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McClinton v. Berryhill

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

October 9, 2019

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



         Yvette McClinton appeals the Social Security Administration's decision to deny her applications for disability insurance benefits and supplemental security income under Title II and XVI of the Social Security Act. McClinton suffers from several medical issues including degenerative joint disease of the hip, diabetic neuropathy, and obesity. [Tr. 14.][1] An administrative law judge found that McClinton was not disabled and that she had the residual functional capacity (RFC) to perform light work with some restrictions.

         McClinton alleges five claims of error by the ALJ but I will limit my discussion to one: whether the ALJ failed to properly weigh the medical opinion evidence.[2] 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.


         Let's start by looking at the legal framework. My role is not to determine from scratch whether or not McClinton 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. This means that 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 McClinton had the severe impairments of moderate degenerative joint disease changes of the right hip, mild degenerative joint disease of the left hip, osteoarthritis, insulin-dependent diabetes, diabetic neuropathy, obesity, patellar hypertrophy of the right knee, and an adjustment disorder with depressed mood. [Tr. 14.] McClinton suffers from multiple other non-severe impairments, including gastritis, small hiatal hernia, irritable bowel syndrome, hypertension, early endplate spurring of the thoracic spine, and back pain. [Tr. 15.] The ALJ determined that McClinton had the RFC:

to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) where the claimant can sit for six hours of an eight-hour workday, and stand and/or walk for two hours of an eight-hour workday. The claimant can occasionally lift 20 pounds, and frequently lift 10 pounds. The claimant requires an assistive device to walk, but not to stand. The claimant can carry with the non-cane bearing arm. The claimant must avoid climbing ladders, ropes, and scaffolds. The claimant can occasionally balance, stoop, kneel, crouch, and crawl. The claimant is precluded from concentrated exposure to hazardous conditions. The claimant is limited to simple repetitive tasks performed in non-public settings with no more than occasional contact with coworkers and supervisors.

[Tr. 17.]

         In analyzing whether this RFC is proper, my focus will be on the ALJ's handling Dr. John Kelly, McClinton's long-time treating physician. First, I will briefly review the medical evidence in the record, concentrating on those facts particularly pertinent to Dr. Kelly's opinion. In November 2015, Dr. Kelly drafted a medical source statement. By that point in time, Dr. Kelly had been treating McClinton for nearly seven years. [Tr. 492-99.] Dr. Kelly checked boxes on the relevant form, but he also wrote a significant amount of handwritten notes on it as well. Dr. Kelly opined that McClinton was limited to lifting 10 pounds or less occasionally, that she could sit no more than 4 hours in a workday with sitting at one time for 45-60 minutes, and that she could stand/walk at least two hours in a workday and with 10-15 minutes at one time with a cane to stabilize her gait. [Tr. 494-95.]

         The ALJ made the following two main comments about Dr. Kelly's medical source statement:

I give Dr. Kelly's opinion some weight, but not great weight, as it is inconsistent with the totality of the evidence. I recognize that the claimant requires a cane but do not agree that she is limited to lifting only 10 pounds from waist level as a 10 pound restriction is not supported by the objective findings. . . . As for the opinion evidence, I grant little weight to the opinion of Dr. John Kelly, who completed a medical source statement. (Ex. 8F). His opinion is not generally consistent with the medical evidence of record, including the evaluation of Dr. Gillespie in March 2017. (Ex. 17F/5).

[Tr. 19-20, 22.]

         There are a few problems with this lean assessment of Dr. Kelly's opinion. First, the ALJ does not describe how Dr. Gillespie's evaluation on March 14, 2017, is inconsistent with Dr. Kelly's opinion. Dr. Gillespie's notes state that McClinton reported that she has had joint pain for 10 years and she was “in extreme pain now.” [Tr. 922.] McClinton told Dr. Gillespie that her knees pop in and out of their sockets, her hands spasm, her feet turn out, she has noticed swelling in her feet and hands, she reports morning stiffness that lasts 30 minutes, her worst areas of pain include her knees, feet and hands, she has tried Indocin without relief, she has numbness and tingling in her hands and feet, and she has been diabetic for the past 13 years. [Id.] Dr. Gillespie also recorded that McClinton's symptoms included “nausea with vomiting 1 x per day” and GERD. [Id.] Dr. Gillespie's exam included a musculoskeletal exam that showed full range of motion in the upper extremities with no swollen or tender joints in her hands or feet. [Tr. 924.] But it also showed left SI joint tenderness, decreased external rotation at hips worse on the right, and mild crepitus at the knees. [Id.]

         Dr. Gillespie arrived at the following assessment: “[McClinton] has neuropathic symptoms in her hands and feet. . . . I think her symptoms are more consistent with neuropathy than arthritis. However, she does have some hip and knee pain.” [Tr. 924.] Dr. Gillespie then recommended imaging her most symptomatic joints and the joints that were not functioning normally. [Id.] She also noted that x-rays showed osteoarthritis changes in both hips, and right medial joint space narrowing of the knee and patella hypertrophy on ...

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