Fieldhouse v. Astrue
Filing
56
MEMORANDUM Opinion and Order. Signed by the Honorable Maria Valdez on 5/27/2016: Mailed notice (lp, )
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
JANINE L. FIELDHOUSE,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security, 1
Defendant.
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No. 09 C 6358
Magistrate Judge
Maria Valdez
MEMORANDUM OPINION AND ORDER
This action was brought under 42 U.S.C. § 405(g) to review the final decision
of the Commissioner of Social Security denying Plaintiff Janine L. Fieldhouse’s
claim for Disability Insurance Benefits. The parties have consented to the
jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c).
For the reasons that follow, Plaintiff’s motion for summary judgment [Doc. No. 42]
is granted, and the matter is remanded for proceedings consistent with this
Opinion.
BACKGROUND
I.
PROCEDURAL HISTORY
On November 17, 2005, Plaintiff filed a claim for Disability Insurance
Benefits (“DIB”), claiming disability since June 17, 2005 due to cellulitis, back
trouble, and sciatica. (R. 138, 162.) Her date last insured under the DIB program
Carolyn W. Colvin is substituted for her predecessor, Michael J. Astrue, pursuant to
Federal Rule of Civil Procedure 25(d).
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was September 30, 2008. After various levels of administrative review, her claim
was denied, and Plaintiff appealed that denial to this Court on June 9, 2010. See
Fieldhouse v. Astrue, No. 09 C 6358, 2012 WL 426702 at *1 (N.D. Ill. Feb. 8, 2012).
In 2012, the Court held that the ALJ’s findings were supported by substantial
evidence. Id. at *14. Nevertheless, the court vacated the Commissioner’s earlier
decision and granted remand pursuant to sentence six of 42 U.S.C. § 405(g), which
allows for the consideration of new and material evidence where there is “good
cause for the failure incorporate the evidence into the record in a prior proceeding.”
Id. at *8-11.
In preparation for her new hearing, Plaintiff submitted additional evidence.
(R. 614-646.) Another hearing was held on December 19, 2012 before a second ALJ,
who on January 7, 2013 again denied Plaintiff’s claim, finding that she was not
disabled from her alleged onset date to her date last insured. Plaintiff now contests
that finding.
II.
FACTUAL BACKGROUND
A.
Background
Plaintiff was born on July 2, 1960 and was forty-eight years old as of her date
last insured and fifty-two years old at her December 2012 hearing. She completed
high school in special education classes and has worked as nursing assistant and as
a part-time cook. (R. 163, 276, 361, 382.) She is married and has one son, who was
sixteen years old at the time of the hearing. (R. 359.)
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B.
Medical Evidence
1.
Treating Sources
Throughout the relevant period, Plaintiff received primary care from Dr.
Elizabeth Ritz and from Dr. David Schlagheck. In September 2005, Plaintiff was
hospitalized for a week due to cellulitis in her leg, which was treated with
antibiotics and steroids. (R. 209-22, 290.) She followed up with Dr. Ritz about
cellulitis and lymphedema in October, November, and December 2005. (R. 286-91.)
Dr. Ritz examined Plaintiff on March 13, 2006 and determined that her cellulitis
had resolved, but she still had lymphedema requiring the use of compression hose.
(R. 307.) In January 2006, she reported leg cramps. (R. 317.) A week later, she
stated that excessive stooping had caused her back pain. (Id.)
On July 24, 2006, Plaintiff complained to Dr. Ritz of abdominal symptoms.
She also reported that she was in the process of applying for disability for low back
pain and radiculopathy, which was treated by her chiropractor. Dr. Ritz noted that
“any strenuous activity” like playing with her son bothered Plaintiff’s back. Though
both her chiropractor and her physician recommended an MRI, Plaintiff chose not
to get one because she would have to pay for it herself, and her “lawyer does not feel
she needs [an] MRI to get disability.” (R. 307.)
Plaintiff next reported “terrible back pain,” worsened by packing and
painting in preparation for a move, on September 6, 2006. She stated that she took
ibuprofen three or four times a day with some relief, and also needed frequent rest
breaks to cope with the pain. (R. 310.) That day, Dr. Ritz wrote a “to whom it may
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concern” letter indicating that Plaintiff had been her patient for approximately two
years and that Plaintiff had back pain and right sciatic nerve pain which was
treated with ibuprofen three times a day. She had “constant” low back pain
radiating down into her right leg and toes with activity, and she could sit for only
fifteen to twenty minutes at a time and stand for only ten to fifteen minutes at a
time. Her pain compromised her activities of daily living and required her to take
frequent rest breaks. (R. 309.)
On September 25, 2006, Plaintiff again reported low back pain shooting down
her right leg during the week she was moving to a new place. (R. 311.) Dr. Ritz
observed a positive straight leg test and prescribed 800 milligrams of ibuprofen,
plus Vicodin. (Id.) On December 21, 2006, Plaintiff visited Family Heath Center,
seeing Dr. Schlagheck for a “flare-up” of her back pain. (R. 629.) Dr. Schlagheck
prescribed Celebrex and Ultram, and in January 2007, he treated her back pain
with a lumbar steroid injection. (R. 630.)
In February 2007, Dr. Ritz noted that Plaintiff had back pain and bruised
ribs from a fall. On December 2007, Plaintiff again returned to Dr. Ritz, reporting
that she had again hurt her lower back while moving to a new house. (R. 317.) In
May 2008, she had an episode of cellulitis in her lower leg, which was again treated
with antibiotics. Plaintiff stated she may have been bitten while mowing the lawn.
(R. 312.)
Plaintiff saw Dr. Schlagheck once in 2008, for a spell of vertigo. In October
2008, two weeks after the date she was last eligible for DIB and one week before her
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ALJ hearing, Plaintiff returned to Dr. Ritz to follow up about her back pain, which
she reported was worsened by prolonged sitting or standing, and relieved by rest.
Dr. Ritz observed limitations and pain in her ranges of motion. (R. 314-15.) That
day, Dr. Ritz wrote a second letter, stating that Plaintiff’s condition was “gradually
worsening as she reports that her chronic pain has increased in intensity.” She
wrote that Plaintiff’s pain affected her ability to sleep and to engage in daily
activities. (R. 318.)
Plaintiff had MRIs taken of her lumbar and thoracic spine on November 29,
2008. Her thoracic spine MRI results described “a slight leftward rotatory scoliotic
curvature at the upper thoracic spine centered at approximately T3–4,” along with
disc desiccation that was “present at each level of the thoracic spine,” with
abnormalities described at all levels, including a T6–7 “left paramedian focal disc
herniation which contacts the cord and flattens the anterior left aspect of the cord.”
(R. 618.) The lumbar spine MRI showed several findings at L4–5, including “disc
desiccation with extruded nucleus,” which “contributes to narrowing the right
lateral recess and may be contacting the queued right L4 nerve root at the entrance
to the neural foramen.” (R. 619.) On January 16, 2009, Dr. Ritz wrote a third letter,
this time opining that Plaintiff’s MRI results were consistent with her pain
complaints. (R. 622.)
Plaintiff first visited pain management specialist Dr. Ronald Kloc on
December 5, 2008, one week after her MRIs and less than three months after her
date last insured. (R. 625-26.) Dr. Kloc’s notes contain a description of the MRI
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scans listing multiple areas of “disc desiccation and bulging,” including a notation
that “the most severe level appears to be at T6–7 on the left where there is actual
cord contact, displacement and slight deformity.” (R. 625.) Dr. Kloc’s physical exam
revealed pain on back extension and flexion and right rotation, and pain on the
right leg straight raise test. (Id.) Dr. Kloc opined that Plaintiff’s right leg radicular
pain was the most serious problem requiring attention first, with the goal of
allowing Plaintiff to return to work. (R. 626.) On Plaintiff’s sole return visit to the
pain clinic in January 2009, Dr. Kloc performed an lumbar epidural steroid
injection. (R. 627.)
Plaintiff continued to receive primary care from Dr. Schlagheck in the years
following her date last insured. Records document treatment for back pain in June
2009 and March 2010 and ongoing treatment for chronic pain, cellulitis, and other
ailments through 2012. (R. 629-40.)
Throughout the relevant period, Plaintiff also received periodic care from
chiropractor Roger Miller. On November 17, 2004, after Plaintiff had hurt herself in
a fall, Miller noted that she had limited ranges of motion; pain on cervical rotation,
flexion, or extension; and sharp lower-back pain with Lasegue’s and Braggard’s
tests. (R. 267, 270-71.) Plaintiff reported pain levels that ranged 6-10/10 in her
upper back that sometimes travelled to her neck with occasional headaches. She
also reported pain at 7-10/10 in her lower back, occasional numbness in both hands,
and right-side sciatic pain. (R. 267.) She returned for approximately fifteen
chiropractic treatments from December 7, 2004 to June 3, 2005, reporting varying
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pain levels and, at times, leg cramps. (R. 268-69.) In May 2005 she reported that her
lower back pain was improved “as long as I’m careful.” At her last documented visit,
on June 3, 2005, Plaintiff indicated that she had strained her back but was not
experiencing severe pain. (R. 269.) In a December 29, 2005 “Progress Report” to a
state agency, Miller reported that he had last seen Plaintiff in April 2005, that
Plaintiff had a history of sciatica and low back pain, and that he had recommended
an MRI. He opined that it would be very difficult for Plaintiff to do any occupation
without acute exacerbations. (R. 266.) A second progress report completed by Miller
on May 17, 2006 stated that he had last seen Plaintiff in January 2006 and opined
that she would continue to have acute onsets of low back pain and sciatica, and that
lifting and bending would cause more damage. (R. 301.)
2.
Consulting Physicians
In connection with Plaintiff’s application for benefits, Dr. Phillip S. Budzinski
performed a consultative examination of Plaintiff on March 3, 2006, more than two
years prior to her later MRI scans. A lumbar x-ray that he ordered was
unremarkable. (R. 281.) He noted that, despite a recommendation that Plaintiff
wear surgical stockings to control her lymphedema, she was not wearing them the
day he examined her. (R. 276.) She had no difficulty bending to attend to her
footwear. (R. 277.) She had moderate thoracic kyphosis (excessive forward
curvature of the upper spine) but normal ranges of motion in her lumbar spine. (R.
279.) He noted pitting edema in both legs, marked swelling in both feet and ankles,
some redness below the right knee, and limited ranges of motion, particularly in the
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cervical area. (R. 278.) Noting a discrepancy between dynamometer grip strength
tests and subjective assessments, Dr. Budzinsky performed further tests and
assessed a grip strength of 5/5 bilaterally. His diagnostic impressions were morbid
obesity, a history of cellulitis, lower extremity edema, thoracic kyphosis, and
tobacco abuse. (R. 280.) He opined that Plaintiff could climb stairs only occasionally;
should avoid extreme heat; could not climb ladders, ropes, or scaffolds; and should
be limited to lifting no more than fifty pounds. (Id.)
Agency Reviewer Sandra Bilinsky, M.D. reviewed Plaintiff’s file on March 27,
2006 and opined that, based on obesity, a history of cellulitis and edema, and
alleged low back pain, Plaintiff should be limited to light work with some postural
and environmental limitations. (R. 299.) This assessment was later confirmed by
Dr. Ramakrishna Madala, M.D. (R. 302-04.)
In December 18, 2012, before Plaintiff’s second hearing, neurologist George
E. DePhillips, M.D. provided an opinion letter based on his review of the images
from her November 2008 MRI scans and her later scans from December 2010. (R.
641-46.) Dr. DePhillips agreed with earlier assessments of the MRI exams. He
concluded that Plaintiff’s degenerative disc disease was consistent with
“predominantly mechanical low back pain worse with activities” and “potential” for
“radicular lower extremity symptoms.” He also wrote, that, in “all probability,
[Plaintiff] would have experienced such symptomatology since at least June 2005
consistent with her history.” (R. 642.)
C.
Plaintiff’s Testimony
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At her hearing on December 19, 2012, Plaintiff testified that, during the
period of time when she left her job in 2005 to the time before her MRI in 2008, her
pain was at 10/10 and shifted to both sides of her lower back, traveling down her
leg. (R. 363.) She stopped seeing the chiropractor because it was expensive and only
helped for three days. (R. 363, 365.) She finally got an MRI at the suggestion of the
first ALJ, which cost her $1,000 out of pocket. (R. 364.) Her steroid injection gave
her a high fever and made her feel “sick to [her] stomach,” so she did not return to
the pain management doctor. (R. 365-66.) She had edema during that period of time
but did not wear support hose because they were too expensive. (R. 368-69.) She
stated that during the relevant period she had been able to sit for just ten to twenty
minutes at a time and stand for five to ten minutes at a time, but could only walk
about five feet without grabbing onto something. (R. 370-72.) She was up three or
four times at night for pain and used a heating pad and ice to relieve pain. (R. 370,
372, 376.)
D.
Vocational Expert Testimony
Vocational Expert (“VE”) Bob Hammond characterized Plaintiff’s past
relevant work as certified nursing assistant, very heavy as performed by Plaintiff.
The ALJ asked the VE to consider an individual of the same age, education, and
work experience as Plaintiff, with a residual functional capacity (“RFC”) limiting
her to work at the light exertional level, who could never climb ladders, ropes or
scaffolds and who could only occasionally climb ramps or stairs and occasionally
crouch, kneel, balance, crawl, stoop; who cannot have concentrated exposure to
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heights, hazards, or extreme heat. (R. 382.) The VE testified that such a person
could not perform Plaintiff’s past work. (Id.) The ALJ asked if there exist jobs such
a person could perform, and the VE replied that yes, such person could work as a
parking lot assembler, as a computer chip assembler, or in a small products bench
assembly position. (R. 383.) On further questioning, the VE testified that if such
person needed to have the option of sitting or standing, changing positions every
thirty minutes for five minutes at a time, the parking lot attendant positions would
not be affected, but the bench assembly and chip assembly positions available would
be reduced by about fifty percent. (Id.) If the individual were instead restricted to
sedentary, instead of light, activity, she could work as a sealer in the
pharmaceutical industry, as an eyewear assembler, or as a circuit board screener.
(R. 384.) No jobs would be available if the individual were off task thirty percent of
the day due to pain, if she had to take extra breaks, or if she had to miss three days
of work per month. (R. 385-86.)
E.
The ALJ Decision
On January 7, 2013, the ALJ issued a decision denying Plaintiff’s claim,
following the required five-step sequence. At step one, the ALJ found that Plaintiff
had not engaged in substantial gainful activity from June 17, 2005 through
September 30, 2008. (R. 336.) At step two, the ALJ found that Plaintiff had the
severe impairments of obesity, a history of cellulitis, lower extremity edema,
herniated and bulging disks of the thoracic and lumbar spine, and thoracic
kyphosis. (Id.) At step three, the ALJ found Plaintiff’s impairments did not meet or
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medically equal one of the listed impairments. (R. 337.)
__*************_____________ [[[rfc]]]]
At step four, the ALJ determined that, due to the effects of her impairments,
Plaintiff was unable to perform any of her past relevant work. (R. 345.) However, at
step five, based on the VE’s testimony and Plaintiff’s age, education, and RFC, the
ALJ concluded that Plaintiff could perform jobs existing in significant numbers in
the national economy, leading to a finding that she was not disabled under the
Social Security Act. (Id. at 345-346.)
DISCUSSION
I.
ALJ LEGAL STANDARD
Under the Social Security Act, a person is disabled if she has an “inability to
engage in any substantial gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period of not less than twelve
months.” 42 U.S.C. § 423(d)(1)(a). In order to determine whether a claimant is
disabled, the Commissioner considers the following five questions in order: (1) Is the
claimant presently unemployed? (2) Does the claimant have a severe impairment?
(3) Does the impairment meet or medically equal one of a list of specific
impairments enumerated in the regulations? (4) Is the claimant unable to perform
her former occupation? and (5) Is the claimant unable to perform any other work?
20 C.F.R. § 416.920(a)(4).
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An affirmative answer at either step 3 or step 5 leads to a finding that the
claimant is disabled. Young v. Sec’y of Health & Human Servs., 957 F.2d 386, 389
(7th Cir. 1992). A negative answer at any step, other than at step 3, precludes a
finding of disability. Id. The claimant bears the burden of proof at steps 1–4. Id.
Once the claimant shows an inability to perform past work, the burden then shifts
to the Commissioner to show the claimant’s ability to engage in other work existing
in significant numbers in the national economy. Id.
II.
JUDICIAL REVIEW
Section 405(g) provides in relevant part that “[t]he 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). Judicial review of a final decision of the
Commissioner (here, the decision of the Appeals Council affirming the findings of
the ALJ) is limited to determining whether its findings are supported by substantial
evidence or based upon legal error. Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir.
2000); Stevenson v. Chater, 105 F.3d 1151, 1153 (7th Cir. 1997). Substantial
evidence is “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); Skinner v.
Astrue, 478 F.3d 836, 841 (7th Cir. 2007). This Court may not substitute its
judgment for that of the Commissioner by reevaluating facts, reweighing evidence,
resolving conflicts in evidence. Skinner, 478 F.3d at 841; see also Elder v. Astrue,
529 F.3d 408, 413 (7th Cir. 2008) (holding that an ALJ’s decision must be affirmed
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even if “‘reasonable minds could differ’” as long as “the decision is adequately
supported.”) (citation omitted).
The Commissioner is not required to address “every piece of evidence or
testimony in the record, [but the] analysis must provide some glimpse into the
reasoning behind [the] decision to deny benefits.” Zurawski v. Halter, 245 F.3d 881,
889 (7th Cir. 2001). In cases where the Commissioner denies benefits to a claimant,
she must “build an accurate and logical bridge from the evidence to [her]
conclusion.” Clifford v. Apfel, 227 F.3d at 872. The written decision must at least
minimally articulate the “analysis of the evidence with enough detail and clarity to
permit meaningful appellate review.” Briscoe ex rel. Taylor v. Barnhart, 425 F.3d
345, 351 (7th Cir. 2005); Murphy v. Astrue, 496 F.3d 630, 634 (7th Cir. 2007) (“An
ALJ has a duty to fully develop the record before drawing any conclusions . . . and
must adequately articulate his analysis so that we can follow his reasoning . . . .”);
see Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005).
Where conflicting evidence would allow reasonable minds to differ, the
responsibility for determining whether a claimant is disabled falls upon the
Commissioner, not the court. See Herr v. Sullivan, 912 F.2d 178, 181 (7th Cir.
1990). However, an ALJ may not “select and discuss only that evidence that favors
his ultimate conclusion,” but must instead consider all relevant evidence. Herron v.
Shalala, 19 F.3d 329, 333 (7th Cir. 1994); see Scrogham v. Colvin, 765 F.3d 685, 698
(7th Cir. 2014) (“This ‘sound-bite’ approach to record evaluation is an impermissible
methodology for evaluating the evidence.”).
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III.
ANALYSIS
On appeal, Plaintiff argues that the ALJ committed multiple errors in
denying her disability claim. Specifically, Plaintiff faults the ALJ for (1) performing
an inadequate analysis of the November 2008 MRI evidence; (2) omitting discussion
of some medical evidence and discrediting Plaintiff’s own testimony in evaluating
the severity of her pain; (3) improperly discounting the opinions of Plaintiff’s
treating physician; and (4) mischaracterizing Plaintiff’s restrictions in the
hypothetical questions posed to the VE.
A.
Omitted Medical Evidence
Plaintiff argues that the ALJ erred in omitting any mention of the treatment
notes of Dr. Kloc and Dr. Schlagheck and the May 2006 opinion of chiropractor
Miller. An ALJ must examine “the full range of medical evidence” pertinent to
claimed impairments. Zurawski v. Halter, 245 F.3d at 888. While an ALJ’s opinion
“need not discuss every piece of evidence in the record,” it must contain sufficient
analysis for a reviewing court to determine whether the decision rests upon
substantial evidence, and cannot omit a line of evidence that tends to show
disability. Id. at 889; see Golbiewski v. Barnhart, 322 F.3d 912, 917 (7th Cir. 2003.)
This case was earlier remanded by this Court for consideration of new
evidence, which at that time consisted of concurrent November 28, 2008 MRIs of
Plaintiff’s lumbar and thoracic spine, and a January 2009 opinion letter from Dr.
Ritz stating that the results of the MRIs were consistent with Plaintiff’s reports of
pain. Fieldhouse v. Astrue, No. 09 C 6358, 2012 WL 426702 at *1; (R. 400-01, 407-
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412, 418). In that Order, the Court encouraged the Commissioner to “use all
necessary efforts to build a logical bridge between the evidence in the record and
[her] ultimate conclusions.” Id. at *14. And although the remand was pursuant to
sentence six, and not sentence four, the Court acknowledged that it is sometimes
necessary to allow parties on remand to expand the record in order to assure that
the Commissioner’s ultimate conclusion is fully supported. Id. at 30 (citing Myles v.
Astrue, 582 F.3d 672, 678 (7th Cir. 2009)) (explaining further that “[t]he
Commissioner should not assume that any other errors not discussed in this order
have been adjudicated in [her] favor. On remand, the Commissioner therefore must
carefully articulate [her] findings as to every step.”).
Since that time, Plaintiff has also submitted treatment records from Dr. Kloc
and Dr. Schlagheck. (R. 625-40.) The ALJ omitted any mention of these treatment
records in her analysis. Additionally, the ALJ did not indicate what weight, if any,
she gave to the January 2009 opinion letter of Dr. Ritz. The Commissioner argues
that, because the majority of the omitted treatment records date from after
Plaintiff’s insured period, any error in omitting them from consideration was
harmless. However, the ALJ may not simply ignore evidence post-dating Plaintiff’s
date last insured. The Seventh Circuit has held that an ALJ must consider all
relevant evidence, including evidence regarding the Plaintiff’s later condition, in
determining whether a claimant was disabled before her last insured date. Parker v.
Astrue, 597 F.3d 920, 924-925 (7th Cir. 2010.) While a remote date might provide a
reason for discounting the importance of some records, “discounting is not the same
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as ignoring.” Alesia v. Colvin, No. 12 C 8395, 2015 WL 5062812 at *6 (N.D. Ill., Aug.
26, 2015.)
Some of the records that the ALJ ignored are relevant to at least some
portion of the period covered by this claim. Dr. Schlagheck’s treatment notes record
a visit for back pain in December 2006, and second visit in which that pain was
treated with an injection in January 2007. Both of visits occurred before her date
last insured. Dr. Schlagheck’s later medical records may also shed some light on
Plaintiff’s condition during her insured period and merit some consideration.
Dr. Kloc’s notes regarding Plaintiff’s December 2008 visit are relevant to her
condition during insured period. Dr. Kloc wrote his notes the week after Plaintiff’s
MRIs and less than three months after her date last insured, and his opinion was
based on his assessment of the MRI data as well as a physical exam. As this Court
noted in its earlier opinion, the numerous spinal abnormalities shown on Plaintiff’s
MRI did not all occur between September 20, 2008 and November 28, 2008.
Fieldhouse, 2012 WL 426702 at *9. Indeed, the ALJ’s opinion acknowledges that
“[t]hough the MRIs were taken after the date last insured, they would reasonably
apply to at least some of the period at issue . . . .” (R. 339.) Reviewing those MRIs,
Dr. Kloc adjudged Plaintiff’s most severe problem to be her right radicular leg pain,
which he hoped to address first, with the goal of helping Plaintiff return to work. (R.
626.) While the notes do not provide a function-by-function capacities assessment,
they do indicate that Dr. Kloc saw in the MRIs and in his physical exam a degree of
impairment that he viewed as severe enough to preclude work, at least for some
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period of time. The question of whether a claimant can work is an issue reserved to
the Commissioner, and medical opinions about such issues are never entitled to
controlling weight. Clifford v. Apfel, 227 F.3d at 870; 20 C.F.R. 404.1527(e).
Nevertheless, the ALJ must explain what consideration she gave to Dr. Kloc’s
assessments. See SSR 96-5p. (“[O]pinions from any medical source on issues
reserved to the Commissioner must never be ignored.”)
As to Dr. Ritz’s January 16, 2009 opinion letter, the Court previously held
that the letter “most reasonably interpreted, indicates that the results of the MRI
exams were consistent with the chronic pain complaints Plaintiff expressed to Dr.
Ritz prior to September 20, 2008.” Fieldhouse, 2012 WL 426702, at *9. The ALJ
explained that she gave “no weight” to Dr. Ritz’s earlier opinions, in part because
they were based solely on Plaintiff’s subjective complaints. (R. 342.) The January
2009 letter, in contrast, is based on the MRI results. The ALJ should have indicated
what weight that letter merited in her analysis.
The ALJ’s failure to weigh Dr. Ritz’s January 2009 opinion and failure to
discuss the treatment notes of Dr. Schlagheck and Dr. Kloc leaves the Court unable
to assess whether or how she considered all of the relevant medical evidence in
assessing Plaintiff’s RFC. Therefore, the case must be remanded in order for the
ALJ to explain her assessment of this evidence.
B.
Assessment of Chiropractor’s Opinion
The record also contains two opinion letters from chiropractor Roger Miller,
dated December 29, 2005 and May 17, 2006. (R. 266, 301.) The ALJ afforded no
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weight to the first letter because it reflected examinations that took place prior to
the insured period, and because a chiropractor is “a non-acceptable medical source
under the regulations.” (R. 343.) She did not mention the chiropractor’s May 17,
2006 opinion letter or indicate what weight, if any, it bore in her analysis. Under
Social Security regulations, only an opinion from a physician, psychologist,
podiatrist or other “acceptable medical source” may establish the existence of a
medically-determinable impairment. 20 C.F.R. 404.1513(a). Evidence from other
medical sources, including chiropractors, may be used to show the severity of a
claimant’s impairments and how they affect her ability to work. 20 C.F.R.
404.1513(d). Voigt v. Colvin, 781 F.3d 871, 878 (7th Cir. 2015); Pierce v. Colvin, 739
F.3d 1046, 1051 (7th Cir. 2014). In deciding how to weigh the opinions of “other
sources,” including chiropractors, ALJs have more discretion than they do with the
opinions of physicians. Fiori v. Colvin, No. 12 CV 50148, 2014 WL 4639468, at *11
(N.D. Ill. Sept. 16, 2014); Mulvaney v. Barnhart, No. 05 C 4439, 2006 WL 2252547,
at *21 (N.D. Ill. Aug. 3, 2006). On remand, the ALJ should indicate what weight, if
any, was given to the May 17, 2006 letter of chiropractor Miller.
C.
Other Matters
Because remand is necessary for the above reasons, the Court need not
explore in detail the remaining errors claimed by Plaintiff at this time. The Court
does note that, since the ALJ issued her decision in this case, the Social Security
Administration has issued new guidance on how it assesses the effects of a
claimant’s claimed symptoms, including pain. Prior policy ruling SSR 96-7p, which
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focused on credibility, has been superseded by SSR 16-3p in order to “clarify that
subjective symptom evaluation is not an examination of the individual's character.”
SSR 16-3p, 2016 WL 1119029, at *1. As SSR 16-3p is simply a clarification the
Administration's interpretation of the existing law, rather than a change to it, the
same regulatory factors for evaluating the severity of Plaintiff’s symptoms will
apply. See Qualls v. Colvin, No. 14 CV 2526, 2016 WL 1392320, at *6 (N.D. Ill. Apr.
8, 2016). On remand, the ALJ should take care to assess the intensity and
persistence of Plaintiff’s symptoms in accordance with the guidelines of SSR 16-3p.
CONCLUSION
For the foregoing reasons, Plaintiff Janine Fieldhouse’s motion for summary
judgment [Doc. No. 42] is granted. The Court finds that this matter should be
remanded to the Commissioner for further proceedings consistent with this order.
SO ORDERED.
ENTERED:
DATE:
___________________________
HON. MARIA VALDEZ
United States Magistrate Judge
May 27, 2016
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