United States District Court, S.D. Indiana, Terre Haute Division
ORDER ON COMPLAINT FOR JUDICIAL REVIEW
L. PRYOR UNITED STATES MAGISTRATE JUDGE
Alexis H. 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.
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
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).
Standard of Review
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. §
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
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).
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).
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.
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.
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.]
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.]
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.
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).]
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).]
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).]
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.
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.
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 ...