United States District Court, N.D. Indiana, South Bend Division
LAURA R. JIMENEZ, Plaintiff,
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
OPINION AND ORDER
P. SIMON, UNITED STATES DISTRICT COURT JUDGE
R. Jimenez appeals the Social Security Administration's
denial of her application for Disability Insurance Benefits.
An Administrative Law Judge found that Jimenez was not
disability within the meaning of the Social Security Act. The
Appeals Council denied Jimenez's appeal and she appealed
the ALJ's decision to me. Because the ALJ in this case
did not adequately consider and evaluate opinion evidence
from Ms. Jimenez's treating physician and a nurse
practitioner who offered evidence on her behalf, the
ALJ's decision cannot be upheld as supported by
substantial evidence. Accordingly, I will reverse and remand.
application, Ms. Jimenez alleged disability on the basis of a
variety of different conditions and ailments. In evaluating
Jimenez's application, the ALJ engaged in the familiar
five-step process to determine disability based on these
allegations under the Social Security Act and its
one, the ALJ found that Jimenez did not engage in substantial
gainful activity during the period of her alleged onset date
of December 28, 2013 and her date last insured of March 31,
2015. [A.R. 12.
two, the ALJ determined whether Jimenez had any severe
impairments which could render her disabled. The ALJ found
the following severe impairments: obesity, status post
complete right shoulder replacement, depression, anxiety,
headaches and fingertip numbness. [A.R. 12.] She further
alleged disability based upon a history of arthritis and mild
carpal tunnel syndrome. The ALJ, however, determined that the
existence of these two conditions were not supported by any
objective medical evidence during the relevant period.
[Id.] Lastly, Jimenez alleged disability due to a
staph infection on her skin and a stroke. While the ALJ found
these two conditions had support within the record, she
determined they did not amount to severe impairments.
Regarding the staph infection, the ALJ found it was diagnosed
in August and September of 2014, but by March 2015 Jimenez
did not have any dermatological problems. [A.R. 13.]
Concerning the stroke, the ALJ stated:
The record also indicates the claimant experienced a left
frontal lobe hematoma/aneurysm in February of 2015. However,
she underwent a successful coil embolization of the aneurysm,
as well as physical therapy. At first, the claimant report
recurrent “spells” and altered mental state
following her stroke, as well as some right sided weakness.
EEG's were also frequently abnormal. However, by August
of 2015 it was noted the claimant had no more attacks at that
point, only some mild weakness on her right side, and still
seemed to be functioning pretty well. She was also able to
move all extremities to command equally well. Similarly, in
March of 2016, the claimant was noted to be neurologically
stable with no recent spells or attacks.
[A.R. 14 (citations to underlying record omitted).] The ALJ
determined that because these two conditions or impairments
were resolved or healed in a period of less than 12 months,
they did not qualify as severe impairments under 20 CFR
on these findings, the ALJ determined at step three that
Jimenez did not meet or medically equal any Social Security
Listing. [A.R. 13-16.] As such, the ALJ determined
Jimenez's residual functional capacity
(“RFC”). In doing so, the ALJ found Jimenez to
have an RFC:
to perform sedentary work as defined in 20 CFR 404.1567(a)
except: she could occasionally climb ramps and stairs, but
should never climb ladders, ropes or scaffolds; she could
occasionally balance, stoop, kneel, crouch, and crawl; she
could frequently reach in all directions including overhead
with her right upper extremity; she could frequently handle
and finger with her right hand; she could perform simple,
routine tasks, but not always at a production-rate pace, but
would have met end of day work goals; and she could have
occasional contact with the general public.
[A.R. 16.] In reaching this RFC determination, the ALJ
reviewed both objective and opinion evidence submitted in
support of the application. This included references and the
weighing of opinions from State agency medical and
psychological consultants (given some but not great,
evidentiary weight); Dr. Sasikala Vemulapalli, M.D., the
State agency consultative medical examine (given some but not
great, evidentiary weight); Sandra Ringer, LCSW and Dr. John
L. Yarling, M.D., two of Jimenez's treating mental health
providers (given little weight); Robin E. Young, Psy.D, and
James Noll Ph.D (given little weight); and Cindy Sells,
Jimenez's case manager (given little weight). [A.R.
18-19.] Strikingly, the ALJ's written decision does not
discuss by name or substance opinions or findings from Dr.
Albert Lee, Jimenez's treating neurologist, or Gary
Allan, a psychiatric mental health nurse practitioner.
four, the ALJ determined that Jimenez could not perform any
of her past relevant work. At step five, the ALJ considered
the RFC and determined whether Jimenez could perform other
substantial gainful work in the national economy, given her
age, education, work experience and RFC. Here, the ALJ relied
upon testimony from a Vocational Expert to find that Jimenez
could perform multiple office jobs, inspector jobs, and word
processing jobs, including document preparer, table operator
and addressing clerk. [A.R. 20.] As such, Jimenez was found
to be not disabled and her application was denied.
review of the ALJ's decision, including their factual
findings, is generally deferential and the decision will be
upheld unless it is not supported by substantial evidence. 42
U.S.C. § 405(g); Terry v. Astrue, 580 F.3d 471,
475 (7th Cir. 2009). Substantial evidence is “such
relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Schmidt v.
Barnhart,395 F.3d 737, 744 (7th Cir. 2005) (quoting
Gudgel v. Barnhart,345 F.3d 467, 470 (7th Cir.
2003)). My review is guided by the fact that while
“[t]he ALJ is not required to address every piece of
evidence or testimony presented, but must provide a
‘logical bridge' between the evidence and the
conclusions so that we can assess the validity of the
agency's ultimate findings and afford the claimant
meaningful judicial review. Jones v. Astrue, 623
F.3d 1155, 1160 (7th Cir. 2010). In sum, a district court
judge's review in a Social Security disability case is