Crawford v. Colvin
Filing
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MEMORANDUM Opinion and Order - Signed by the Honorable Maria Valdez on 4/11/2017. [For further details see order] Mailed notice (np, )
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
MELISSA CRAWFORD,
Plaintiff,
v.
NANCY A. BERRYHILL, Acting
Commissioner of Social Security, 1
Defendant.
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No. 14 C 4329
Maria Valdez
Magistrate Judge
MEMORANDUM OPINION AND ORDER
Claimant Melissa Crawford (“Claimant”) seeks review of the final decision of
Respondent Carolyn W. Colvin, Acting Commissioner of Social Security (“the
Commissioner”), denying Claimant’s application for Supplemental Security Income
(“SSI”) under Title XVI of the Social Security Act (“the Act”). Pursuant to 28 U.S.C.
§ 636(c) and Local Rule 73.1, the parties have consented to the jurisdiction of a
United States Magistrate Judge for all proceedings, including entry of final
judgment. For the reasons that follow, Plaintiff’s motion for summary judgment
[Doc. No. 13] is granted and the Commissioner’s cross-motion for summary
judgment [Doc. No. 21] is denied.
PROCEDURAL HISTORY
On June 22, 2011, Claimant filed an application for SSI, alleging a disability
onset date of May 11, 2011. (R. 192-98.) The claim was denied initially on August
Nancy A. Berryhill is substituted for her predecessor pursuant to Federal Rule of Civil
Procedure 25(d).
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24, 2011, and upon reconsideration on December 13, 2011. (R. 77-78.) On December
23, 2011, Claimant requested a hearing before an Administrative Law Judge
(“ALJ”) (R. 93-94), which was held on November 19, 2012. (R. 26-76.) At that
hearing, Claimant, who was represented by counsel, appeared and testified. (Id.) A
vocational expert (“VE”) and medical expert (“ME”) also appeared and testified. (Id.)
On March 14, 2013, the ALJ issued a written decision. (R. 8-21.) In the
decision, the ALJ went through the five-step sequential evaluation process and
ultimately found Claimant not disabled under the Act. (R. 21.) At step one, the ALJ
found that Claimant had not engaged in substantial gainful activity (“SGA”) since
June 22, 2011, the application date. (R. 13.) At step two, the ALJ found that
Claimant had the severe impairments of laceration of the right hand and finger,
and obesity. (Id.) At step three, the ALJ found that Claimant did not have an
impairment or combination of impairments that met or medically equaled the
severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix
1 (20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526). (Id.)
Before step four, the ALJ found that Claimant had the residual functional
capacity (“RFC”) to perform light work. (R. 14.) The ALJ also found that Claimant’s
RFC was further limited to lifting/carrying up to twenty pounds occasionally and
ten pounds frequently; standing/walking six hours in an eight hour workday; and
sitting about six hours in an eight hour workday. (Id.) Claimant can use her fourth
and fifth digits of her right hand only occasionally for fine and gross manipulations
and fingering; no limitation in the use of her thumb or second and third digits on
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her right hand; and can still push or pull only occasionally with the right upper
extremity. Claimant has not limitations in her left upper extremity, is right hand
dominant, and has no other limitations. (Id.) At step four, the ALJ concluded that
Claimant was capable of performing her past relevant work. (R. 19.) Finally, at step
five, the ALJ found that there were additional jobs that existed in significant
numbers in the national economy that Claimant could perform. (R. 19-20.)
Specifically, the ALJ found that Claimant could work as an usher, self-serve sales
attendant, or cashier. (R. 20.) Because of this determination, the ALJ found that
Claimant was not disabled under the Act. (R. 21)
STANDARD OF REVIEW
A decision by an ALJ becomes the Commissioner’s final decision if the
Appeals Council denies a request for review. Sims v. Apfel, 530 U.S. 103, 106–07
(2000). Under such circumstances, the district court reviews the decision of the ALJ.
Id. Judicial review is limited to determining whether the decision is supported by
substantial evidence in the record and whether the ALJ applied the correct legal
standards in reaching her decision. Nelms v. Astrue, 553 F.3d 1093, 1097 (7th Cir.
2009).
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). A “mere scintilla” of evidence is not enough. Scott v. Barnhart, 297 F.3d
589, 593 (7th Cir. 2002). Even when there is adequate evidence in the record to
support the decision, however, the findings will not be upheld if the ALJ does not
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“build an accurate and logical bridge from the evidence to the conclusion.” Berger v.
Astrue, 516 F.3d 539, 544 (7th Cir. 2008). If the Commissioner’s decision lacks
evidentiary support or adequate discussion of the issues, it cannot stand. Villano v.
Astrue, 556 F.3d 558, 562 (7th Cir. 2009).
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). Though
the standard of review is deferential, a reviewing court must “conduct a critical
review of the evidence” before affirming the Commissioner’s decision. Eichstadt v.
Astrue, 534 F.3d 663, 665 (7th Cir. 2008). It may not, however, “displace the ALJ’s
judgment by reconsidering facts or evidence, or by making independent credibility
determinations.” Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). Thus, judicial
review is limited to determining whether the ALJ applied the correct legal
standards and whether there is substantial evidence to support the findings. Nelms,
553 F.3d at 1097. The reviewing court may enter a judgment “affirming, modifying,
or reversing the decision of the [Commissioner], with or without remanding the
cause for a rehearing.” 42 U.S.C. § 405(g)
DISCUSSION
Claimant asserts that the ALJ made a series of errors weighing the medical
opinion evidence. First, Claimant argues that the ALJ erred by adopting and
assigning great weight to the opinion of the testifying ME, Dr. Ernest Mond, M.D.,
in support of Claimant’s RFC. Second, Claimant argues that the ALJ failed to
evaluate or weigh the disability statement of orthopedic surgeon, Dr. Brian Chilelli,
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M.D. Lastly, Claimant argues that the ALJ failed to adequately weigh the opinions
of treating physician Dr. Robert Wysocki, M.D. and treating nurse, Ms. Mary
McLean, APN, using the regulatory factors set forth in 20 C.F.R. § 416.927(c).
Claimant first asserts that the ALJ made a series of errors weighing the
medical opinion evidence, including adopting and assigning great weight to the
opinion of ME Dr. Mond in support of the RFC determination. Claimant contends
that the ALJ’s rationale for assigning the ME’s opinion great weight was
contradicted the testimonial evidence at the hearing because Dr. Mond explicitly
did not give an opinion on the updated medical records and Claimant’s condition.
The Commissioner concedes that Dr. Mond could not give an opinion related to the
operative reports he obtained the day of the administrative hearing because he was
not an orthopedic surgeon and was unfamiliar with the tendons operated on.
However, the Commissioner contends that Dr. Mond gave an opinion regarding
Claimant’s limitations based on the evidence as a whole and the results of a
physical examination performed by state agency consultant, Dr. Liana G. Palacci,
D.O. (Id.) The Commissioner’s arguments are illogical and unpersuasive for several
reasons.
First, the Commissioner concedes that Dr. Mond did not give an opinion
based on the operative reports but then asserts that Dr. Mond’s opinion was based
on the evidence as a whole. If Dr. Mond did not evaluate the operative reports, and
had limited knowledge about the tendons that were operated on and the effects of
surgery, then he did not base his opinion on the complete medical record. Dr. Mond
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testified that his opinion regarding Claimant’s manipulative limitations was based
on a July 2011 consultative examination, which was performed one month after the
initial surgery, but before two subsequent surgeries performed by Dr. Wysocki. SSR
96-6p provides that
the opinion of a State agency medical or psychological consultant may
be entitled to greater weight than a treating source’s medical opinion if
the State agency medical or psychological consultant’s opinion is based
on a review of a complete case record that includes a medical report
from a specialist in the individual’s particular impairment which
provides more detailed and comprehensive information than what was
available to the individual’s treating source.
SSR 96-6p (emphasis added).
In addition, the record suggests that Claimant’s hand impairment and
symptoms continued or progressed as evidenced by the two subsequent surgeries
and ongoing physical therapy. Without the assistance of an ME or consultative
opinion based on the complete medical record, the ALJ could not evaluate how
Claimant’s alleged swelling, pain, or subsequent surgeries impacted her other three
fingers or hand as a whole, and therefore he could not properly assess Claimant’s
RFC. The ALJ had a duty to fully develop the record before drawing any
conclusions. Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005); see Chase v.
Astrue, 458 F. App’x 553, 557 (7th Cir. 2012) (unpublished opinion). An ALJ may
not “play doctor” by using his own lay opinions to fill evidentiary gaps in the record.
Furthermore, the ALJ should not have rejected Dr. Wysocki’s RFC opinion without
a contradictory opinion that assessed Claimant’s RFC or at the very least an
updated opinion assessing Claimant’s use of her thumb, index, and middle finger.
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See Hopgood ex rel. L.G. v. Astrue, 578 F.3d 696, 702 (7th Cir. 2009) (holding that
determinations must be based on testimony and medical evidence in the record).
The Court does not intend to suggest that Claimant is disabled or meets or equals a
particular listing. However, the ALJ’s analysis failed to build a logical bridge from
the facts to the conclusion that Claimant’s RFC was not as limited as Dr. Wysocki
opined.
Next, Claimant argues that the ALJ failed to evaluate or weigh the disability
statement of Dr. Brian Chilelli, M.D. An ALJ is required to evaluate every medical
opinion in the record. 20 C.F.R. § 416.927(c). The ALJ noted that Dr. Chilleli
provided an opinion dated March 20, 2012, which indicated that Claimant was
unable to work from March 20, 2012, until a date to be determined, due to her right
ring finger chronic flexor tendon laceration and stage one hunter rod reconstruction.
(R. 18.) Although the ALJ did not specifically list the reasons why he rejected this
opinion, the Court concludes that any error was harmless. Dr. Chilelli was the
assistant surgeon during the March 20, 2012 Phase I Hunter-Rod Reconstruction
surgery, which was performed by Dr. Wysocki. Dr. Chilelli’s opinion about
Claimant’s ability to work provided no more insight or evidence about Claimant’s
impairments or RFC than did Dr. Wysocki’s opinion.
Finally, Claimant argues that the ALJ failed to adequately weigh the
opinions of treating physician Dr. Robert Wysocki, M.D. and treating nurse, Ms.
Mary McLean, APN, because the ALJ failed to consider the regulatory factors in 20
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C.F.R. § 416.927(c). The Commissioner responds that the ALJ provided sufficient
reasons for rejecting Dr. Wysocki’s opinion.
An ALJ must give controlling weight to a treating physician’s opinion if the
opinion is both “well-supported” and “not inconsistent with the other substantial
evidence” in the case record. 20 C.F.R. § 416.927(c); see Scott v. Astrue, 647 F.3d
734, 739 (7th Cir. 2011). If the ALJ does not give the treating physician’s opinion
controlling weight, the ALJ cannot simply disregard it without further analysis.
Campbell v. Astrue, 627 F.3d 299, 308 (7th Cir. 2010.) Instead, the ALJ must still
determine what value the assessment does merit. 20 C.F.R. § 416.927 (c); Scott, 647
F.3d at 740; Campbell, 627 F.3d at 308. The regulations require the ALJ to consider
a variety of factors, including: (1) the length, nature, and extent of the treatment
relationship; (2) the frequency of examination; (3) the physician’s specialty; (4) the
types of tests performed; and (5) the consistency and support for the physician’s
opinion. See id.
The ALJ gave limited weight to the October 17, 2011 Dexterity
Questionnaire opinion of Dr. Wysocki and Nurse McLean because “it [was]
undated,” and there was no basis in the record that Claimant could never
grasp/handle or finger with her right hand. (R. 18.) The ALJ also opined that it was
hard to accept the opinion that Claimant had zero ability to grasp/handle or finger,
when she had three unimpaired digits, including her thumb. (Id.) However, the ALJ
failed to evaluate the opinion of Dr. Wysocki and Nurse McLean, as well as Dr.
Wysocki’s subsequent opinions, using the regulatory factors set forth in 20 C.F.R. §
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416.927(c). While the ALJ does note that Dr. Wysocki was Claimant’s treating
physician, he did not appear to consider that Dr. Wysocki had been treating
Claimant for her hand at the very least since June 7, 2011. (R. 301.) The ALJ also
failed to note or mention that Dr. Wysocki had examined Claimant at least five
times during the period at issue. (R. 376-77, 379-80, 415.) Additionally, the ALJ did
not expressly consider that Dr. Wysocki is an orthopedic surgeon specializing in
hands, and that his assessment of Claimant’s condition was based on his expertise.
(R. 378.) The ALJ also did not explore that Dr. Wysocki’s opinions were consistent
with Claimant having Hunter Rod Reconstruction surgery; the ALJ disregarded Dr.
Wysocki’s opinions because it was “hard to accept the opinion that [Claimant] had
zero ability to grasp/handle or finger,” but Dr. Wysocki’s opinions are not
inconsistent with the other medical evidence in the record. The ALJ even admitted
that on August 15, 2011, Claimant was treated at Holy Cross Hospital for decreased
sensation in her right hand, the inability to flex her right index finger, and
numbness in the fourth and fifth fingers of her right hand. (R. 16.) Thus, the ALJ
failed to support his findings with substantial evidence.
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CONCLUSION
For the reasons set forth above, Claimant’s motion for summary judgment
[Doc. No. 13] is granted in part, and the Commissioner’s cross-motion for summary
judgment [Doc. No. 21] is denied. The decision of the Commissioner is reversed, and
the case is remanded for further proceedings consistent with this opinion.
SO ORDERED.
ENTERED:
DATE:
___________________________
HON. MARIA VALDEZ
United States Magistrate Judge
April 11, 2017
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