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Smith v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

August 29, 2019

SHEILA D. SMITH, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.



         Sheila 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. 13.][1] 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.

         Smith 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 issue.


         The ALJ 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.]

         Before 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).

         Smith's 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. 388.]

         Smith's 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 level.” [Id.]

         Smith 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 issues. [Id.]

         On 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.]

         Smith's 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.]

         Following 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.]

         On 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.]

         Two 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.] ...

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