Little v. Commissioner of Social Security

Filing 14

OPINION: Plaintiff's Motion for Summary Judgment 6 is ALLOWED. The Defendant's Motion for Summary Judgment 10 is DENIED. The Commissioner's Decision is Reversed and the action is Remanded for a new decision. (SEE WRITTEN OPINION) Entered by Judge Richard Mills on 6/16/2016. (GL, ilcd)

E-FILED

Friday, 17 June, 2016 09:57:59 AM
Clerk, U.S. District Court, ILCD

IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION
BETHANY DARLENE LITTLE,
Plaintiff,
v.
CAROLYN W. COLVIN, ACTING
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

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No. 13-3100

OPINION
RICHARD MILLS, U.S. District Judge:
Following the denial of her application for supplemental security
income benefits, Bethany Darlene Little filed this action for judicial review
pursuant to 42 U.S.C. § 405(g).
Pending before the Court are her Motion for Summary Judgment and
the Commissioner’s Motion for Summary Affirmance.
I. INTRODUCTION
On May 7, 2010, the Plaintiff filed an application for supplemental
security benefits which was denied initially and also upon reconsideration.

The Plaintiff requested an administrative hearing.
On September 16, 2011, a hearing was held before Administrative
Law Judge (“ALJ”) Shreese M. Wilson. On November 30, 2011, the ALJ
found the Plaintiff not disabled. The Appeals Council denied the Plaintiff’s
request for review on February 14, 2013, and this action followed.
The Plaintiff was born in 1964 and was 45 years old at the time of her
alleged onset date. She has an eleventh grade education. The Plaintiff’s
past relevant work was as a housekeeping cleaner and bagger. The ALJ
concluded that Plaintiff cannot perform any of her past relevant work.
II. FACTUAL BACKGROUND
A. Medical evidence
(1) Graham Hospital
X-rays of the Plaintiff’s lumbar spine dated February 7, 2010 revealed
findings consistent with mild lumbar spondylosis. A lumbar spine MRI
dated February 22, 2010 revealed a moderately large left posterolateral disc
extrusion at L3-L4 compressing the thecal sac as well as the left L4 nerve
root.

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(2) Patrick Renick, M.D.–Treating Family Practitioner
Dr. Renick is board certified in family medicine. In a letter dated
August 26, 2010, Dr. Renick wrote that Plaintiff suffered from herniated
discs at L3-L4 and L4-L5 which resulted in compression of the L4 nerve
root. He noted that without surgical correction–which the Plaintiff could
not afford–her pain and disability would likely continue for at least one
year.
On August 26, 2010, the Plaintiff reported leg pain related to a
herniated disc. She received some relief with Neurontin. The Plaintiff
noted recent migraines, hypertension and hypothyroidism. The doctor’s
physical examination revealed pain on extension of the back and a positive
straight-leg raising test on the left. Dr. Renick diagnosed a left-sided
lumbar disc herniation, migraines, hypertension and hypothyroidism and
prescribed Flexeril for her symptoms.
Following the examination on August 26, 2010, Dr. Renick diagnosed
the Plaintiff with a disc herniation and radiculopathy. His clinical findings
included left leg pain and the MRI showed findings consistent with disc

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herniation. The Plaintiff’s primary symptoms included lower back pain
that radiated into the leg and worsened with movement. Dr. Renick found
the symptoms and limitations had been present since June of 2009.
Dr. Renick opined that Plaintiff was limited to sitting for up to two
hours total, standing/walking for up to one hour total and occasionally
lifting up to five pounds during an eight-hour workday. She had significant
limitations in doing repetitive reaching, handling, fingering or lifting due to
an exacerbation of pain with lifting or overhead activity. The doctor noted
moderate bilateral limitations in using the arms for reaching. The Plaintiff
was referred to neurosurgery but could not pursue treatment as she lacked
insurance. Dr. Renick found that Plaintiff would likely be absent from
work more than three times per month because of her impairments. He
found she was unable to push, pull, kneel, bend and stoop on a sustained
basis.
On September 29, 2010, Dr. Renick observed that Plaintiff’s
symptoms were not relieved with medication management and therapeutic
exercises. He noted the results of the February MRI and again observed

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she would be disabled indefinitely without neurosurgical intervention. The
Plaintiff reported on September 30, 2010 that Flexeril was not helpful and
only put her to sleep. Dr. Renick prescribed Ultram and continued her
prescription for Neurontin.
On December 17, 2010, Dr. Renick completed a second Multiple
Impairment Questionnaire and diagnosed the Plaintiff with herniated disc
syndrome. His clinical findings included left low back pain with radiation
into the leg and he noted an MRI that showed a lesion at the appropriate
nerve root to explain the Plaintiff’s symptoms. The Plaintiff’s primary
symptoms included only daily pain in the low back that radiated into the
left leg and worsened with sitting or standing. The doctor concluded that
the symptoms and limitations described in the questionnaire had been
present since October 15, 2009.
Dr. Renick was of the opinion that Plaintiff was limited to sitting for
up to one hour total, standing/walking for up to one hour total and
occasionally lifting up to five pounds during an eight-hour workday. He
believed her symptoms were severe enough to constantly interfere with

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attention and concentration and he further noted that she suffered from
depression at times. The doctor found that Plaintiff would likely be absent
from work more than three times per month because of her impairments.
He precluded her from pushing, pulling, kneeling, bending and stooping on
a sustained basis.
On January 13, 2011, the Plaintiff reported that she was falling out
of bed while sleeping but otherwise doing well. Dr. Renick diagnosed
morbid obesity and renewed the Plaintiff’s prescription for Neurontin. On
March 31, 2011, the Plaintiff advised she had recently been hospitalized for
five days due to depression and placed on Prozac. The Plaintiff also
reported neck pain radiating into the arm. Dr. Renick advised her to
continue counseling and he placed her back on Flexeril for the neck pain.
On April 28, 2011, the Plaintiff returned with left arm numbness over
the previous month that worsened with overhead activity and was
associated with tingling. Dr. Renick diagnosed her with paresthesias and
prescribed Prednisone. On May 26, 2011, the doctor noted that Plaintiff’s
paresthesias were short-lived and not a serious problem. On June 23, 2011,

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the Plaintiff reported feeling “pretty good” but still suffered from leg pain.
Her depression was improved with Prozac. Dr. Renick diagnosed her with
chronic lower back pain and stable depression. On July 28, 2011, the
Plaintiff presented with pain in both knees and back spasms with pain
radiating down the legs. She declined a muscle relaxer. Dr. Renick advised
her to perform extension exercises.
(3) Daniel Fassett, M.D.–Examining Neurosurgeon
On April 1, 2010, the Plaintiff presented to Dr. Fassett, a board
certified neurosurgeon, for a neurosurgery consultation.

She reported

severe pain radiating down her left leg over the previous four months with
numbness, tingling and difficulty walking. Her treatment consisted only of
Neurontin.
Dr. Fassett’s physical examination noted the Plaintiff was 5'3'’ and
weighed 218 pounds. He found her strength was full but difficult to assess
due to pain in the left lower extremity. Dr. Fassett noted compression of
the L4 nerve root by the recent MRI. The doctor advised the Plaintiff to
pursue conservative options before considering surgery.

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(4) Methodist Medical Center of Illinois
On March 11, 2011, the Plaintiff was admitted to Methodist Medical
Center of Illinois with depression and suicidal ideation. She reported
calling the sheriff’s department because she wanted to overdose on her
medications. The Plaintiff expressed increasing depression due to her
financial situation. Upon admission, she began attending therapy sessions
and was started on Prozac as well. The Plaintiff’s condition improved and
on March 16, 2011, she was discharged with a diagnosis of depression, not
otherwise specified, and her GAF was rated at 60.1 She was advised to
continue psychotherapy sessions at the Canton Health and Wellness
Center.
B. Plaintiff Bethany Little’s testimony
The Plaintiff testified that she suffered a slip-and-fall on October 1,
2009 and was unable to work as a result. She suffers from constant leftA GAF (Global Assessment of Functioning) score of 51-60 denotes
moderate symptoms or moderate difficulty in social, occupational, or school
functioning. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed.
Text Revision (“DSM-IV”), p.34. However, the newly released Diagnostic and
Statistical Manual of Mental Disorders 5th Ed., 2013 (“DSM-V”) no longer
uses GAF scores as a diagnostic tool for assessing a patient’s functioning.
1

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side pain from her lower back down into the left foot.

The Plaintiff

experiences tingling in the left leg from the hip down to the ankle. Her
pain worsens with sitting for more than thirty minutes and with prolonged
standing. The Plaintiff testified she can stand for fifteen minutes at a time
before having to sit down. She uses a walker when standing. The Plaintiff
can lift up to a gallon of milk.
The Plaintiff testified she experiences one to three “bad days” per
month wherein she spends most of the day in bed. The Plaintiff could not
afford surgery or spinal injections. She began using a walker on a daily
basis in November of 2009 until she was placed on Neurontin.

The

Plaintiff then used the walker occasionally at the grocery store. When she
ran out of her medication, the Plaintiff would go back to using the walker
on a daily basis. She had migraines once a month.
The Plaintiff reported a five-day hospital stay because she “just
snapped.” She was placed on medication but could not get therapy because
she could not afford transportation.
The Plaintiff testified that she watches television and does word

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puzzles during the day. She has to change positions frequently and moves
from chair to chair in her home, elevating her leg. The Plaintiff does not
do any cooking and gets help with grocery shopping. She gets help with
dressing approximately twice weekly and has help showering. The Plaintiff
also has help taking care of her dog. She visits with friends, plays cards and
enjoys karaoke.
C. Vocational expert’s testimony
The vocational expert testified that an individual of the Plaintiff’s age,
education and work history who was limited to lifting and carrying up to
twenty pounds occasionally and ten pounds frequently; sitting, standing,
or walking up to six hours each during an eight-hour workday; no climbing
ladders, ropes or scaffolds; occasionally climbing ramps or stairs; and
occasionally stooping, kneeling, crouching, or crawling could perform her
past relevant work as a housekeeper and cashier.
The vocational expert testified that an individual with the same
limitations except for standing and walking for a total of only two hours per
eight-hour workday would be unable to perform the Plaintiff’s past relevant

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work. Such an individual would be able to perform work as a circuit board
screener, assembler, document preparer and order clerk. An individual with
these limitations who would need to alternate sitting and standing at least
one time per hour and remain in the alternate position for about five
minutes would still be able to perform the identified jobs.
The vocational expert testified that an individual who also could not
perform jobs involving “production requirements” would be unable to work.
Additionally, an individual limited to sitting for six hours and standing for
two hours during an eight-hour workday, lifting up to ten pounds
occasionally, a sit/stand option at will and who needed to hold on to a
walker with both hands while standing would be unable to work.
D. Decision of the ALJ
In a decision dated November 30, 2011, ALJ Wilson found that
Plaintiff had severe impairments of degenerative disc disease, obesity and
depression, but retained the residual functional capacity to perform light
work except that she could never climb ladders, ropes, or scaffolds;
occasionally climb ramps or stairs; occasionally stoop, kneel, crouch and

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crawl; stand and walk no more than two hours total; a sit/stand option once
per hour for five minutes; and, was limited to unskilled work. Given this
residual functional capacity, the ALJ found that Plaintiff could not perform
any of her past relevant work.
The ALJ did find that Plaintiff could perform other work as a circuit
board screener, eyewear assembler and document preparer.
The Plaintiff contends that the ALJ erred in failing to follow the
Treating Physician Rule and also in relying on flawed vocational expert
testimony.
The Defendant alleges the ALJ’s residual functional capacity was
supported by substantial evidence. Moreover, the ALJ reasonably rejected
Dr. Renick’s opinions. The Defendant further contends that substantial
evidence supports the ALJ’s assessment of the vocational expert’s testimony.
III. DISCUSSION
A. Standard of review
When, as here, the Appeals Council denies review, the ALJ’s decision
stands as the final decision of the Commissioner. See Schaaf v. Astrue, 602

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F.3d 869, 874 (7th Cir. 2010). The Act specifies that “the findings of the
Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive.” 42 U.S.C. § 405(g). “Substantial evidence”
is defined as “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Yurt v. Colvin, 758 F.3d 850, 856 (7th
Cir. 2014) (citations omitted). Although the Court’s task is not to re-weigh
evidence or substitute its judgment for that of the ALJ, the ALJ’s decision
“must provide enough discussion for [the Court] to afford [the Plaintiff]
meaningful judicial review and assess the validity of the agency’s ultimate
conclusion.” Id. at 856-57.
B. Evaluation of disability
The ALJ found that Plaintiff had not engaged in substantial gainful
activity after her onset date and had severe impairments which included
degenerative disc disease, obesity and depression. At step three, however,
the ALJ found that Plaintiff does not have an impairment or combination
of impairments that meets or medically equals the severity of one of the
listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.

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The ALJ found that Plaintiff had the residual functional capacity to
perform light work2 as defined in 20 C.F.R. § 416.967(b), except that she
could never climb ladders, ropes or scaffolds; could only occasionally climb
ramps or stairs, stoop, kneel, crouch or crawl; could stand or walk no more
than two total hours and had to alternate between sitting and standing one
time per hour for five minutes; and could only perform unskilled work. The
ALJ found that although the Plaintiff could not perform her past work, she
could perform other work in the national economy.
(1) Plaintiff’s alleged failure to comply with procedures
The Commissioner notes that Plaintiff refused to cooperate with the
agency’s procedures for gathering objective, reliable evidence concerning her
functionality.

The Plaintiff did not attend her scheduled physical

Light work involves lifting no more than 20 pounds at a time with
frequent lifting or carrying of objects weighing up to 10 pounds. Even though
the weight lifted may be very little, a job is in this category when it requires a
good deal of walking or standing, or when it involves sitting most of the time
with some pushing and pulling of arm or leg controls. To be considered
capable of performing a full or wide range of light work, you must have the
ability to do substantially all of these activities. If someone can do light work,
we determine that he or she can also do sedentary work, unless there are
additional limiting factors such as loss of fine dexterity or inability to sit for
long periods of time. 20 C.F.R. § 416.967(b).
2

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consultative examination. The Commissioner states the record shows that
Plaintiff later said she would attend an exam if it was scheduled in Peoria.
However, when the agency accommodated her request and scheduled an
exam in Peoria–and explained to her the consequences of failure to
attend–the Plaintiff still did not attend or call to cancel her exam. The
Plaintiff behaved similarly with respect to her psychological consultative
exam–she refused to attend an initial exam that was scheduled and failed
to respond to subsequent call-in cards sent to her and a third party.
As the Commissioner states, the Plaintiff’s failure to comply with
agency procedures would have been grounds to deny her claim. See 20
C.F.R. § 416.918(a) (“If you are applying for benefits and do not have a
good reason for failing or refusing to take part in a consultative examination
or test which we arrange for you to get information we need to determine
your disability . . . we may find that you are not disabled.”).
Although the ALJ makes reference to the Plaintiff’s “noncooperation,” which “has precluded the agency from developing objective
and unbiased medical information and opinions regarding her impairment,”

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see R. at 30, the Plaintiff’s claim was not denied due to her failure to
cooperate, even though it could have been under § 416.981(a).
Accordingly, the Court cannot uphold the ALJ’s decision on that basis. See

Spiva v. Astrue, 628 F.3d 346, 348 (7th Cir. 2010).
(2) Treating physician rule
“A treating physician’s opinion that is consistent with the record is
generally entitled to controlling weight.” Jelinek v. Astrue, 662 F.3d 805,
811 (7th Cir. 2011) (citing 20 C.F.R. § 404.1527(d)(2)). An ALJ who
rejects a treating physician’s opinion “must provide a sound explanation”
in support of the rejection. See id. If the treating physician’s opinion is
internally inconsistent or inconsistent with other medical evidence in the
record, the ALJ may reject that medical opinion if she “minimally
articulates [her] reasons for crediting or rejecting evidence of disability.”

See Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007) (citation
omitted).
Although infrequent treatment or the failure to follow a treatment
plan can support an adverse credibility finding if the claimant does not have

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a good reason, “the ALJ must not draw any inferences about a claimant’s
condition from this failure unless the ALJ has explored the claimant’s
explanations as to the lack of medical care.” Craft v. Astrue, 539 F.3d 668,
679 (7th Cir. 2008) (internal quotation marks omitted) (citing SSR 96-7p).
An ALJ should not draw a negative inference regarding a claimant’s
credibility from her lack of medical care or medical noncompliance without
first inquiring about why she did not receive treatment. See id; see also

Myles v. Astrue, 582 F.3d 672, 677 (7th Cir. 2009) (noting that ALJ’s must
consider a claimant’s explanation for failing to keep up with her treatment
and an inability to pay for medication may excuse the failure to pursue
treatment under SSR 96-7p).
Because the ultimate opinion as to disability is reserved to the
Commissioner, see Denton v. Astrue, 596 F.3d 419, 424 (7th Cir. 2010),
the ALJ was entitled to discount Dr. Renick’s conclusion that Plaintiff was
disabled.
Dr. Renick stated that in the absence of surgery, the Plaintiff would
remain disabled for at least one year. The ALJ stated that although she

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considered the opinion of Dr. Renick, his statements are not supported by
objective medical findings.
The ALJ stated that while an MRI showed disc herniation with nerve
root compression, Dr. Renick did not cite any objective findings which
supported the conclusion that Plaintiff has debilitating pain. There was no
evidence that Plaintiff had difficulty ambulating, limited range of motion,
muscle spasms, muscle atrophy, motor weakness, sensation loss or reflex
abnormalities.
The ALJ also found that Dr. Renick’s letter appeared to contain
inconsistencies and was thus less persuasive. Although the doctor noted
that medication management had provided the Plaintiff no relief and she
was denied surgery due to her financial situation, the Plaintiff stated that
medication such as Neurontin and over the counter pain medication
provided some relief. The Plaintiff testified that Flexeril did little other
than make her tired. However, Neurontin “works pretty good.” R. 59.
The Plaintiff was able to walk without the aid of a walker every day when
taking Neurontin. At the time of the hearing before the ALJ, the Plaintiff

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was out of her medication and said she was using the walker every day.
Dr. Fassett recommended that Plaintiff undergo conservative therapy
before pursuing surgical options.

Dr. Fassett, a neurosurgeon,

recommended against neurosurgery due to the Plaintiff’s weight. In April
of 2010, he recommended a conservative course of treatment which
included an epidural steroid injection. If the pain were to persist, Dr.
Fassett stated that surgery might then be considered. Although the ALJ
observes that the record does not show whether the Plaintiff underwent the
recommended steroid injections, it would appear that she did not. When
asked about the epidural injection as a course of treatment the Plaintiff
testified, “But I don’t have the insurance and nobody will help me. I can’t
get any help with that.” R. 58.
Dr. Renick noted multiple times in August, September and October
of 2010 that Plaintiff was denied surgery due to her financial situation.
The Commissioner states that Plaintiff’s financial situation had nothing to
do with the fact that she did not undergo neurosurgery.
The Plaintiff testified that the neurosurgeon informed her that surgery

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was a 50/50 proposition. It may or may not help. The Plaintiff testified
that the neurosurgeon left the decision up to her. The Plaintiff stated she
contacted the hospital and was asked about her husband’s income, even
though she had not seen her husband in twelve years. She testified she
could not get any help because she did not have information about her
husband’s income. Accordingly, the Plaintiff testified she could not afford
the surgery if she elected to have the procedure.
Given the invasive nature of the surgery, however, the Plaintiff
testified she was not certain she would have decided to go through with the
procedure even if she had the financial means.
The ALJ also noted that Dr. Renick is a family practice physician, not
a neurologist, and some of his conclusions seem to rely on his assessment
of an impairment outside his area of expertise. Pursuant to 20 C.F.R. §§
404.1527 and 416.927 and SSR 96-5p, the ALJ did not give controlling
weight to Dr. Renick’s conclusions that did not have corresponding medical
findings. The ALJ stated that more weight was given to objective medical
findings and the reasonable limitations that could be deduced therefrom.

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The ALJ also observed that Dr. Renick completed two Multiple
Impairment Questionnaires wherein various restrictions were observed as
to the Plaintiff’s ability to work. For example, in one questionnaire, the
doctor observed that Plaintiff could sit for two hours and do minimal
grasping; in the other, he opines that Plaintiff could sit for one hour and
had no limitations as to grasping. The ALJ states that nothing in the record
or Dr. Renick’s notes reveal any long term exacerbation, degeneration or
new injury that might explain the contradicting restrictions. Moreover, Dr.
Renick does not note any restrictions regarding the Plaintiff’s activities in
his treatment notes. These questionnaires were given little, if any, weight
by the ALJ as inconsistent with the record and each other.
The Defendant contends that because Dr. Renick’s extreme opinion
was not reflected in the treatment notes, it is not well-supported. Although
Dr. Renick’s opinion that Plaintiff could sit for no more than one hour per
day was particularly extreme, that restriction is not memorialized in his
ongoing treatment notes.
The Plaintiff alleges that the ALJ’s conclusory finding that Dr.

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Renick’s opinions are inconsistent with the “overall record” is insufficient
to permit meaningful review. Moreover, the inconsistencies identified by
the ALJ are so de minimis as to be meaningless when the limitations are
disabling, given that none of Dr. Renick’s assessments are consistent with
even sedentary work, which requires sitting at least six hours a day.
Additionally, the ALJ’s finding that it was significant Dr. Renick did
not record the specific limitations found for the Plaintiff in her treatment
records is misplaced because medical charts are not kept in anticipation of
litigation. The Plaintiff contends the doctor’s opinions are supported with
appropriate medical findings. Dr. Renick noted that Plaintiff’s assessed
limitations were based on evidence of left low back pain that radiated to the
left leg and was worsened with movement, as well as MRI findings
consistent with disc herniation.
The Defendant alleges that Dr. Renick’s opinions did not address the
objective evidence of record that he observed her to have normal and full
motion and strength.
Because she alleges the ALJ failed to cite to any evidence that

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contradicted the limitations or medical findings described by Dr. Renick,
the Plaintiff claims the treating physician’s opinions must be given
controlling weight under 20 C.F.R. § 416.927(c)(2).
The Plaintiff contends that, at the very least, the ALJ was required to
weigh the opinions from Dr. Renick under the enumerated factors in 20
C.F.R. § 416.927(c)(2)-(6). Moreover, the factors listed in SSR 96-2p
support crediting the doctor’s opinion. Dr. Renick treated the Plaintiff
regularly throughout the applicable period. The treatment focused on the
Plaintiff’s disabling musculoskeletal impairments. Additionally, Dr. Renick
provided specific medical findings to support his opinions. The Plaintiff
further asserts that the evidence cited by the treating physician as
supporting his findings is borne out by the longitudinal treatment record.
Accordingly, the ALJ had no basis to ignore these findings.
The Plaintiff contends that the ALJ failed to appropriately weigh Dr.
Renick’s opinions in determining that Plaintiff could perform a range of
light work. In making this finding, the ALJ did not comply with SSR 96-8p
(1996 WL 374184), which provides:

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The RFC assessment must include a narrative discussion
describing how the evidence supports each conclusion, citing
specific medical facts (e.g. laboratory findings) and nonmedical
evidence (e.g. daily activities, observations). In assessing RFC,
the adjudicator must discuss the individual’s ability to perform
sustained work activities in an ordinary work setting on a
regular and continuing basis (i.e., 8 hours a day, for 5 days a
week, or an equivalent work schedule), and describe the
maximum amount of each work-related activity the individual
can perform based on the evidence available in the case record.
The adjudicator must also explain how any material
inconsistencies or ambiguities in the evidence in the case record
were considered and resolved.
SSR 96-8p (footnote omitted).
The Plaintiff asserts that the ALJ did not cite specific medical facts or
nonmedical evidence that is consistent with a finding that Plaintiff could
perform light exertional work. Because the ALJ simply listed the Plaintiff’s
severe impairments and concluded they are consistent with light work
activity, the Plaintiff contends the finding as to residual functional capacity
is not supported by substantial evidence.
IV. CONCLUSION
Upon reviewing the entire record, the Court is unable to conclude
that the ALJ’s decision is supported by substantial evidence. There are a

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number of gaps in the record. The ALJ did not consider the apparent
inability of the Plaintiff to follow the more conservative course
recommended by Dr. Fassett–that being an epidural injection–due to the
Plaintiff’s lack of insurance and inability to afford the treatment. This
course of treatment was recommended in April of 2010.

The Court

declines to speculate on whether Dr. Fassett’s recommended course would
have alleviated the need for surgery, as recommended by Dr. Renick in
August of 2010. Although the Plaintiff testified she is uncertain she would
have elected to have surgery, she could not get approval from her insurance
company because she lacked financial information pertaining to her
husband, who apparently was no longer in her life.
The Court agrees with the Commissioner that there do appear to be
some inconsistencies and other issues with Dr. Renick’s opinions and
conclusions. However, there is very little medical evidence in the record
and nothing that is entirely inconsistent with his opinions. While this may
be due to the Plaintiff’s failure to cooperate with the agency in developing
the record, the Court cannot use that as a basis to reject her claim.

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Despite the problems with Dr. Renick’s opinions, identified by the
Commissioner, the ALJ did not point to any evidence that contradicted the
limitations or medical findings. Accordingly, although the doctor’s opinion
may be flawed, it stands uncontradicted on the record before the Court.
Ergo, the Plaintiff’s Motion for Summary Judgment [d/e 6] is
ALLOWED.
The Defendant’s Motion for Summary Judgment [d/e 10] is DENIED.
The Commissioner’s Decision is Reversed and the action is Remanded
for a new decision.
Pursuant to the fourth sentence of 42 U.S.C. § 405(g), the Clerk shall
enter a Judgment. This case is remanded to the Commissioner of Social
Security for further proceedings consistent with this Opinion.
ENTER: June 16, 2016
FOR THE COURT:

s/Richard Mills
Richard Mills
United States District Judge

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