Shanahan et al v. Saul

Filing 15

MEMORANDUM Opinion and Order signed by the Honorable Virginia M. Kendall on 2/16/2021. The Court denies the Commissioner's Motion for Summary Judgment 12 , vacates the Commissioner's Judgment, and remands the case to the Social Security Administration for further proceedings consistent with Opinion. See Opinion for further details. Mailed notice(lk, )

Case: 1:20-cv-02190 Document #: 15 Filed: 02/16/21 Page 1 of 12 PageID #:538

IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
TIMOTHY SHANAHAN and PATRICIA
SHANAHAN,
Plaintiffs,
v.
ANDREW SAUL, Commissioner of Social
Security,
Defendant.

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No. 20 C 2190
Judge Virginia M. Kendall

MEMORANDUM OPINION AND ORDER
Plaintiffs Timothy and Patricia Shanahan seek review of an Administrative Law Judge’s
(“ALJ”) denial of Timothy Shanahan’s application for disability benefits under the Social Security
Act. (Dkt. 11). They argue the ALJ erred in determining Mr. Shanahan’s residual functional
capacity and ability to perform past relevant work. Before the Court is Defendant Commissioner’s
motion for summary judgment requesting the Court to affirm the ALJ’s decision. (Dkt. 12). For
the following reasons, the Court denies the Commissioner’s motion, vacates the Commissioner’s
judgment, and remands the case to the Social Security Administration for further proceedings
consistent with this opinion.
BACKGROUND
I.

Procedural History
On September 30, 2016, Timothy Shanahan applied for disability benefits with the Social

Security Administration claiming disability due to lower back pain, “hand problems,” carpel tunnel
syndrome, and hernia beginning on October 15, 2014. (Dkt. 10 at R. 173–74, 193). Shanahan's
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“date last insured”—the date by which he must have proven disability in order to be eligible for
benefits—was December 31, 2015. (Id. at R. 189). In January and March 2017, the Social Security
Administration denied Shanahan’s application on initial review and reconsideration, explaining
that the record contained no evidence of disability prior to December 31, 2015. (Id. at R. 81, 90).
Shanahan requested a hearing before an ALJ, which took place on July 16, 2018. (Id. at R. 32–77).
On November 2, 2018, the ALJ issued a decision denying Shanahan’s application. (Id. at R. 19–
26). On October 9, 2019 the Social Security Appeals Council denied Shanahan’s request for
review and upheld the ALJ's decision. (Id. at R. 1–3). 1 Shanahan subsequently filed the present
action seeking this Court’s review. (Dkt. 1).
II.

Relevant Medical History
The entirety of the medical record before the Court is from after Shanahan’s date last

insured, December 31, 2015. Shanahan represented he did not receive medical treatment in 2014
and 2015. (Dkt. 10 at R. 81). On February 22, 2016, Shanahan underwent endoscopy and
colonoscopy procedures to address issues regarding his longstanding gastroesophageal reflux
disease and history of colon polyps. (Id. at R. 301–03, 310-18). Doctors removed multiple polyps
during the procedures, diagnosed him with gastritis and hemorrhoids, and advised him to continue
treatment with medication. (Id. at R. 311, 314). In August 2016, Shanahan visited his primary care
provider, Dr. Shervin Derodi and complained of back pain. (Id. at R. 332-33). Dr. Derodi noted
that Shanhan had two back surgeries in 1991 and 1993, in addition to a surgery for his carpel tunnel
syndrome in 2013 and an ankle surgery. (Id.) Dr. Derodi diagnosed Shanahan with back pain and
inguinal hernia and ordered imaging to address these issues. (Id.) On September 6, 2016,

On or around this date, Timothy Shanahan passed away due to gastrointestinal bleeding. (Dkt. 11 at fn 1). His wife,
Patricia Shanahan, subsequently became the substitute party in the proceedings before the Social Security
Administration. (Id.)

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radiographic imaging of Shanahan’s back revealed surgical changes at L4–S1 and degenerative
disc changes at L2–L3. (Id. at R. 433). On September 9, 2016, Dr. Joubin Khorsand affirmed the
diagnosis of inguinal hernia and performed a hernia repair surgery on October 7, 2016. (Id. at R.
289–90, 292–93). Through a series of follow up appointments, Dr. Khorsand confirmed the
surgery had been successful. (Id. at R. 283–87).
On September 23, 2016, Shanahan saw Dr. Mehul Sekhadia at Advocate Lutheran General
Hospital for his back pain. (Id. at R. 409-419). Shanahan reported continuous stabbing and
shooting pain in his back that he ranked at 10/10 in intensity. (Id. at R. 409-10). He also reported
weakness in his legs. (Id. at R. 409). Dr. Sekhadia diagnosed him with sacroiliitis 2 and gave him
bilateral sacroiliac joint injections. (Id. at R. 411-19). He also noted a positive FABER test 3 and
limited range of motion in Shanahan’s lumbar spine. (Id. at R. 411). On November 3, 2016, an
MRI of Shanahan’s lumbar spine indicated moderate degenerative disc disease at T-12–L1 and
severe degenerative disc disease and mild stenosis at L2-L3. (Id. at R. 341-42). On November
22, 2016, Shanahan saw an orthopedic specialist who opined:
His [Shanahan’s] symptoms are back pain with no real radiation of pain and his
physical exam reveals a well-healed scar on his back [from previous surgery] with
negative straight leg raising and some complaints of pain with range of motion
testing. An MRI scan and standing x-rays do not reveal any substantial degenerative
changes adjacent to his previous fusion [surgery]. It is my opinion his symptoms
are largely arthritic.
(Id. at R. 343). The specialist prescribed medication for Shanahan’s symptoms and “recommended
that he continue [to] pursue his social security disability claim”. (Id.)
Sacroiliitis is the inflammation of the sacroiliac joints connecting the lower spine and pelvis. See
https://www.mayoclinic.org/diseases-conditions/sacroiliitis/symptoms-causes/syc20350747#:~:text=Sacroiliitis%20(say%2Dkroe%2Dil,climbing%20can%20worsen%20the%20pain.
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A FABER test is a diagnostic tool used to measure range of motion in the hips, lumbar spine, and sacroiliac regions.
A positive FABER test is indicative of limited range of motion.
See https://www.physiopedia.com/FABER_Test#:~:text=The%20FABER%20test%20is%20used,dysfunction%2C%20or%20an%20iliopso
as%20spasm.

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Medical records from 2017 and 2018 continue to indicate a diagnosis of intervertebral disc
disease, as well as hypertension and benign prostatic hyperplasia. (Id.at R. 364–87). In March
2018, Shanahan visited Dr. Derodi and complained of bilateral hip pain. (Id. at R. 366). Imaging
of Shanahan’s hips revealed “[v]ery mild degenerative changes.” (Id. at R. 434). In May 2018,
Shanahan saw Dr. Simon Adanin at the Interventional Pain Management Center at Advocate
Lutheran General Hospital. (Id. at R. 420-27). Shanahan reported constant and severe pain in his
back, hips, and legs. (Id. at R. 420). Dr. Adanin opined, “Shanahan is experiencing back and
bilateral lower extremity pain likely as a result of chronic lumbar radiculopathy, failed back
syndrome of the lumbar spine, lumbar degenerative disk disease. He also has left hip osteoarthritis
and insomnia.” (Id. at R. 425). He recommended physical therapy and a CT scan of the lumbar
spine due to the inefficacy of previous conservative treatment and surgical intervention. (Id. at R.
426).
III.

Relevant Work History
From 1988 to 2013, Shanahan worked as a sheet metal installer for a roofing company.

(Dkt. 10 at R. 194, 212). As part of this position, Shanahan claimed he had to climb ladders, work
off of scaffolds and lifts, and frequently lift 50 pounds or more. (Id. at R. 212-13). He further
alleged the job required walking, climbing, stooping, kneeling, crouching, and handling or
grasping large objects. (Id.)
IV.

Hearing Testimony
At the July 16, 2018 hearing before the ALJ, Shanahan testified regarding the pain in his

lower back, hips, and legs. (Dkt. 10 at R. 46). Shanahan stated he can walk only about a block
before he is “in so much pain [his] legs give out” and can stand for about 15 to 20 minutes at a
time. (Id. at R. 46, 60). He further testified that his “back hurts all the time,” including when sitting

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and that he “lose[s] feeling in [his] hands a lot.” (Id. at R. 60–61). Shanahan takes medication for
his pain which helps “somewhat” but not completely. (Id. at R. 46-47).
In addition to Shanahan, medical and vocational experts also testified at the hearing.
Medical expert, Dr. Sai Nimmagadda, endorsed diagnoses of degenerative disc disease, bilateral
carpel tunnel syndrome, and inguinal hernial repair based on the medical record. (Id. at R. 50).
Based on his review of the medical records, Dr. Nimmagadda concluded Shanahan did not meet
the requirements of any disability listings in 20 CFR 404 and placed Shanahan’s residual
functional capacity “at a medium exertional function capacity” as of December 31, 2015. (Id. at
R. 50-51). He testified that he would not place any postural limitations on Shanahan other than
limiting stooping and bending to frequent, and imposed weight limits of 50 pounds occasionally
and 25 pounds frequently. (Id. at R. 53–54).
On the day of the hearing, Shanahan presented the Court with medical records from
Shanahan’s visits to Advocate Lutheran General Hospital in 2016 and 2018 that were not reviewed
by Dr. Nimmagadda. (Id. at R. 54–55). Shanahan’s attorney requested Dr. Nimmagadda review
the new records during the hearing to see if they might alter his conclusions. (Id. at R. 55). The
ALJ interjected, however, that he had already “look[ed] at the records” and “didn’t find anything
earthshaking in them….” (Id.) Consequently, Dr. Nimmagadda did not review the novel evidence.
(Id. at R. 56).
Next, vocational expert Linda Gels classified Shanahan’s sheet metal installation job as
requiring medium strength based on the Dictionary of Occupational Titles’ (“DOT”) description
of a “sheet metal worker.” DOT 804.281-010. (Id. at R. 63). Gels stated that per DOT descriptions,
the job would not require more than frequent climbing, balancing, stooping, kneeling, crouching,
and other similar postural movements. (Id. at R. 74).

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V.

The ALJ’s Findings
To determine whether a claimant is disabled and thus ineligible for disability insurance

benefits, an ALJ uses a sequential five-step inquiry. See 20 C.F.R. § 416.920(a)(4); Kastner v.
Astrue, 697 F.3d 642, 646 (7th Cir. 2012). The inquiry asks: (1) whether the claimant is currently
employed; (2) whether the claimant has a severe impairment; (3) whether the claimant's
impairment is one that the Commissioner considers conclusively disabling; (4) if the claimant does
not have a conclusively disabling impairment whether he can perform his past relevant work, in
light of his residual functional capacity (“RFC”); and (5) if the claimant cannot perform his past
relevant work, whether he is capable of performing any work in the national economy. Kastner,
697 F.3d at 646. Here, the ALJ found Shanahan had not engaged in substantially gainful
employment since October 15, 2014 and that Shanahan had the following severe impairments
during the relevant period: status post L4–S fusion, L2–L3 and T12–L1 degenerative disc disease,
arthritis of the bilateral hips, and status post hernia repair. (Dkt. 10 at R. 22). He also determined
Shanahan had several non-severe medical impairments, including hypertension, bilateral carpal
tunnel syndrome, and prostatic hyperplasia. (Id.) The ALJ did not, however, find Shanahan’s
impairments conclusively disabling at step three. (Id. at R. 22-23). At step four, the ALJ
determined Shanahan “had the residual functional capacity to perform medium work … except
frequently balance, climb ladders/ropes/scaffolds/stairs/ramps, stoop, crouch, kneel, and crawl,”
and consequently found Shanahan capable of performing his past relevant work as a sheet metal
worker. (Id. at R. 23, 26). The ALJ dismissed Shanahan’s subjective statements regarding his pain,
on the basis that Shanahan's “statements concerning the intensity, persistence, and limiting effects
of [his] symptoms are not entirely consistent with the medical evidence and other evidence in the
record ….” (Id. at R. 24).

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LEGAL STANDARD
Because the Appeals Council denied review, this Court evaluates the ALJ's decision as “the
final word of the Commissioner of Social Security.” Moreno v. Berryhill, 882 F.3d 722, 728 (7th
Cir. 2018), as amended on reh'g (Apr. 13, 2018). A reviewing court will affirm the Commissioner's
final decision where it is supported by “substantial evidence” and the ALJ applied the correct legal
standard. Bates v. Colvin, 736 F.3d 1093, 1097-98 (7th Cir. 2013) (citing 42 U.S.C. § 405(g)).
“Substantial evidence” is “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.’” Beardsley v. Colvin, 758 F.3d 834, 836 (7th Cir. 2014) (quoting
Richardson v. Perales, 402 U.S. 389, 401 (1971)). “To determine whether substantial evidence
exists, the court reviews the record as a whole but does not attempt to substitute its judgment for
the ALJ's by reweighing the evidence, resolving material conflicts, or reconsidering facts or the
credibility of witnesses.” Id. at 836-37. The ALJ's decision, however, must rest on “adequate
evidence contained in the record and must explain why contrary evidence does not persuade.”
Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 2008). The ALJ must “build a logical bridge from
the evidence to his conclusion….” Shideler v. Astrue, 688 F.3d 306, 310 (7th Cir. 2012) (quotations
and citation omitted). If the ALJ's decision “lacks evidentiary support or is so poorly articulated
as to prevent meaningful review,” remand is required. Kastner, 697 F.3d at 646 (quotations and
citation omitted).
DISCUSSION
Shanahan challenges the ALJ’s step four findings regarding his residual functional capacity
and ability to perform past relevant work. Specifically, he argues the ALJ erred by (1) failing to
consider the effects of non-severe impairments on his RFC, (2) dismissing his subjective testimony

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regarding his limitations, (3) relying too heavily on unreliable medical expert testimony, and (4)
relying on an inaccurate DOT classification.
I.

Residual Functional Capacity

A claimant's RFC represents the maximum he can do in a work setting despite his mental
and physical limitations. 20 C.F.R. § 404.1545(a). An RFC determination must account for the
combined effects of all impairments, including those that are not severe.” Villano v. Astrue, 556
F.3d 558, 563 (7th Cir. 2009). The ALJ must follow a two-step process in considering a claimant’s
symptoms. First, he must determine whether there is an underlying medically determinable
physical or mental impairment(s) that could reasonably be expected to produce the claimant’s pain
or symptoms. See Nicholson v. Astrue, 341 F. App'x 248, 251 (7th Cir. 2009). Second, the ALJ
must evaluate the intensity, persistence, and limiting effects of the claimant’s symptoms to
determine the extent to which they limit the claimant’s functioning. See 20 C.F.R. § 404.1529(c).
Consideration of Non-Severe Impairments
In Shanahan’s case, the ALJ failed to consider the effects of Shanahan’s hypertension,
bilateral carpel tunnel syndrome, and prostatic hyperplasia on his RFC. Although the ALJ
previously found that these impairments were not severe, he remained obligated to consider their
effects in his separate assessment of Shanahan’s RFC. See § 404.1545(a)(2). The ALJ’s opinion
is also devoid of mention, let alone consideration, of other medical conditions evidenced in the
record, such as Shanahan’s gastroesophageal reflux disease and history of colon polyps for which
Shanahan required endoscopy and colonoscopy procedures in February 2016, mere months after
his date last insured. (Dkt. 10 at R. 301–03; 310-18). The ALJ’s boilerplate explanation that he
“has considered all symptoms and the extent to which these symptoms can reasonably be accepted
as consistent with the objective medical evidence and other evidence” is not enough. (Id. at R. 23).

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Shanahan raised these conditions to the ALJ and produced medical evidence to support the
diagnoses, so they required consideration. See Spicher v. Berryhill, 898 F.3d 754, 759 (7th Cir.
2018). Moreover, the ALJ precluded himself from review of the combined effects of Shanahan’s
impairments by not considering the effects of many in the first place. This, too, was error. See §
423(d)(2)(B).
Shanahan’s Credibility
In evaluating Shanahan’s RFC, the ALJ dismissed Shanahan’s subjective statements
regarding the intensity, persistence, and limiting effects of his symptoms on grounds that the
statements “are not entirely consistent with the medical evidence and other evidence in the
record….” (Dkt. 10 at R. 24). An ALJ’s credibility determination is reviewed with deference and
is reversed “only if it is so lacking in explanation or support that” it is “patently wrong.” Simila v.
Astrue, 573 F.3d 503, 517 (7th Cir. 2009) (quotations and citation omitted). The ALJ must
nevertheless “articulate specific reasons for discounting a claimant’s testimony” and cannot
“rely[] solely on a conflict between the objective medical evidence and the claimant's testimony
as a basis for a negative credibility finding.” Schmidt v. Barnhart, 395 F.3d 737, 746–47 (7th Cir.
2005); se e also Johnson v. Barnhart, 449 F.3d 804, 806 (7th Cir. 2006) (“[T]he administrative
law judge cannot disbelieve her testimony solely because it seems in excess of the ‘objective’
medical testimony.”). 20 C.F.R. § 404.1529 requires the ALJ to consider multiple sources of
evidence in making a credibility determination, including the claimant’s daily activities and the
efficacy of medications in relieving the claimant’s pain.
At the outset, the ALJ relied only on medical evidence and medical expert testimony to
support his adverse credibility determination and failed to consider other factors such as
Shanahan’s daily activities or the efficacy of the pain medication he takes. (Dkt. 10 at R. 24-25).

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Furthermore, the ALJ afforded “significant weight” to the hearing testimony of medical expert Dr.
Sai Nimmagadda, but Dr. Nimmagadda’s conclusions are based on an incomplete review of the
medical records. After unilaterally determining that some of records had nothing “earthshaking”
in them, the ALJ did not allow Dr. Nimmagadda to review them. (Id. at R. 55). Significantly, the
unreviewed documents include medical records from 2016 evidencing Shanahan’s sacroiliitis and
the need for bilateral sacroiliac injections that is not evidenced elsewhere in the record. (Id. at R.
411-19). During this 2016 visit, the diagnosing physician also noted a positive FABER test and
limited range of motion in Shanahan’s lumbar spine. (Id. at R. 411). The ALJ precluded Dr.
Nimmagadda from determining whether this diagnosis and treatment, along with other information
reflected in the unreviewed records, would have altered his conclusion that Shanahan had a
medium exertional functional capacity. The Court must discount the ALJ’s heavy reliance on Dr.
Nimmagadda’s testimony for that reason. Given the “significant weight” placed on Dr.
Nimmagadda’s hampered testimony and the ALJ’s sole reliance on medical evidence, the Court
concludes the ALJ’s adverse credibility and RFC determinations were unsupported by substantial
evidence.
The Court does not, however, discredit the ALJ’s analysis of the medical evidence itself.
While Shanahan claims the ALJ neglected to mention certain evidence and testimony in his
discussion, (see Dkt. 11 at 9-10), an ALJ “need not mention every strand of evidence in h[is]
decision but only enough to build an accurate and logical bridge from evidence to conclusion.”
Simila, 573 F.3d at 517 (quotations and citations omitted). Here, the ALJ clearly explained why
the medical records cited tend to undermine Shanahan’s subjective accounts of pain. Shanahan
also faults the ALJ for giving greater weight to benign clinical findings from September 2016 than
to more serious findings in later years. He argues: “As all of the evidence reflects examination and

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testing subsequent to the date last insured, it makes no sense that a single anomalous finding would
carry more weight than the rest of the findings, which are more dire.” (Dkt. 11 at 11). First, it is
not clear that the September 2016 findings are “anomalous,” as findings from even November
2016 indicate less severity in Shanahan’s condition than Shanahan claims. (See Dkt. 10 at R. 343).
Second, and more importantly, the ALJ’s decision to place greater weight on evidence closer to
the date last insured is reasonable, as medical records closer in time to that date would tend to
better represent Shanahan’s physical condition during the relevant time period. Shanahan had the
burden to produce medical evidence and prove a disability prior to December 31, 2015. By failing
to produce medical records prior to that date, he “bears the risk of uncertainty, even if the reason
for the sparse record is” a lack of treatment. Eichstadt v. Astrue, 534 F.3d 663, 668 (7th Cir. 2008).
II.

Ability to Perform Past Relevant Work

Finally, Shanahan argues the ALJ erred in accepting the vocational expert’s classification
of Shanahan’s sheet metal installation job under DOT 804.281-010. Shanahan maintains this
classification is an inaccurate description of his job because he testified his job required him to
work on a roof, and DOT 804.281-010 does not include that requirement. As the vocational
expert testified, however, the alternative DOT classification for sheet metal worker is “metal
roofer.” (Dkt. 10 at R. 72). Notably, the DOT description for a regular “roofer,” DOT 866.381010, explicitly excludes sheet metal installation (id. at R. 74), leaving DOT 804.281-010 as a
reasonably applicable DOT classification to Shanahan’s past relevant work. The ALJ did not err
in using DOT 804.281-010 as a description of Shanahan’s past relevant work.

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CONCLUSION
For the foregoing reasons, the Court denies the Commissioner’s motion for summary
judgment [12], vacates the Commissioner’s judgment, and remands the case to the Social Security
Administration for further proceedings consistent with this opinion.

____________________________________
Virginia M. Kendall
United States District Judge
Date: February 16, 2021

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