United States District Court, S.D. Indiana, Indianapolis Division
ORDER ON COMPLAINT FOR JUDICIAL REVIEW
L. Pryor United States Magistrate Judge
Walter R. seeks judicial review of the denial by the
Commissioner of the Social Security Administration
(“Commissioner”) of his application for Social
Security Disability Insurance Benefits (“DIB”)
under Title II of the Social Security Act (“the
Act”). See 42 U.S.C. §§ 423(d),
405(g). For the reasons set forth below, this Court hereby
REVERSES the ALJ's decision denying the
Plaintiff benefits and REMANDS this matter
for further consideration.
October 8, 2014, Walter filed for disability and disability
insurance benefits, alleging that his disability began on
April 15, 2014. Walter asserts that his disability is caused
by shoulder problems, gastroesophageal reflux disease
(GERD), chronic venous
insufficiency, non-insulin dependent type II diabetes,
recurrent cellulitis of the lower left leg, hypertension,
headaches, insomnia, obesity, and depression. Walter's
claim was denied initially and upon reconsideration. Walter
then filed a written request for a hearing on August 12,
2015, which was granted.
1, 2017, Administrative Law Judge (“ALJ”) Albert
J. Velasquez conducted the hearing, where Walter and a
vocational expert testified. On August 29, 2017, ALJ
Velasquez issued an unfavorable decision finding that Walter
was not disabled as defined in the Act. On February 13, 2018,
the Appeals Council denied Walter's request for review of
this decision, making the ALJ's decision final. Walter
now requests judicial review of the Commissioner's
decision. See 42 U.S.C. § 1383(c)(3). On August
7, 2019, the Court held oral argument.
Standard of Review
prove disability, a claimant must show he 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, a claimant's
impairments must be of such severity that he is not able to
perform the work he previously engaged in and, based on his
age, education, and work experience, he 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 [him] unable to perform [his] 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 his 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 Walter 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 42 years old at the time of the alleged onset date in
2014. [Dkt. 5-3 at 2 (R. 54).]. He obtained his General
Educational Development (“GED”) in 2012 followed
by eight months of college courses at Ivy Tech. [Dkt. 5-2 at
40-41 (R. 39-40).] The Plaintiff last engaged in substantial
gainful activity in April 2014 when he worked as a mechanic
for Pep Boys. [Dkt. 5-2 at 39 (R.38).].
March 1, 2012, Walter went to the emergency department at St.
Vincent hospital complaining of lower left leg cellulitis.
While at the hospital, the medical staff performed an
ultrasound of the legs, which revealed no evidence of deep
vein thrombosis (“DVT”) but some abnormality with a
lymph node. The staff administered an IV for Walter and his
condition improved. Walter was released from St. Vincent the
next day. [Dkt. 5-10 at 58-78 (R. 496-521).]
April 17, 2013, Walter visited IU Health Methodist Hospital
emergency room complaining of severe dental pain, including
swelling, redness, and bleeding of the mouth. The medical
staff noted Walter reported having a headaches and his
history of hypertension. He was given over-the-counter pain
medication and instructions to visit a dentist. [Dkt. 5-8 at
11-13 (R. 285-87).]
6, 2013, Walter visited Dr. Mark Freije at Westfield Primary
Care. Dr. Freije noted that Walter was not taking
hypertension medication, that he reported issues with daily
fatigue and sleeping, and that he was experiencing chronic
joint pain in his shoulder. Dr. Freije also noted that Walter
had developed a skin rash. At the conclusion of the visit,
Dr. Freije placed Walter on hypertension medication and
prescribed him testosterone for his fatigue and a topical
cream for his rash. [Dkt. 5-7 at 27-29 (R. 238-40).]
August 12, 2014, Walter presented to IU Health Methodist
Hospital emergency department complaining of lower left
extremity pain, erythema,  and swelling. He stated that his pain
was a 10 out of 10 and that he had a fever as high as 103
degrees. Medical personnel noted that at the time of his
visit Walter did not have a fever and that his pain
eventually subsided to a 3 or 4 out of 10. Walter notified
staff that he had visited the emergency room about 20 times
in the last 15 years for the same symptoms. He was diagnosed
with recurrent cellulitis and the doctor noted a history of
hypertension and GERD. [Dkt. 5-8 at 14-24 (R. 288-98).] The
next day, Walter had a venous duplex scan performed on his
legs, which indicated that there was no evidence of DVT in
either leg. [Dkt. 5-8 at 41 (R. 315).] There were some issues
with the lymph nodes in his left leg, but the scan was
otherwise unremarkable and unchanged from scans performed in
February 2012 and October 2011. [Id.] Walter was
discharged the next day with antibiotics and a recommendation
to follow up with his primary care physician. [Dkt. 5-8 at
14-24 (R. 288-98).]
September 6, 2014, Walter presented to the IU Health
Methodist Hospital emergency room complaining of shortness of
breath and chest pain. His initial examination was normal and
showed no signs of abnormalities. [Dkt. 5-8 at 46 (R. 320).]
Dr. Jeffrey Mossler performed an electrocardiogram
(“EKG”), which was normal, [Dkt. 5-8 at 42 (R.
316).] and Dr. Jessica Smith performed a chest x-ray, which
was also normal. [Dkt. 5-7 at 14 (R. 225).] Walter was later
September 17, 2014, Walter visited Dr. Keith Banks at
Infectious Disease of Indiana, P.S.C. because he was
continuing to struggle with lower extremity cellulitis. Dr.
Banks noted Walter's previous diagnoses of obesity,
hypertension, hyperlipidemia,  and borderline diabetes. Dr.
Banks also noted that Walter suffered from lower leg
edema and that this likely contributed to his
issues with cellulitis. Dr. Banks suggested not using chronic
suppressive antibiotics and instead focusing on controlling
Walter's edema. Dr. Banks requested for Walter to return
to the clinic in a month. [Dkt. 5-7 at 3-4 (R. 214-15).]
mid-September 2014, Walter visited Dr. Freije for an
examination of his legs. Contrary to Dr. Banks's
recommendation, Dr. Freije recommended putting Walter on
suppressive antibiotic therapy. Dr. Freije also provided
Walter with prescription grade medical compression stockings
for below his knee. [Dkt. 5-8 at 33-40 (R. 307-14).]
days later, Walter participated in a treadmill stress test
with Dr. Harvey Feigenbaum at IU Health Methodist Hospital.
The test consisted of incline walking and was terminated
after nine minutes due to leg fatigue. Dr. Feigenbaum
concluded that the stress test results were normal. [Dkt. 5-8
at 43-45 (R. 317-19).]
October 16, 2014 Walter visited Dr. Freije for a routine
checkup. This was a quick visit, and Walter was directed to
maintain his current treatment plan and return to Dr. Freije
on October 27, 2014. [Dkt. 5-7 at 20-22 (R. 231-33).] On
October 27, 2014, Walter returned to Dr. Freije reporting
concerns with small sores on the bottom of his left foot.
According to Walter, in the past, similar sores had turned
into cellulitis. Dr. Freije noted that Walter continued to
struggle with hypertension, edema, skin rashes, GERD,
shoulder pain, fatigue, and mild depressive episodes. Dr.
Freije gave Walter a new dosage for his heart medications,
new medication for his mild depression, and medication for
the sores on his feet. His edema was noted to be stable.
[Dkt. 5-7 at 17-19 (R. 228-30).]
November 22, 2014, Walter returned to Dr. Freije because the
topical cream prescribed to him in May for his skin rash was
not working. Upon examination, Dr. Freije determined that the
rash was a reaction to grease that Walter was encountering as
a mechanic and altered Walter's medication accordingly.
[Dkt. 5-7 at 27-29 (R. 238-240).]
December 16, 2014, Walter returned to Dr. Freije because he
was experiencing chest pain. Dr. Freije diagnosed
Walter's pain as pleurisy and gave him medication to
resolve this issue. Dr. Freije also noted Walter's
restless leg syndrome and gave him medication for it. [Dkt.
5-7 at 55-58 (R. 266-69).]
January 8, 2015, Walter visited Dr. Andrew Cunningham at IU
Health Family Medicine and Internal Medicine South because
Dr. Freije was no longer covered by Walter's insurer.
[Dkt. 5-8 at 33 (R. 307).] Dr. Cunningham diagnosed Walter
with hypertension, a ganglion cyst, obstructive sleep apnea,
and chronic insomnia. Walter was prescribed antibiotics and
anti-anxiety medication. [Dkt. 5-8 at 28-32 (R. 302-06).]
January 2015, Walter completed a headache questionnaire.
[Dkt. 5-6 at 18 (R.166).] Walter claimed to have been
suffering from migraine headaches since April 2012. He
reported experiencing migraines approximately three times per
week, which would last anywhere from three hours to all day.
He also represented that during a headache he would lay down
in a dark quiet room for a few hours, or longer, if needed.
[Dkt. 5-6 at 18 (R. 166).]
January 27, 2015, Walter was examined by consultative
examiner (“CE”) Dr. Diane Elrod of the Indiana
State Disability Determination Bureau. Dr. Elrod noted that
there were no rashes or other issues with Walter's skin,
his body systems were normal, his lower extremities had good
range of motion and were not swollen. His gait was stable and
within normal limits, but he was not able to walk on his toes
or on his heels or perform a squat without difficulty. [Dkt.
5-8 at 48-52 (R. 322-26).]
February 10, 2015, state agency physician Dr. Brill reviewed
Walter's medical history and Dr. Elrod's CE report.
Dr. Brill concluded that Walter was not disabled and denied
Walter's application at the initial level. [Dkt. 5-3 at
2-10 (R. 54-62).]
March 19, 2015, Walter returned to Dr. Freije for what
appears to be a follow up appointment after he had fallen off
a ladder and fractured his ribs earlier in the
month. His prescriptions for pain medications
had expired, so he was given new pain medications. Other than
pain management, Walter was doing well overall and his
insomnia and restless leg syndrome had improved. [Dkt. 5-8 at
85-89 (R. 359-63.]
12, 2015, Walter returned to Dr. Freije for another checkup.
At the appointment, Walter noted that his rib pain was
better, but that many of his other chronic conditions were
either the same or getting worse. Specifically, his shoulder
pain and restless leg syndrome had worsened. [Dkt. 5-9 at
24-28 (R. 392-96).]
August 7, 2015, Walter presented to the emergency department
of IU Health Methodist complaining of lower left extremity
symptoms. He complained of recurrent cellulitis with pain in
his groin and swelling and redness in his left leg. Dr. Jason
Schaffer noted that Walter's exam was “quite
unremarkable, ” and that Walter had minimal redness and
no swelling in his legs. Walter was discharged and instructed
to follow up with his primary care doctor in a few days.
[Dkt. 5-10 at 52- 57 (R. 490-95).]
February 23, 2016, Walter sought treatment from Dr. Freije
because of left hip pain that he experienced while walking.
He indicated that he had no pain in the past and nothing
popped, but that the pain developed when he walked. Dr.
Freije noted that Walter had no swelling or bruising but that
he did have decreased range of motion in his left hip and was
ambulating with a limp. [Dkt. 5-9 at 17-20 (R. 385-88).] An