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Dianna R. v. Saul

United States District Court, S.D. Indiana, Terre Haute Division

August 29, 2019

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



         Plaintiff Dianna R.[1] seeks judicial review of the denial by the Commissioner of the Social Security Administration (“Commissioner”) of her 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 August 7, 2014, Dianna filed a Title II application for a period of disability and disability insurance benefits, alleging that her disability began on June 3, 2010. Dianna asserts that her disability is caused by comorbid impairments including coronary artery disease with congestive heart failure, lumbar degenerative disk disease[2] with significant back, hip, and radicular leg pain, and depression. Dianna's claim was denied initially and upon reconsideration. Dianna then filed a written request for a hearing, which was granted.

         Administrative Law Judge (“ALJ”) Roy E. LaRoche, Jr. conducted a video hearing on July 24, 2017, where Dianna and a vocational expert testified. After the hearing, Dianna amended her alleged onset date of disability from June 3, 2010 to November 9, 2013. On August 15, 2017, ALJ LaRoche issued an unfavorable decision finding that Dianna was not disabled as defined in the Act. On June 1, 2018, the Appeals Council denied Dianna's request for review of this decision, making the ALJ's decision final. Dianna now requests judicial review of the Commissioner's decision. See 42 U.S.C. § 1383(c)(3).

         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 Dianna 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

         Dianna was 54 years old at the time of her date of last insured in December 2015. [Dkt. 11-2 at 19 (R. 18).] She has a high school education, [Dkt. 11-2 at 38 (R. 37), ] and last engaged in substantial gainful activity in 2010 when she worked as a cafeteria worker for Compass Group. [Dkt. 11-2 at 39 (R. 38).]

         B. Medical History

         In October 2008, Dianna was hospitalized for ST-elevation with myocardial infarction[3]. She ultimately underwent bypass surgery and valve replacement on October 14, 2008. [Dkt. 11-11 at 67-68 (R. 478-79).] After her surgery, Dianna was prescribed Coumadin[4], a blood-thinner, that she continues to take today, and she started being seen in an anticoagulation clinic at Premier Healthcare. [Dkt. 11-9 at 7-48 (R. 334-75).]

         On November 20, 2014, State Agency physician Dr. Jason Fish conducted a consultative physical examination of Dianna for the purpose of establishing disability. [Dkt. 11-9 at 3-6 (R. 330-33).] Dr. Fish observed that Dianna appeared underweight; had tenderness to palpation/squeeze in the lower back; had a stooped posture; an antalgic gait; moderate pain in the lower back when walking on her heels and toes; and her squat was limited by back pain. After the physical examination, Dr. Fish concluded Dianna was able to stand and walk at least two out of eight hours of the day and carry at least 20 pounds. [Dkt. 11-9 at 3-5 (R. 330-32).]

         On November 24, 2014, State Agency physician Dr. Joshua Eskonen reviewed Dianna's medical history. Dr. Eskonen concluded that Dianna was not disabled and denied Dianna's application at the initial level. [Dkt. 11-3 at 2-12 (R. 57-67).] Subsequently, on March 16, 2015, State Agency physician Dr. M. Brill reviewed Dianna's medical history and determined she was not disabled at the reconsideration level. [Dkt. 11-3 at 14-26 (R. 69-81).]

         On June 16, 2015, Dianna began seeing Internal Medicine Specialist Dr. Eric Bannec in order to establish primary care. After the first visit, Dr. Bannec promptly ordered a lumbar spine MRI, which was done on June 30, 2015. The MRI exam revealed degenerative disc disease[5]; mild disc space narrowing, an annular fissure at ¶ 4-5[6]; disc bulge at ¶ 2-3; moderate right and mild left facet arthropathy, and mild central canal stenosis at ¶ 3-4; moderate right neuroforaminal narrowing with possible impingement at right L3 nerve root. [Dkt. 11-15 at 38-39 (R. 634-35).]

         After reviewing her MRI, on July 29, 2015, Dr. Bannec referred Dianna to Dr. Marshall Poor for a neurosurgical consultation and prescribed physical therapy and Meloxicam to manage the pain. [Dkt. 11-16 at 19-22 (R. 657-60).] On August 26, 2015, Dianna returned to Dr. Bannec for a regular check-up. He noted that she continued to have significant lower back pain and prescribed Gabapentin for the pain. [Dkt. 11-16 at 16-18 (R. 654-56).]

         On September 24, 2015, Dianna attended her first appointment with Dr. Poor. [Dkt. 11-15 at 2 (R. 598).] Dr. Poor evaluated her back, right groin, and bilateral L5 radicular pain. Dr. Poor reviewed the June 30, 2015 lumbar spine MRI. [Id.] During the physical examination, Dr. Poor noted that Dianna had very limited flexion and extension in her back, a normal gait, and normal reflexes in the lower extremities. [Dkt. 11-15 at 2-4 (R. 598-600).] Dr. Poor diagnosed Dianna with displacement and degeneration of lumbar intervertebral disc without myelopathy[7], lumbosacral intervertebral disc, and spinal stenosis[8] in the lumbar region. [Id.] For treatment, Dr. Poor did not think Dianna would handle injections well due to her mechanical heart valve and because she regularly took Coumadin, and instead recommended that she try a trial of Transcutaneous Electrical Nerve Stimulation (“TENS”) unit[9] for a month. Dr. Poor also prescribed Talacen for Dianna's pain. [Dkt. 11-15 at 2-4 (R. 598-600).]

         On October 13, 2015, Dianna returned to Dr. Bannec for a routine check-up. Dianna was taking Meloxicam, Neurontin, Pentazosine, and undergoing physical therapy to manage her pain. [Dkt. 11-16 at 13-15 (R. 651-53).]

         In his November 12, 2015 examination, Dr. Poor noted that Dianna's L4-5 disk herniation may possibly be causing her L5 radicular pain. He recommended surgery, but noted that Dianna was still not interested given her cardiac problems. During this visit, Dianna's gait was antalgic. This was a significant change from the September 2015 visit and suggestive of Dianna's attempt to avoid pain while walking. All other findings during the physical examination were similar to her prior visits. Dr. Poor prescribed Talwin NX[10] for her pain. [Dkt. 11-15 at 5-7 (R. 601-03).]

         On April 4, 2016, Dianna saw Dr. Bannec for a routine follow-up. Her medications and treatment plan remained the same. [Dkt. 11-16 at 9-12 (R. 647-50).] On April 28, 2016, Dianna returned to Dr. Poor, who noted that Dianna's physical examination reported normal findings. Dr. Poor maintained Dianna's prescription of Talwin NX, as it had provided Dianna with some temporary relief from her pain. [Dkt. 11-15 at 8-10 (R. 604-06).]

         On August 2, 2016, Dr. Poor met with Dianna again and noted the same findings as in previous examinations. He did note that she had some right hip bursitis and cautioned against a long-term use of narcotic medication, but renewed her prescription for Talwin NX because it had provided pain relief. [Dkt. 11-15 at 11-13 (R. 607-09).]

         On October 11, 2016, Dianna attended her six-month follow up with her primary care doctor, Dr. Bannec. Dr. Bannec ordered her a new prescription of pain medication and noted that Dianna had been seen by Dr. Ferguson for an ankle-brachial index/stress ABI[11] test which showed minimal disease. Her atypical lower extremity claudication had improved, and the remainder of the examination was normal. [Dkt. 11-16 at 5-8 (R. 643-46).]

         During her February 14, 2017 visit with Dr. Poor, he noted that Dianna had developed some problems with weakness, pain, and heaviness in her legs when walking. He believed this to be vascular claudication[12]. [Dkt. 11-15 at 14-15 (R. 610-11).]

         On April 26, 2017, Dr. Bannec evaluated Dianna for her six-month follow-up and completed a disability medical source statement at that time. [Dkt. 11-16 at 2-4 (R. 640-42).] All of his findings were normal and in line with the previous visits. [Id.] In his medical source statement, under diagnosis, Dr. Bannec listed lumbosacral disc disease and a mechanical heart valve in the context of coronary artery disease. [Dkt. 11-15 at 30-34 (R. 626-30).] When explaining Dianna's symptoms, Dr. Bannec identified chronic back pain that was worse with sitting or standing for too long. [Id. at 30 (R. 626).] He indicated that Dianna's impairments had lasted or could be expected to last at least ...

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