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Walter R. v. Saul

United States District Court, S.D. Indiana, Indianapolis Division

August 12, 2019

WALTER R., Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.


          Doris L. Pryor United States Magistrate Judge

         Plaintiff Walter R.[1] 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.

         I. Procedural History

         On 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)[2], chronic venous insufficiency[3], non-insulin dependent type II diabetes, recurrent cellulitis[4] 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.

         On May 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.

         II. Standard of Review

         To 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 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 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).

         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 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).

         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. Background

         A. Factual Background

         Walter 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).].

         B. Medical History

         On 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”)[5] 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.[6] [Dkt. 5-10 at 58-78 (R. 496-521).]

         On 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).]

         On May 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).]

         On August 12, 2014, Walter presented to IU Health Methodist Hospital emergency department complaining of lower left extremity pain, erythema, [7] 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).]

         On 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 discharged. [Id.]

         On 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, [8] and borderline diabetes. Dr. Banks also noted that Walter suffered from lower leg edema[9] 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).]

         In 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).]

         A few 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).]

         On 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).]

         On 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).]

         On December 16, 2014, Walter returned to Dr. Freije because he was experiencing chest pain. Dr. Freije diagnosed Walter's pain as pleurisy[10] 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).]

         On 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).]

         In 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).]

         On 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).]

         On 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).]

         On 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.[11] 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.]

         On June 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).][12]

         On 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).]

         On 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 x-ray ...

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