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Rayford v. Berryhill

United States District Court, N.D. Indiana, Hammond Division

September 30, 2019

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.



         Theresa Rayford appeals the Social Security Administration’s decision to deny her application for supplemental security income disability benefits. Rayford suffers from several medical issues including obesity, hypertension, breast cancer, and transient ischemic attack (a stroke that only lasts a few minutes). [Tr. 17, 220.][1] An administrative law judge found that Rayford 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 restrictions.

         Rayford challenges the ALJ’s decision on three grounds: her mental limitations were not properly evaluated; the ALJ erred in evaluating the medical opinion evidence; and the ALJ erred in evaluating her subjective allegations, or credibility. Because I find the ALJ’s analysis of the medical opinion evidence is flawed, I will REVERSE the ALJ’s decision and REMAND on this issue.


          In looking at the legal framework, my role is not to determine from scratch whether or not Rayford 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. In fact, 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).

         The ALJ found that Rayford had the severe impairments of obesity, hypertension, breast cancer, transient ischemic attack, adjustment disorder with anxiety, and substance use disorder. [Tr. 17.] She determined that Rayford had the RFC:

to perform light work as defined in 20 CFR 416.967(b) except no climbing ladders, ropes, or scaffolding; occasional balancing, stooping, kneeling, crouching, crawling, and climbing ramps and stairs; no concentrated exposure to hazards, defined as work at unprotected heights; and the work should involve only simple instructions, routine, repetitive tasks, and no more than occasional changes in the workplace setting.

[Tr. 19-20.]

         In analyzing whether this RFC is proper, my focus will be on the ALJ’s handling of the examining source opinion of Dr. Amer S. Sidani, Rayford’s treating oncologist. First, let’s briefly review the medical evidence in the record, concentrating on the evidence relating to Rayford’s physical issues (and not psychological), since this largely relates to the analysis of Dr. Sidani’s opinion.

         The first medical event in the record is a controversial one. From June 21-23, 2014, Rayford was in the hospital for “altered mental status” after complaints of slurred speech and trouble speaking and not responding accordingly. [Tr. 299, 325.] Although Rayford and her counsel refer to this event as a stroke, she was not actually diagnosed with a stroke for this incident - her speech returned to normal in the emergency room and testing showed that she was intoxicated with alcohol. [Tr. 299, 330, 333, 338.] An MRI revealed “the patient has an old stroke” but the staff specifically “rule[d] out new onset of stroke.” [Tr. 332, 334.] Rayford was diagnosed with dysarthria and anemia, and she was discharged after a few days in the hospital. [Tr. 299-300.]

         On February 28, 2015, state agency consultative examiner Dr. Jao recorded that Rayford had a limited ability to bend and stoop, frequent dizziness, headaches, blurred vision, a slight stutter, change in mood, memory loss, memory problems, poor concentration, obesity, abnormal coordination, unsteady-walk, an ataxic gait, was unable to walk heel to toe tandemly, and had difficulty standing from a sitting position, stooping, squatting, and getting on and off the examination table. [Tr. 384-86.] Rayford had reduced strength in her upper and lower extremities, and her strength was rated 3 out of 5, her reflexes were rated at 2/4, but the range of motion was normal throughout her extremities. [Tr. 386-87.]

         On March 2, 2015, state agency physician Dr. Sands reviewed the existing medical evidence, including Dr. Jao’s report. [Tr. 85.] Dr. Sands opined Rayford had the ability to perform activities consistent with light work (as defined at 20 C.F.R. § 416.967(b)), with only occasional balancing, stooping, kneeling, crouching, crawling; only occasional climbing of ramps/stairs; no climbing of ropes/ladders/scaffolds; and the avoidance of concentrated exposure to unprotected heights. [Tr. 83-85.] The ALJ gave this opinion “great weight, ” even though acknowledging that the medical record was developed after this opinion (which is an issue I’ll discuss later). [Tr. 23.]

         The state agency physician, Dr. Corcoran, reviewed the available evidence on July 6, 2015. [Tr. 97.] Dr. Corcoran agreed with Dr. Sands’ opinion regarding Rayford’s physical functional limitations. [Tr. 95-99.] Again, the ALJ gave this great weight. [Tr. 23.]

         Rayford was hospitalized again in August 2015 for 2 days, complainting of blurred vision, mild headache, and difficulty ambulating for two to three weeks. [Tr. 539.] Her history was described in the medical records as “[h]ad an old CVA without any residual deficit.” [Id.] A CT scan showed “cortical and subcortical infarcts which appear old.” [Tr. 521.] She had hypertension and was kept on ...

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