United States District Court, N.D. Indiana, South Bend Division
SHEILA D. SMITH, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.
OPINION AND ORDER
P. SIMON, UNITED STATES DISTRICT JUDGE.
Smith appeals the Social Security Administration's
decision to deny her application for disability insurance
benefits and supplemental security income - both applications
alleging disability beginning May 10, 2014. Smith suffers
from several serious medical issues including degenerative
disc disease of the cervical and lumbar spine. [Tr.
An administrative law judge determined Smith was not disabled
within the meaning of the Social Security Act and that she
had the residual functional capacity (RFC) to perform light
work with some additional postural limitations. Although she
could not perform her past work, the ALJ found that Smith
could perform other jobs such as electronics worker,
production assembler, and small products assembler.
argues that the ALJ erred in relying on the state agency
physicians who did not consider nearly two years of medical
records. Because I find that over two hundred pages of
medical evidence, spanning a time frame of two years, was not
examined by the state agency physicians, and the ALJ
improperly weighed this evidence by herself, I will REVERSE
the ALJ's decision and REMAND on this
found that Smith has the following severe impairments:
degenerative disc disease of the cervical and lumbar spine,
osteoarthritis in her left hip, mild osteoarthrisits of the
bilateral knees, diabetes, and bursitis of the bilateral
shoulders. [Tr. 13-14.] Additionally, Smith also suffers from
fibromyalgia which the ALJ found to be a non-medically
determinable impairment pursuant to SSR 12-2p, and the
non-severe impairments of overactive bladder and mental
impairments of depression and anxiety, which are fully
recounted in the ALJ's opinion and need not be repeated
here. [Tr. at 14-16.]
reviewing the evidence, let's start with an overview of
the legal framework. My role is not to determine from the
beginning whether or not Smith is disabled. Rather, I only
need to determine whether the ALJ applied the correct legal
standards and whether the decision is supported by
substantial evidence. See 42 U.S.C. § 405(g);
Shideler v. Astrue, 688 F.3d 306, 310 (7th Cir.
2012); Castile v. Astrue, 617 F.3d 923, 926 (7th
Cir. 2010); Overman v. Astrue, 546 F.3d 456, 462
(7th Cir. 2008). My review of the ALJ's decision is
deferential. This is because the “substantial
evidence” standard is not particularly demanding. The
Supreme Court announced long ago that the standard is even
less than a preponderance-of-the-evidence standard.
Richardson v. Perales, 402 U.S. 389, 401 (1971). Of
course, there has to be more than a “scintilla”
of evidence. Id. So in conducting my review, I
cannot “simply rubber-stamp the Commissioner's
decision without a critical review of the evidence.”
Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir.
2000). Nonetheless, the review is a light one and the
substantial evidence standard is met “if a reasonable
person would accept it as adequate to support the
conclusion.” Young v. Barnhart, 362 F.3d 995,
1001 (7th Cir. 2004).
qualms with the ALJ's opinion largely center on Listing
1.04, which involves disorders of the spine - so my review of
her medical history will concentrate on the same. Back in
December 2010, Smith had right-sided lower back pain
extending to her legs, and an MRI showed probable recurrent
disc extrusion and degenerative disc disease at ¶ 4-5
and L5-S1 and associated facet joint spondylosis, and
conjoined origin of the L5 and S1 nerve root sleeves. [Tr.
problems increased after a workplace accident in October
2012, where a metal bar on a trash bin came down on her head,
resulting in shoulder and neck pain. [Tr. 433.] Following the
incident, Smith had a CT cervical spine exam which showed
bulging disc material with endplate osteophytic ridging
producing mild stenosis of the canal along with mild facet
degenerative changes at the C5-6 canal. [Tr. 448.] The C6-7
canal was also narrowed due to a bulging disc with
“[m]ild cervical degenerative changes resulting in only
mild stenosis of the canal, predominantly at the C5-6
saw Dr. Douglas Streich on December 4, 2013, for a social
security disability evaluation. [Tr. 471-76.] Dr. Streich
found Smith suffered from major depressive disorder, anxiety
disorder, spinal stenosis, diabetes, hyperlipidemia, chronic
pain issues, and being overweight. [Tr. 475.] Dr. Streich
opined that Smith's depression stemmed from chronic pain
January 14, 2014, Smith had multiple x-rays, including one of
her lumbar spine. The x-ray showed a severe narrowing of the
L5-S1 disc space with some mild anterior and posterior
osteophyte formation. [Tr. 492.] In interpreting the x-ray,
Dr. Jonathan Kraas opined that Smith had degenerative disc
disease at the L5-S1 and noted degenerative changes in the
S-I joints as well. [Id.]
bad luck continued. On February 19, 2014, she slipped and
fell backwards, causing more back and hip pain. A doctor in
the emergency room noted a chronic deformity of the proximal
femur and left hip contusion. [Tr. 509-10.] Bilateral
shoulder pain was another malady Smith suffered, and Dr.
Clemency commented that it was severe and originating from
her cervical spine. [Tr. 525.]
unsuccessful therapy, Smith had an MRI on November 14, 2014,
which Dr. George DePhillips, a neurosurgeon, interpreted as
Smith having a bulging disc and protrusion at the C5-C6
level, and “[t]here may be mild nerve root
impingement” at the S1 level. [Tr. 590-91.]
March 26, 2015, Smith started pain management with Dr. Ajit
Pai. [Tr. 605.] Dr. Pai administered nerve blocks and
epidural steroid injections which provided some relief, but
Smith was still experiencing pain, including lower back pain.
[Tr. 647-48; 649; 657-58; 665-66.] Dr. Pai also prescribed
medication to Smith including Oxycodone. [Tr. 700.]
agency consultants reviewed Smith's medical records - Dr.
Corcoran on January 16, 2015, and Dr. Ruiz on April 30, 2015.
Both of these doctors specifically mentioned, and
specifically considered Listing 1.04, but found that Smith
did not meet or equal that Listing. [Tr. 102-105; 123-25.]
The consultants assessed Smith with the ability to perform
medium work, which the ALJ gave “little weight”
because she found the evidence received at the hearing level
supported limiting Smith to work at the light level of
exertion instead. [Tr. 20.] However, the ALJ did adopt the
state agency consultant's determinations that Smith did
not meet or equal the requirements of Listing 1.04. [Tr.
102-05; 123-25.] ...