Jackson v. Kijakazi

Filing 18

MEMORANDUM Opinion and Order: The Court denies the Commissioner's motion for summary judgment [dkt. no. 15], grants Jackson's request to reverse and remand the agency's decision, and directs the Clerk to enter judgment vacating the decision of the Social Security Administration and remanding the case for further consideration consistent with the Court's decision. Civil case terminated. Signed by the Honorable Matthew F. Kennelly on 9/19/2022. Mailed notice. (mma, )

Case: 1:21-cv-05208 Document #: 18 Filed: 09/19/22 Page 1 of 9 PageID #:604

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
DEMARIO R. JACKSON,
Plaintiff,
vs.
KILOLO KIJAKAZI, Acting
Commissioner of Social Security,
Defendant.

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Case No. 21 C 5208

MEMORANDUM OPINION AND ORDER
MATTHEW F. KENNELLY, District Judge:
Demario Jackson seeks to overturn the denial of his application for Supplemental
Security Income (SSI). Jackson contends that he is disabled because he suffers from
congestive heart failure, cervical degenerative disc disease, and vision problems.
An Administrative Law Judge (ALJ) found that only Jackson's congestive heart
failure was a severe impairment. The ALJ went on to find that it significantly limited
Jackson's functional capability in various ways but ultimately concluded that there were
jobs that he could perform that existed in significant numbers. The ALJ thus determined
that Jackson did not qualify as disabled as of January 24, 2019, the date he submitted
his application for SSI. The Social Security Administration's Appeals Council denied
Jackson's request for review of the ALJ's decision.
Jackson has filed suit to challenge the decision. He argues that the ALJ failed to
properly evaluate his cervical disc disease, did not properly account for his limitations in
determining his residual functional capacity (RFC), and improperly evaluated his

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subjective statements regarding his impairments.
For the reasons explained below, the Court concludes that the ALJ erred in its
RFC determination and therefore reverses the agency's decision and remands the case
for further consideration.
Background
Jackson applied for SSI on January 24, 2019, claiming a disability onset date of
January 1, 2019. The Court will summarize Jackson's condition and ALJ Robert Long's
decision as relevant to this appeal. The following facts are undisputed except where
otherwise noted.
After presenting to an emergency room with shortness of breath and chest
pressure on January 15, 2019, Jackson was diagnosed with severe coronary artery
disease, cardiomyopathy, and congestive heart failure. He had at least twelve follow-up
appointments throughout 2019 and 2020, all of which were for treatment related to
cardiac issues. Records from two of those appointments noted that Jackson had
normal range of motion or normal motor function. None of those records mentioned any
cervical disc or vision issues.
An August 2019 examination by consultative examiner Dr. Robert Cotler stated
that Jackson reported having his first heart attack in December 2018 and that he was
hospitalized for a second heart attack in April 2019. Dr. Cotler assessed Jackson with
coronary artery disease, ischemic cardiomyopathy, left ventricular thrombus, congestive
heart failure, hypertension, and diminished visual acuity.
Dr. Cotler also determined that Jackson suffered from cervical spine disease. He
stated that Jackson had full painless range of motion in degrees of all nonaxial joints,

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normal grip strength, and normal use of his hands and fingers. Dr. Cotler noted,
however, that Jackson had moderate multilevel degenerative change of the cervical
spine and a reduced range of motion in that area.
In September 2019, State agency medical consultant Dr. Calixto Aquino opined
that Jackson could perform work at the light exertional level. Dr. Aquino did not
personally examine Jackson.
In December 2020, Jackson testified at a hearing about his impairments. He
stated that he experienced regular chest pain, fatigue, dizziness, and difficulty moving
his neck. He also said that he could not stand or sit for long periods of time, walk more
than a mile, or lift more than 30 pounds.
An April 2020 determination by a different State agency medical consultant, Dr.
Richard Bilinsky, arrived at a different conclusion from Dr. Aquino. Dr. Bilinsky found
that Jackson could only perform work at the sedentary exertional level. Dr. Bilinsky did
not personally examine Jackson.
On February 21, 2021, the ALJ issued a decision denying Jackson's SSI claim.
The ALJ found that Jackson was more limited than Dr. Aquino opined, but he agreed
with Dr. Bilinsky that Jackson could work at the sedentary exertional level. He
determined that Jackson's residual functional capacity included—but was not limited
to—lifting and carrying up to ten pounds and standing or walking two hours in an eighthour workday.
Jackson challenges three of the ALJ's findings as erroneous: (1) his cervical disc
disease was not a severe impairment, (2) he had the residual functional capacity to
work at the sedentary exertional level, and (3) he could perform jobs that exist in

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significant numbers in the national economy.
When the Appeals Council denied Jackson's request for review on July 28, 2021,
the ALJ's decision became the final decision of the Commissioner of Social Security.
See Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015). Jackson then filed this lawsuit
seeking judicial review of the Commissioner's final decision, in accordance with 42
U.S.C. § 405(g). Jackson asks the Court to remand the case to the agency to calculate
and award benefits, or in the alternative, for further proceedings. The Commissioner of
Social Security has moved for entry of judgment against Jackson.
Discussion
After exhausting administrative remedies, an applicant for Social Security
benefits may seek review of a denial in federal district court. 42 U.S.C. § 405(g). "The
court shall have power to enter, upon the pleadings and transcript of the record, a
judgment affirming, modifying, or reversing the decision of the Commissioner of Social
Security, with or without remanding the cause for a rehearing." Id.
On review, the ALJ's findings of fact are conclusive if they are supported by
substantial evidence. Meuser v. Colvin, 838 F.3d 905, 910 (7th Cir. 2016). Substantial
evidence is evidence that "a reasonable mind might accept as adequate to support a
conclusion." Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014). The substantial
evidence standard, however, does not insulate the ALJ's findings and conclusions from
review. "Although this standard is generous, it is not entirely uncritical." Overman v.
Astrue, 546 F.3d 456, 462 (7th Cir. 2008) (internal quotation marks omitted). A court
conducts "a critical review of the evidence," considering the evidence that supports and
evidence that detracts from the SSA's decision. Briscoe ex rel. Taylor v. Barnhart, 425

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F.3d 345, 351 (7th Cir. 2005) (internal quotation marks omitted). "'The decision cannot
stand if it lacks evidentiary support or an adequate discussion of the issues.'" Id.
(quoting Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003)). "In
addition to relying on substantial evidence, the ALJ must also explain his analysis of the
evidence with enough detail and clarity to permit meaningful appellate review." Id.
The ALJ followed a five-step evaluation process to determine whether Jackson
was disabled during the relevant period. See 20 C.F.R. § 404.1520(a). The second
and fourth steps of this evaluation are the most relevant to this appeal. At the second
step, the ALJ determines whether the claimant's impairment or combination of
impairments limits his physical or mental ability to do basic work activities. Id. §
404.1520(c). The fourth step involves determining the claimant's RFC, that is, his ability
to work on a sustained basis despite impairment limitations. Id. § 404.1520(e).
A.

Severity
Jackson argues that the ALJ erred in determining that his cervical degenerative

disc disease was not severe at step two. Although he is correct that this step is "a de
minimis screening for groundless claims," Thomas v. Colvin, 826 F.3d 953, 960 (7th Cir.
2016), errors at this stage are harmless if the ALJ "properly considered all of [the
claimant]'s severe and non-severe impairments, the objective medical evidence, her
symptoms, and her credibility when determining her RFC immediately after step 3."
Curvin v. Colvin, 778 F.3d 645, 649 (7th Cir. 2015); see also Arnett v. Astrue, 676 F.3d
586, 591 (7th Cir. 2012) ("But even if there were a mistake at Step 2, it does not matter.
Deciding whether impairments are severe at Step 2 is a threshold issue only; an ALJ
must continue on to the remaining steps of the evaluation process as long as there

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exists even one severe impairment.") (emphasis in original).
The ALJ in this case satisfied step two by categorizing Jackson's congestive
heart failure as a severe impairment. Thus even if the ALJ erred in finding that cervical
disc disease is not severe, it is a harmless error unless he also failed to incorporate all
the impairments—both severe and non-severe—into his RFC determination. Jackson
contends that the ALJ erred in this regard by failing to consider the impact of his cervical
disc condition. Because the argument that an ALJ failed to consider the cumulative
impact of all of the claimant's impairments "boil[s] down to a contention that the ALJ
overstated [his] RFC by making this mistake," Jackson's appeal "comes down to
whether the ALJ erred in assessing [his] RFC." Arnett, 676 F.3d at 591.
B.

RFC determination
Jackson argues next that the ALJ erred at step four of the evaluation process.

Among other arguments, he contends that the ALJ's determination of his RFC does not
adequately take into account his cervical degenerative disc disease. 1 The Seventh
Circuit has "frequently reminded the agency that an ALJ must consider the combined
effects of all of the claimant's impairments, even those that would not be considered
severe in isolation." Terry v. Astrue, 580 F.3d 471, 477 (7th Cir. 2009) (collecting
cases). If an ALJ believes that certain impairments are not severe, "that would only
justify discounting their severity, not ignoring them altogether." Id. "Although an ALJ
need not mention every snippet of evidence in the record, the ALJ must connect the

Because an ALJ's failure to consider all impairments in his RFC determination
warrants remand, Curvin, 778 F.3d at 649, the Court need not address Jackson's other
arguments, including the constitutional argument that Jackson withdrew in his reply
brief.

1

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evidence to the conclusion; in so doing, he may not ignore entire lines of contrary
evidence." Arnett, 676 F.3d at 591.
In this case, the ALJ did not properly consider Jackson's cervical degenerative
disc disease. The ALJ’s opinion is almost eleven pages—over four pages of which
discuss the RFC—but it references that condition only once in passing after concluding
that it was not a severe impairment. Much of the RFC analysis consists of stating the
results of Jackson's medical appointments between January 2019 and July 2020.
When summarizing Dr. Cotler's examination, the ALJ mentions only that Jackson
"demonstrated reduced cervical range of motion" but "full painless range of motion
otherwise." Admin. Rec. 22. After evaluating Dr. Aquino's and Dr. Bilinsky's opinions,
the ALJ concluded that he had "accommodated [Jackson]'s impairments and associated
symptoms by limiting him to work at the sedentary exertional level." Id. at 23–24. The
ALJ only stated, however, that Jackson's "congestive heart failure has been
accommodated by the postural limitations" without mentioning the cervical disc
impairment or indicating how the RFC accommodated it.
Although courts do not reweigh the evidence before the ALJ, remand is
appropriate if "[n]othing in the ALJ's opinion explains how" the RFC is consistent with
the limitations associated with an impairment and "the RFC makes no reference to any
work limitations that would accommodate [the impairment]." Arnett, 676 F.3d at 592.
Given the lack of any discussion of Jackson's cervical disc condition in the RFC
determination, this case warrants remand because (at a minimum) the Court "has no
idea what the ALJ thought about this evidence." Id.
The Commissioner argues that the RFC determination was supported by

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substantial evidence because (1) records from Jackson's other appointments either
stated that his range of motion was normal or failed to mention any limitations, and (2)
the ALJ properly relied on the opinion of Dr. Bilinsky. Yet Jackson's cervical disc
disease was diagnosed by Dr. Cotler, the agency's examining physician, and "rejecting
or discounting the opinion of the agency's own examining physician that the claimant is
disabled, as happened here, can be expected to cause a reviewing court to take notice
and await a good explanation for this unusual step." Beardsley v. Colvin, 758 F.3d 834,
839 (7th Cir. 2014) ("The problem in this case is that the ALJ did not provide a valid
explanation for preferring the record reviewer's analysis over that of the agency's
examining doctor."). A “good explanation” was lacking here.
The ALJ found Dr. Bilinsky's opinion most persuasive—even though he never
examined Jackson as Dr. Cotler did—because the ALJ believed that opinion was
consistent with the record as a whole. Jackson correctly points out, however, that the
record in this case consists almost exclusively of documents from appointments for his
cardiac issues. The Seventh Circuit has rejected relying on medical records to
contradict the opinion of a disinterested expert where the doctor who prepared the
records "is not looking for [a specific condition] and may not even be competent to
diagnose it." Wilder v. Chater, 64 F.3d 335, 337 (7th Cir. 1995). 2 The Court therefore
cannot conclude that the lack of any mention of cervical disc issues in these cardiology
records is a valid reason for preferring Dr. Bilinsky's analysis over Dr. Cotler's. But even

Although Wilder involved the lack of a diagnosis of depression in medical records of
purely physical ailments and all of Jackson's impairments are physical, nothing in the
record or the ALJ's opinion suggests that the cardiologists who examined Jackson were
looking for cervical spine issues or would be able to properly diagnose them.

2

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if the medical records were enough, "that would only justify discounting" the severity of
Jackson's cervical disc condition rather than "ignoring [it] altogether." Terry, 580 F.3d at
477.
In short, substantial evidence does not support the ALJ's determination of
Jackson's residual functional capacity.
C.

Award of benefits vs. remand for further proceedings
Jackson asks the Court to remand the case with directions to award him benefits.

The Court agrees with the agency that this is inappropriate. Remand with an instruction
to award benefits is the appropriate resolution "only if all factual issues involved in the
entitlement determination have been resolved and the resulting record supports only
one conclusion—that the applicant qualifies for disability benefits." Allord v. Astrue, 631
F.3d 411, 415 (7th Cir. 2011). That is not the case here; factual issues remain
regarding how Jackson's cervical disc disease impacts his RFC. The Court therefore
overrules Jackson's request for a remand with a direction to award him disability
benefits.
Conclusion
For the reasons stated above, the Court denies the Commissioner's motion for
summary judgment [dkt. no. 15], grants Jackson's request to reverse and remand the
agency's decision, and directs the Clerk to enter judgment vacating the decision of the
Social Security Administration and remanding the case for further consideration
consistent with the Court's decision.
________________________________
MATTHEW F. KENNELLY
United States District Judge

Date: September 19, 2022
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