Jimenez v. Berryhill

          OPINION AND ORDER

          PHILIP P. SIMON, UNITED STATES DISTRICT COURT JUDGE

         Laura 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.

         Background

         In her 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 regulations.

         At step 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.^[1]

         At step 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 404.1509. [Id.]

         Based 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.

         At step 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.

         Discussion

         My 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 ...