Garcia v. Saul

Filing 29

MEMORANDUM Opinion and Order: Signed by the Honorable M. David Weisman on 7/14/2021. Mailed notice (ao, )

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
JOSE G.
Plaintiff,
v.
ANDREW SAUL,
Commissioner of Social Security,
Defendant.

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No. 20-cv-1669
Magistrate Judge M. David Weisman

MEMORANDUM OPINION AND ORDER
Jose G. brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the Social
Security Administration (“SSA’s”) decision that his medical condition improved and that he is no
longer entitled to disability benefits. For the reasons set forth below, the Court reverses the SSA’s
decision.
Background
On January 28, 2010, plaintiff was found disabled due to blindness in his right eye and
vision loss in his left eye. (R. 15-23.) On April 15, 2013, the SSA conducted a continuing
disability review and determined that plaintiff’s disability continued. (R. 65-68.) On August 30,
2016, the SSA conducted another continuing disability review and determined that “medical
improvement” (“MI”) had occurred. (R. 72-73.) Plaintiff filed a request for a hearing before an
administrative law judge (“ALJ”), which was held on December 10, 2018. (R. 29-60.) On
February 11, 2019, the ALJ issued a decision finding that plaintiff’s disability ended on August
30, 2016 and, thus, he was no longer disabled as of that date. (R. 15-23.) The Appeals Council
declined to review the decision (R. 1-6.), leaving the ALJ’s decision as the final decision of the

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SSA, reviewable by this Court pursuant to 20 U.S.C. § 405(g). See Villano v. Astrue, 556 F.3d
558, 561-62 (7th Cir. 2009).
Discussion
The Court reviews the ALJ’s decision deferentially, affirming if it is supported by
“substantial evidence in the record,” i.e., “‘such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.’” White v. Sullivan, 965 F.2d 133, 136 (7th Cir. 1992)
(quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). While generous, this standard “is not
entirely uncritical,” and the case must be remanded if the “decision lacks evidentiary support.”
Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).
According to the SSA’s regulations, MI “is any decrease in the medical severity of [the]
impairment(s) which was present at the time of the most recent . . . decision [in plaintiff’s favor.]”
20 C.F.R. § 404.1594(b)(1).

SSA regulations prescribe an eight-part sequential test for

determining whether MI has occurred. See 20 C.F.R. § 404.1594(f). The SSA must consider
whether: (1) the claimant is engaged in substantial gainful activity; (2) the claimant has an
impairment or combination of impairments that meets or equals a listed impairment; (3) there has
been MI; (4) the MI is related to the claimant’s ability to work; (5) any exceptions to MI apply;
(6) the claimant’s current impairments are severe; (7) if so, the claimant has the residual functional
capacity (“RFC”) to do past relevant work; and (8) if not, the claimant’s RFC enables him to do
other work. Id.
Here, the ALJ found that plaintiff was disabled as of January 28, 2010 and continued to be
disabled as of April 15, 2013, his comparison point decision (“CPD”). (R. 15, 17.) At the time of
his CPD, plaintiff had the following medically determinable impairments: blindness in the right
eye and vision loss in the left eye. (Id.) At step one, the ALJ found that plaintiff had not engaged

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in substantial gainful activity through August 30, 2016. (Id.) At step two, the ALJ found that
plaintiff did not have an impairment or combination of impairments which met or medically
equaled the severity of a listed impairment since August 30, 2016. (Id.) At steps three and four,
the ALJ found that MI related to plaintiff’s ability to work occurred on August 30, 2016. (R. 1718.) At step six,1 the ALJ found that plaintiff continued to have severe impairments of blindness
in the right eye and vision loss in the left eye. (R. 18.) At steps seven and eight, the ALJ found
that plaintiff has no past relevant work and that, as of August 30, 2016, plaintiff had the RFC to
perform a significant number of jobs in the national economy. (R. 18-22.) Thus, the ALJ
concluded, plaintiff’s disability ended on August 30, 2016. (R. 22.)
Plaintiff first argues that the ALJ failed to properly assess his RFC. According to plaintiff,
the evidence does not support the ALJ’s finding that plaintiff could work if he were able to avoid
bright sunlight or bright flickering lights, and the Vocational Expert (“VE”) should have
considered plaintiff’s use of dark, polarized glasses in his hypothetical. Additionally, plaintiff
complains that the ALJ failed to explain whether he found plaintiff’s reported limitations
consistent with the record, and the ALJ erred by relying on outdated medical opinions.
While an ALJ “is not required to address every piece of evidence,” he must “build an
accurate and logical bridge” connecting the evidence to the conclusions reached. Clifford v. Apfel,
227 F.3d 863, 872 (7th Cir. 2000). The ALJ’s 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).” SSR 968p, 1996 WL 374184, at *7 (July 2, 1996). The determination of RFC rests with the ALJ, not the
physicians. 20 C.F.R. § 404.1527(d)(2).

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Step five does not apply.

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Here, plaintiff testified that his eyes are sensitive to light, he cannot tolerate light for long
periods of time, light causes his eyes to become watery/teary, he gets headaches at least twice a
day, he lies down for a couple of hours in a dark room to alleviate his headaches, his impairments
have progressively worsened, he has pain in both eyes (more so in his right eye), and he wears a
patch and prescription polarized glasses. (R. 19, 41-50.) The ALJ determined that plaintiff’s
testimony concerning the intensity, persistence and limiting effects of his symptoms is not entirely
consistent with the medical records. (R. 19.) The ALJ noted that Dr. Beltran conducted a
consultative examination on August 19, 2016 and determined that plaintiff’s corrected vision in
his left eye was 20/25. (R. 19, 275.) He also acknowledged a Disability Hearing Officer’s
Decision, dated December 11, 2017, which noted that plaintiff “wears his prescription polaroid
glasses due to light sensitivity,” that plaintiff’s polaroid glasses help with pain in his left eye, and
that plaintiff gets headaches if he does not wear his glasses. (R. 20, 76.) The ALJ also noted that
plaintiff went for a second opinion on January 2, 2018 at the Midwest Eye Center about his eye
pain and light sensitivity. (R. 20, 327.) The notes from that consultation state that Plaintiff denied
having any symptoms. (Id.) As to opinion evidence, state agency medical consultants, Drs.
Kenney and Dow, issued opinions on August 25, 2016 and September 28, 2016, respectively. (R.
20, 279-286, 287-294.) Dr. Kenney determined that plaintiff could do work at all exertional levels
and had some visual limitations. (R. 20, 280-283.) Dr. Dow agreed and further determined that
plaintiff had some environmental limitations, including avoiding unprotected heights and
hazardous machinery. (R. 20, 288-291.) The ALJ gave great weight to Drs. Kenney and Dow’s
opinions and applied additional physical and environmental limitations based on plaintiff’s visual
limitations. (R. 20-21.)

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Plaintiff complains that his RFC is faulty because “[n]o medical opinions or treatment notes
in the record stated that [plaintiff] would be able to work if he were able to avoid bright sunlight
or bright flickering lights,” and “no medical opinion or other evidence reflected that he could use
his vision occasionally (or up to one third of a workday) for near visual acuity.” (Dkt. 17 at 7.)
As discussed, the ALJ considered plaintiff’s visual problems and complaints related to light
sensitivity and headaches. He noted that, while light irritates plaintiff’s eyes and causes headaches,
plaintiff’s polarized prescription glasses help. The ALJ also noted that plaintiff denied symptoms
of pain and light sensitivity in his left eye when he went for his second consultative eye exam on
January 2, 2018. Additionally, while the ALJ gave great weight to the state agency medical
consultants’ opinions, the ALJ created a more restrictive RFC. “When no doctor’s opinion
indicates greater limitations than those found by the ALJ, there is no error.” See Dudley v.
Berryhill, 773 F. App’x 838, 843 (7th Cir. 2019); Best v. Berryhill, 730 F. App’x 380, 382 (7th
Cir. 2018) (same). Accordingly, the Court finds that the ALJ’s decision sufficiently explains how
the RFC accommodates plaintiff’s visual limitations related to his light sensitivity.2
Plaintiff also argues that the ALJ erred by relying on outdated medical evidence. Plaintiff
points to the medical reports of Dr. Sarwar Zahid, Dr. M. Ovais Peracha, and Dr. Chee who discuss
plaintiff’s sensitivity to light and generally discuss plaintiff’s limited vision. (R. 324, 327, and
339.) Plaintiff also points to Dr. Mieler’s medical report3, dated April 27, 2018, which notes that

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Because the RFC is not faulty, the questions posed to the VE likewise were not faulty. See Wayne P. v. Saul,
No. 19-cv-8137, 2020 WL 5909066, at n.2 (N.D. Ill. Oct. 6, 2020).
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The ALJ gave little weight to Dr. Mieler’s opinion, explaining that Dr. Mieler’s opinion and eye exam results
are inconsistent. (R. 21.) The ALJ stated, “Dr. Mieler opined that the [plaintiff] had a left eye vision of 20/100, with
prescription glasses. However, the eye exam results attached to his opinion show the left eye vision of 20/70, which
is better than 20/100 . . . [a]dditionally, with regard to the eye exam results, it is unclear whether the exam was
conducted with prescription lenses.” (Id.) The Court notes that Dr. Mieler’s opinion is dated March 6, 2018 and,
therefore, pre-dates the April 27, 2018 examination. (Dkts. 333 and 335.) It is unclear if plaintiff underwent an eye
examination prior to the issuance of Dr. Mieler’s March 6, 2018 letter and whether the results of that (possible) earlier
examination would support Dr. Mieler’s opinion that plaintiff had 20/100 visual acuity.

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plaintiff has 20/70 vision.4 The evidence about plaintiff’s sensitivity to light is not new. However,
Dr. Mieler’s medical report about plaintiff’s reduced visual acuity is new and potentially
significant such that it could have informed the state agency medical consultants’ decision about
plaintiff’s ability to work. “An ALJ should not rely on an outdated assessment if later evidence
containing new, significant medical diagnoses reasonably could have changed the reviewing
physician’s opinion.” Moreno v. Berryhill, 882 F.3d 722, 728 (7th Cir. 2018). An ALJ may not
rely on a state agency medical consultant’s opinion if the physician did not review all pertinent
medical evidence. See, e.g., Goins v. Colvin, 764 F.3d 677, 680 (7th Cir. 2014) (“Fatally, the
administrative law judge failed to submit that MRI to medical scrutiny, as she should have done
since it was new and potentially decisive medical evidence.”). Dr. Beltran examined plaintiff in
August 2016 and determined plaintiff’s corrected vision in his left eye to be 20/25. The state
agency medical examiners reviewed these reports and determined that plaintiff had MI. Dr.
Mieler’s examination results from April 2018, however, show that plaintiff had 20/70 visual acuity
in his left eye, which represents low visual acuity.5 This medical evidence is new and potentially
decisive and should have been subjected to medical scrutiny. This matter is remanded for the ALJ
to address this issue.
Plaintiff also challenges the ALJ’s subjective symptom analysis. The Court declines to
discuss this issue at length given the need for remand that already exists.

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It is unclear whether this visual acuity number is with or without correction. (R. 325); (See also dkt. 17 at 910; dkt. 23 at 10-11.)
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Visual acuity of 20/70 to 20/160 is considered a moderate visual impairment or moderate low vision. See
American Optometric Association, Low Vision and Vision Rehabilitation, https://www.aoa.org/healthy-eyes/caringfor-your-eyes/low-vision-and-vision-rehab?sso=y (last visited March 17, 2021).

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Conclusion
For the reasons set forth above, the Court reverses the Commissioner’s decision, denies the
Commissioner’s motion for summary judgment [22], and remands this case for further proceedings
consistent with this Memorandum Opinion and Order.

SO ORDERED.

ENTERED: July 14, 2021

________________________________
M. David Weisman
United States Magistrate Judge

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