part, prescribing a five- step sequential evaluation process for determining disability. 20 C.F.R. § 404.1520.

         The ALJ must consider whether:

(1) the claimant is presently [un]employed; (2) the claimant has a severe impairment or combination of impairments; (3) the claimant's impairment meets or equals any impairment listed in the regulations as being so severe as to preclude substantial gainful activity; (4) the claimant's residual functional capacity leaves [her] unable to perform [her] past relevant work; and (5) the claimant is unable to perform any other work existing in significant numbers in the national economy.

Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351-52 (7th Cir. 2005) (citation omitted). An affirmative answer to each step leads either to the next step or, at steps three and five, to a finding that the claimant is disabled. 20 C.F.R. § 404.1520; Briscoe, 425 F.3d at 352. A negative answer at any point, other than step three, terminates the inquiry and leads to a determination that the claimant is not disabled. 20 C.F.R. § 404.1520. The claimant bears the burden of proof through step four. Briscoe, 425 F.3d at 352. If the first four steps are met, the burden shifts to the Commissioner at step five. Id. The Commissioner must then establish that the claimant-in light of her age, education, job experience and residual functional capacity to work-is capable of performing other work and that such work exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. § 404.1520(f).

         The Court reviews the Commissioner's denial of benefits to determine whether it was supported by substantial evidence or is the result of an error of law. Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). Evidence is substantial when it is sufficient for a reasonable person to conclude that the evidence supports the decision. Rice v. Barnhart, 384 F.3d 363, 369 (7th Cir. 2004). The standard demands more than a scintilla of evidentiary support, but does not demand a preponderance of the evidence. Wood v. Thompson, 246 F.3d 1026, 1029 (7th Cir. 2001). Thus, the issue before the Court is not whether Plaintiff is disabled, but, rather, whether the ALJ's findings were supported by substantial evidence. Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995).

         In this substantial-evidence determination, the Court must consider the entire administrative record but not “reweigh evidence, resolve conflicts, decide questions of credibility, or substitute our own judgment for that of the Commissioner.” Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). Nevertheless, the Court must conduct a critical review of the evidence before affirming the Commissioner's decision, and the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003); see also Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).

         When an ALJ denies benefits, he must build an “accurate and logical bridge from the evidence to his conclusion, ” Clifford, 227 F.3d at 872, articulating a minimal, but legitimate, justification for his decision to accept or reject specific evidence of a disability. Scheck v. Barnhart, 357 F.3d 697, 700 (7th Cir. 2004). The ALJ need not address every piece of evidence in his decision, but he cannot ignore a line of evidence that undermines the conclusions he made, and he must trace the path of his reasoning and connect the evidence to his findings and conclusions. Arnett v. Astrue, 676 F.3d 586, 592 (7th Cir. 2012); Clifford v. Apfel, 227 F.3d at 872.

         III. Discussion

         A. Factual Background

         Plaintiff was born on December 9, 1955, and was 56 years old at the time of her alleged disability date in 2012. [Dkt. 26 at 4.] She completed high school in 1974. [Dkt. 17-7 at 19 (R. 267).] The Plaintiff does not drive because of vision problems and has a history of smoking. [Dkt. 17-8 at 5 (R. 338).] Plaintiff previously worked as a cook in a restaurant and a hotel. [Id.]

         B. Medical History

         On September 6, 2011, the Plaintiff was examined by consultative examiner Shuyan Wang MD, wherein Dr. Wang noted that the Plaintiff had decreased range of motion in her spine, shoulders and elbows. [Dkt. 17-8 at 1 (R. 335).] Dr. Wang also observed tenderness in the Plaintiff's back, shoulders, elbows, left hip, and left knee. [Dkt. 17-8 at 7-8 (R. 340-41).] Ultimately, Dr. Wang found that the Plaintiff suffered from chronic back pain, arthritis, chronic headaches and dizziness, hypertension, diabetes, hyperlipidemia, coronary artery disease, depression, anxiety, obesity, sickle cell trait, intermittent blurry vision, and very slight scoliosis. [Dkt. 17-8 at 7, 9 (R. 340, 342).] Dr. Wang concluded that the Plaintiff needed treatment and follow-ups for all of her medical problems, but, with appropriate treatment for pain, she should be able to do light work. [Dkt. 17-8 at 10 (R. 343).] Dr. Wang also recommended additional restrictions for standing, walking, climbing, lifting above the waist, and exposure to extreme temperature changes and high humidity. [Id.]

         A few months later, on December 1, 2011, Dr. Neil G. Kabous performed various heart procedures on the Plaintiff. During the procedure, he discovered a stent in the Plaintiff's right coronary artery. [Dkt. 17-10 at 25-26 (R. 459-60).] At the time of the examination, Dr. Kabous noted that the Plaintiff had developed in-stent restenosis. [Dkt. 17-10 at 25 (R. 459).] Based on these findings, Dr. Kabous diagnosed the Plaintiff with moderate coronary artery disease. [Id.]

         Almost two years later, on December 16, 2013, consultative examiner Dr. Olivia Cronin examined the Plaintiff, finding that the Plaintiff had limited range of motion in her back, neck, and shoulders. [Dkt. 17-13 at 68, 72 (R. 731, 735).] Plaintiff refused to participate in hip mobility testing because she was fearful of the pain that the testing may cause. Dr. Cronin was not, therefore, able to assess Plaintiff's range of motion in her hips. [Id.] Dr. Cronin noted in the record the Plaintiff's use of a cane, but found that the cane “was not medically necessary.” [Dkt. 17-13 at 72 (R. 735).] Later on in her report, however, Dr. Cronin noted that the cane “was medically required for ambulation, as [the Plaintiff] refused to walk without it . . . .” [Id.] Dr. Cronin concluded that the Plaintiff suffered from chronic back pain due to mild-to-moderate degenerative disc changes in the lumbar spine, experienced chest pain due to coronary artery disease, and headaches due to hypertension and diabetes. [Dkt. 17-13 at 73 (R. 736).]

         In January 2014, the Plaintiff returned to Dr. Kabous because she was experiencing, among other things, chest pains, neuropathy in her feet, dizziness, and fainting spells. [Dkt. 17-15 at 68 (R. 841).] Dr. Kabous concluded that the Plaintiff continued to suffer from coronary artery disease and that her foot deformity was caused by her diabetes. [Dkt. 17-15 at 69-70 (R. 842-41).]

         In March 2014, the Plaintiff underwent a computed tomography (“CT”) scan of her head to address her ongoing issues with headaches. Dr. Michael Brown reviewed the CT scan and concluded that the minor changes found in the Plaintiff's deep white matter could represent small vessel disease. [Dkt. 17-17 at 52 (R. 958).]

         A few months later in July 2014, an x-ray was performed on the Plaintiff's hip after she fell in the bath tub. [Dkt. 17-17 at 22 (R. 928).] The x-ray showed no fractures or dislocations, but did show mild degenerative changes. [Id.]

         Throughout 2015, the Plaintiff was admitted several times to the emergency room at Union Hospital for complaints of chest pain and fatigue. [Dkt. 17-21 (R. 1202-84).] On March 10, 2015, Dr. Kabous performed a second cardiac catheterization on the Plaintiff. And concluded that the Plaintiff's mild-to-moderate coronary artery disease had now become moderate-to-severe. [Dkt. 17-20 at 34 (R. 1152).] On September 27, 2015, an x-ray was taken of the Plaintiff's back that showed space narrowing throughout the cervical spine, but was otherwise unremarkable. [Dkt. 17-22 at 3 (R. 1285).]

         In January 2016, a magnetic resonance imaging test (“MRI”) was performed on the Plaintiff's back because she was reporting that her chronic neck and back pain had worsened. The MRI found multilevel degenerative spondylosis at ¶ 3 to C6 in the Plaintiff's neck. [Dkt. 17-26 at 70 (R. 1527).] At the same time, an electromyogram test ...

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