United States District Court, S.D. Indiana, Terre Haute Division
ORDER ON COMPLAINT FOR JUDICIAL REVIEW
L. PRYOR UNITED STATES MAGISTRATE JUDGE.
Dianna R. 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.
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 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.
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).
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 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).
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 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).]
October 2008, Dianna was hospitalized for ST-elevation with
myocardial infarction. 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, 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.
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).]
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).]
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; mild disc space narrowing, an annular
fissure at ¶ 4-5; 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).]
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
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, lumbosacral
intervertebral disc, and spinal stenosis 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”)
for a month. Dr. Poor also prescribed Talacen for
Dianna's pain. [Dkt. 11-15 at 2-4 (R. 598-600).]
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).]
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 for her pain. [Dkt. 11-15 at 5-7 (R.
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).]
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).]
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 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
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. [Dkt. 11-15 at 14-15 (R. 610-11).]
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