Marquez v. Commissioner of Social Security
MEMORANDUM Opinion and Order Signed by the Honorable Sunil R. Harjani on 1/18/2023. Mailed notice(lxs, )
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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
Case No. 21 C 5565
Acting Commissioner of Social Security,
Magistrate Judge Sunil R. Harjani
MEMORANDUM OPINION AND ORDER
Plaintiff Rodolfo M. seeks review of the final decision of the Acting Commissioner of
Social Security denying his claim for Disability Insurance Benefits (“DIB”) and Supplemental
Security Income (“SSI”). Rodolfo requests reversal of the ALJ’s decision and remand, and the
Acting Commissioner moves for summary judgment affirming the decision. For the following
reasons, the Court affirms the ALJ’s decision.
Born on September 7, 1963, Rodolfo was 56 years old when he applied for DIB and SSI
on September 20, 2019. Rodolfo alleges disability as of July 19, 2019 due to gout and knee and
back problems. Rodolfo obtained a GED and last worked in July 2019 as a delivery driver for a
On February 11, 2021, the administrative law judge (“ALJ”) issued a decision denying
Rodolfo’s applications. (R. 15-24).
The ALJ concluded that Rodolfo’s gout was a severe
impairment but did not meet or equal any of the impairments listed in 20 C.F.R. Part 404, Subpart
P, Appendix 1. Id. at 18-19. The ALJ specifically considered Listing 14.09 for inflammatory
arthritis. Id. at 19.
The ALJ found Rodolfo’s mental impairments of mood disorder and
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posttraumatic stress disorder to be non-severe impairments. Id. at 18. Under the “paragraph B”
analysis, the ALJ found that Rodolfo had no more than a mild limitation in the four functional
areas of understanding, remembering or applying information, interacting with others,
concentrating, persisting, or maintaining pace, and adapting or managing oneself. Id. The ALJ
then determined that Rodolfo had the residual functional capacity (“RFC”) to perform medium
work except that he had the following additional limitations: frequently climb ramps and stairs,
but never climb ladders, ropes, or scaffolds; frequently balance, stoop, kneel, crouch or crawl; and
occasional exposure to heat, vibration and hazards. Id. at 19. Based on the vocational expert’s
testimony, the ALJ found that Rodolfo is able to perform his past relevant work as a route driver.
Id. at 22. Alternatively, the ALJ found that Rodolfo was not disabled because he can perform jobs
existing in significant numbers in the national economy, including cleaner, kitchen helper, and
packer. Id. at 22-23.
Under the Social Security Act, disability is defined as the “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 12 months.” 42 U.S.C. § 423(d)(1)(A). To determine whether
a claimant is disabled, the ALJ conducts a five-step inquiry: (1) whether the claimant is currently
unemployed; (2) whether the claimant has a severe impairment; (3) whether the claimant’s
impairment meets or equals any of the listings found in the regulations, see 20 C.F.R. § 404, Subpt.
P, App. 1 (2004); (4) whether the claimant is unable to perform his former occupation; and (5)
whether the claimant is unable to perform any other available work in light of his age, education,
and work experience. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); Clifford v. Apfel, 227 F.3d 863,
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868 (7th Cir. 2000). These steps are to be performed sequentially. 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). “An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a
finding that the claimant is disabled. A negative answer at any point, other than Step 3, ends the
inquiry and leads to a determination that a claimant is not disabled.” Clifford, 227 F.3d at 868
(internal quotation marks omitted).
Judicial review of the ALJ’s decision is limited to determining whether the ALJ’s findings
are supported by substantial evidence or based upon a legal error. Steele v. Barnhart, 290 F.3d
936, 940 (7th Cir. 2002). Substantial evidence is “more than a mere scintilla” and means “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek
v. Berryhill, --- U.S. ----, 139 S.Ct. 1148, 1154 (2019) (internal quotation marks omitted). In
reviewing an ALJ's decision, the Court “will not reweigh the evidence, resolve debatable
evidentiary conflicts, determine credibility, or substitute [its] judgment for the ALJ's
determination.” Reynolds v. Kijakazi, 25 F.4th 470, 473 (7th Cir. 2022) (internal quotation marks
omitted). Nevertheless, where the ALJ’s decision “lacks evidentiary support or is so poorly
articulated as to prevent meaningful review, the case must be remanded.” Steele, 290 F.3d at 940.
Rodolfo raises only one alleged error in the ALJ’s decision—namely, that the ALJ
improperly rejected the opinions of his treating physician Maria Castellon, M.D., when
formulating his RFC. 1 Rodolfo generally argues that the ALJ failed to provide a legally sufficient
explanation to discount Dr. Castellon’s opinions. The Court disagrees and concludes that the ALJ
Rodolfo does not challenge the ALJ’s handling of the other opinion evidence. The ALJ also
considered the opinions of Dr. Rochelle Hawkins (consulting examining physician), Dr. Ana A. Gil
(consulting examining psychiatrist), and the state agency medical and psychological consultants (Drs.
Karen Hoelzer, Rohini Mendonca, Ellen Rozenfeld, and Nichole Robicheau).
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offered an adequate explanation supported by more than a scintilla of evidence for finding that
certain opinions provided by Dr. Castellon were not persuasive.
The ALJ's evaluation of the medical opinion evidence in Rodolfo’s case was subject to new
regulations pertaining to claims filed on or after March 27, 2017. 20 C.F.R. §§ 404.1520c,
416.920c (2017). Under the new regulations, the ALJ “will not defer or give any specific
evidentiary weight, including controlling weight, to any medical opinion(s) or prior administrative
medical finding(s), including those from [a claimant's] medical sources.” 20 C.F.R. §§
404.1520c(a), 416.920c(a). An ALJ need only articulate “how persuasive [she] find[s] all of the
medical opinions and all of the prior administrative medical findings in [a claimant's] case record.”
20 C.F.R. §§ 404.1520c(b), 416.920c(b). The regulations direct the ALJ to consider the
persuasiveness of medical opinions using several listed factors, including supportability,
consistency, relationship with the claimant, specialization, and other factors that tend to support or
contradict a medical opinion or prior administrative medical finding. 20 C.F.R. §§ 404.1520c(a),
(c), 416.920c(a), (c). Supportability and consistency are the two most important factors. 20 C.F.R.
§§ 404.1520c(a), 416.920c(a).
An ALJ must explain how she considered the factors of
supportability and consistency in her decision, but she is not required to explain how she
considered the other factors. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).
On September 15, 2020, Dr. Castellon completed a Treating Source Statement – Physical
Conditions form. (R. 406-09). On this form, Dr. Castellon noted that she had been treating Rodolfo
every two weeks for one month. Id. at 406. She listed Rodolfo’s diagnoses as gout, acute
exacerbation of chronic back pain, renal insufficiency, and prediabetes. Id. Dr. Castellon checked
boxes indicating that Rodolfo could maintain concentration for less than two hours before needing
a break, would likely be off task greater than 25% of the workday due to his symptoms such as
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pain or medication side effects, would likely be absent from work more than four days per month
due to his impairments, could occasionally lift 10 pounds and rarely lift 20 pounds, could
occasionally carry 50 pounds and rarely carry 20 pounds, could sit for six hours in a workday,
could stand/walk for five hours in a workday, and would require the option to sit/stand-at will and
sometimes lie down or recline throughout the workday. Id. at 406-07. In response to a question
asking Dr. Castellon to identify the particular medical or clinical findings that support her assessed
lifting and carrying limitations, she wrote: “Patient has tenderness on palpation on paraspinal
thoracic vert[ebrae], limited range of motion of back and shoulders bilaterally.” Id. at 407. Dr.
Castellon provided the following medical or clinical findings to support her opined sitting,
standing, and walking restrictions: “Patient uncomfortable when standing/sitting for long periods
of time [without] changing position.” Id.
In addition, Dr. Castellon checked boxes indicating that Rodolfo could rarely reach
overhead, but occasionally reach in all other directions and push and pull, and that he could
frequently handle, finger, feel, and operate foot controls bilaterally. (R. 408). Moreover, Dr.
Castellon indicated that Rodolfo could rarely climb ladders and scaffolds, stoop, crouch, and
operate moving mechanical parts; occasionally climb stairs and ramps, kneel, and crawl; and
frequently balance, rotate head and neck, work at unprotected heights, operate a vehicle, tolerate
exposure to humidity and wetness, dust, odors, fumes, pulmonary irritants, extreme temperatures,
and vibrations. Id. at 409. When asked to describe the medical or clinical findings that support her
postural limitations, Dr. Castellon explained that “Patient’s back ROM is limited.” Id.
Two weeks later, on September 29, 2020, Dr. Castellon completed a Treating Source
Statement – Psychological Conditions form. (R. 418-22). In this statement, Dr. Castellon noted
she had treated Rodolfo for a month for back pain, osteoporosis, gout, fatigue, possible PTSD,
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depression and memory impairment. Id. at 418. She opined that Rodolfo’s prognosis was good
and that his psychological symptoms and limitations would not be expected to last for at least 12
months. Id. Dr. Castellon noted that Rodolfo suffered from the following symptoms of depressive
syndrome: anhedonia or pervasive loss of interest in almost all activities, sleep disturbance,
decreased energy, difficulty concentrating or thinking, and recurrent or intrusive recollections of
a traumatic experience, which are a source of marked distress. Id.
Dr. Castellon opined that Rodolfo was mildly limited in his ability to: understand,
remember, or apply information; and concentrate, persist, or maintain pace. (R. 420). She also
reported that Rodolfo was moderately limited in his ability to interact with others and not limited
in his ability to adapt and manage himself. Id. Dr. Castello opined that Rodolfo would be mildly
limited in his short-term memory, moderately limited in understanding and carrying out very short
and simple instructions, and mildly limited in understanding and carrying out detailed but
uninvolved written or oral instructions. Id. at 421.
Rodolfo could maintain attention and
concentration for less than one hour before requiring a break. Id. According to Dr. Castellon,
Rodolfo can sometimes work appropriately with the general public and co-workers and sometimes
respond appropriately to changes in work settings. Id. at 421-22. Dr. Castellon opined that he
would be off-task 15% of the workday and absent more than four days per month. Id. at 422.
In assessing Rodolfo’s RFC, the ALJ determined that Dr. Castellon’s opinions were not
persuasive for three reasons. (R. 22-23). First, the ALJ found that Dr. Castellon’s opinions “are
not consistent with the overall conservative treatment of record, including the lack of formal
psychiatric treatment and the medical management of physical impairments.” Id. at 21-22. Second,
according to the ALJ, “the opinions are not well supported by Dr. Castellon, as she relies at least
in part on the claimant’s subjective complaints when formulating her opinion.” Id. at 22. Third,
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the ALJ pointed out that “the opinions were rendered after only treating the claimant for
approximately one month and two visits” and the “claimant testified that his visits with her were
short, about 15 minutes.” Id. The Court finds that the ALJ’s first and third reasons constitute valid
bases supported by substantial evidence for discounting opinions of Dr. Castellon. The second
ground for the ALJ’s decision to discount Dr. Castellon’s opinions, while arguably improper, was
(as discussed below) harmless.
The ALJ’s first reason for discounting Dr. Castellon’s opinions was that her findings were
not consistent with the record as a whole showing conservative treatment for Rodolfo’s physical
and mental impairments. “Medical opinions may be discounted if they are inconsistent with the
record as a whole.” Chambers v. Saul, 861 F. App’x 95, 101 (7th Cir. 2021); 20 C.F.R. §§
404.1520c(c)(2), 416.920c(c)(2) (“[t]he more consistent a medical opinion . . . is with the evidence
from other medical sources and nonmedical sources in the claim, the more persuasive the medical
opinion(s) . . . will be.”).
Specifically, the ALJ found Dr. Castellon’s opinion that Rodolfo would be absent four or
more days per month, he would be able to maintain attention for less than two hours at a time, he
could rarely lift/carry even 20 pounds and occasionally only 10 pounds, he could stand/walk five
of eight hours in a workday with the need for a sit/stand option, and he could rarely lift overhead
and only occasionally reach in other directions inconsistent with Rodolfo’s overall conservative
course of treatment. (R. 21). In characterizing his treatment as conservative, the ALJ noted
Rodolfo’s treatment with only medication management for his gout and knee and back pain,
limited diagnostic and clinical findings, and physical therapy referral. Id. Rodolfo does not take
issue with the ALJ’s characterization of his treatment as “conservative” during the relevant period
or argue the ALJ improperly considered his conservative treatment history. Similar or more
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invasive treatment plans involving injections have been considered conservative in other cases.
See Prill v. Kijakazi, 23 F.4th 738, 749 (7th Cir. 2022) (“Prill’s treatment—injections, orthotics,
and physical therapy—was conservative.”); Olsen v. Colvin, 551 F. App'x 868, 875 (7th Cir. 2014)
(characterizing prescription pain medication, physical therapy, and epidural steroid injections for
back pain as conservative treatment) Burnam v. Colvin, 525 F. App'x 461, 464-65 (7th Cir. 2013)
(conservative treatment for disc pain included physical therapy, Tylenol, and epidural injections).
Simila v. Astrue, 573 F.3d 503, 519 (7th Cir. 2009) (noting claimant's “relatively conservative”
treatment consisting of “various pain medications, several injections, and one physical therapy
session”); Caldarulo v. Bowen, 857 F.2d 410, 413-14 (7th Cir. 1988) (painkillers, rest, and therapy
are considered conservative treatment).
The ALJ’s characterization of Rodolfo’s treatment as conservative is amply supported by
During the relevant period, Rodolfo’s gout treatment plan involved primarily
medication (allopurinol, indomethacin, and colchicine) and diet changes (such as decreased
alcohol and meat intake). (R. 313, 316, 317). For example, the ALJ observed that at Rodolfo’s
annual exam on December 20, 2019 with Nurse Practitioner Hannah Holmes, he reported
experiencing a gout flare “about every month or so” but only taking medication as needed when
pain seemed to be starting. Id. at 305. Although Rodolfo reported generalized body pain and
muscle pain, he had normal musculoskeletal range of motion on physical examination. Id. at 305.
NP Holmes recommended Rodolfo consider taking allopurinol daily given the frequency of his
reported flares. Id. at 307, 317. At his follow-up appointment a month later, Rodolfo reported that
allopurinol did not help with his gout and that he previously used colchicine which helped more.
Id. at 313. He exhibited normal range of motion on musculoskeletal examination and minimal
tenderness to his upper shoulders. Id. at 314. NP Holmes recommended allopurinol, indomethacin,
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and colchicine for Rodolfo’s gout. Id. at 316. For pain, NP Holmes recommended Flexeril and
ibuprofen and upper back rehabilitation exercises with consideration of physical therapy in the
future if no improvement. Id. at 317. Rodolfo was advised to return in three month or sooner if
new or different symptoms presented. Id.
Rodolfo was next seen almost seven months later on August 18, 2020 at Erie Humboldt
Park Health Center, reporting a gout attack involving his knees and big toes four days earlier. (R.
445). The ALJ noted that Rodolfo had been drinking alcohol and felt this triggered the attack. Id.
at 21, 445. Rodolfo took some indomethacin at home which helped with the pain. Id. At the
appointment, Rodolfo reported that his pain had improved. Id. On exam, Ahmad A. Abdl-Haleem,
D.O., noted Rodolfo’s left medial knee had tenderness to palpation with mild effusion, no
erythema, and normal skin temperature. Id. at 446. Dr. Abdl-Haleem refilled Rodolfo’s allopurinol
and colchicine prescriptions, discussed diet to prevent gout flare-ups, and instructed Rodolfo to
get his serum uric acid levels drawn to assess if his allopurinol needed to be adjusted up from 100
mg. Id. On September 1, 2020, Rodolfo follow-up with Dr. Castellon at Erie Humboldt Park
Health Center and stated that he felt much better after his latest gout flare. Id. at 439. He had only
mild swelling and tenderness of his medial left knee, but said it was “almost gone now.” Id.
Rodolfo reported that he had stopped allopurinol prior to his last gout episode but had been
adhering to the medication regime since. Id. Dr. Castellon did not increase Rodolfo’s gout
medications. Id. at 442.
As for Rodolfo’s back pain, the treatment regime also involved conservative management,
including pain medication and a physical therapy referral in September 2020. On September 1,
2020, Rodolfo presented with upper back pain for months and reported taking ibuprofen with mild
symptomatic relief. (R. 439). Dr. Castellon noted reduced range of motion in Rodolfo’s upper
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extremities and prescribed pain medication (gabapentin) daily at bedtime, rest, and cold and warm
compresses. Id. at 442. Two weeks later, Rodolfo’s back pain had improved, he had recovered
some mobility in his upper extremities, and he had stopped taking ibuprofen. Id. at 434. Rodolfo
reported taking gabapentin as prescribed and said it helped him with his pain as well as insomnia.
Id. Dr. Castellon instructed Rodolfo to continue gabapentin and recommended physical therapy
to work on his range of motion. Id. at 436. As the ALJ observed, the results of Rodolfo’s
September 23, 2020 spine x-ray showed some evidence of osteoporosis but no acute changes. Id.
at 21, 430, 470. The ALJ recognized that at Rodolfo’s next appointment with Dr. Castellon on
September 29, 2020, he had improved range of motion despite complaints of some back pain. Id.
at 21, 428. Dr. Castellon noted Rodolfo continued taking gabapentin but had not followed-up with
the referral to physical therapy. Id. For back pain, she recommended Rodolfo continue gabapentin
and schedule a physical therapy evaluation and therapy. Id. at 430. She further instructed Rodolfo
to start calcium and vitamin D supplements for his osteoporosis and to return in one month. Id. at
430, 431. The record reflects no further appointments with Dr. Castellon or any other provider.
In addition to the above evidence showing conservative treatment, Dr. Castellon’s opinions
were inconsistent with the opinions of the non-examining state agency medical physicians. An
ALJ may reasonably discount a treating physician opinion if it conflicts with a reviewing state
agency consultant’s opinion. Zoch v. Saul, 981 F.3d 597, 602 (7th Cir. 2020). The ALJ first
considered the results of Rodolfo’s physical consultative examination, which were considered by
the state agency medical reviewers. (R.21). The ALJ noted that at his February 2020 physical
consultative examination performed by Rochelle Hawkins, M.D., Rodolfo exhibited: full rangeof-motion in all joints, full motor strength in the upper and lower extremities, full fist and grip
strength, normal fine and gross manipulative ability, normal sensation, normal motion of the spine,
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and normal gait without the use of an assistive device. Id. at 21, 351-52. Dr. Hawkins opined that
Rodolfo could sit, stand, lift, and carry without difficulty. Id. at 353. She also opined that Rodolfo
would have some difficulty with prolonged walking due to his chronic bilateral knee pain from
The ALJ credited Dr. Hawkins’ opinions regarding Rodolfo’s ability to sit, stand, lift and
carry because they were supported by her examination findings, including 5/5 strength throughout,
normal motion of the spine, and full range of motion in all joints. (R. 21). Additionally, the ALJ
found these findings by Dr. Hawkins to be consistent with Rodolfo’s limited and conservative
treatment record of medication management. Id. On one point, the ALJ did not credit Dr. Hawkins’
opinion. The ALJ found that “the opined difficulty in prolonged walking is persuasive only to the
extent it is consistent with the above-defined residual functional capacity for standing/walking six
of eight hours.” Id. The ALJ found Dr. Hawkins’ prolonged-walking concern inconsistent with
Rodolfo’s lack of an assistive device at the consultative examination and the objective findings of
normal gait and the ability to walk greater than fifty feet unassisted. Id. at 21, 352.
The ALJ then considered the opinions of two reviewing state agency physicians. (R. 21).
On March 17, 2020, Karen Hoelzer, M.D., reviewed the medical record with respect to Rodolfo’s
physical impairments, including the consultative examination by Dr. Hawkins that found him to
have some difficulty in prolonged walking, and opined that Rodolfo’s physical RFC allowed him
to occasionally lift 50 pounds, frequently lift 25 pounds, stand and/or walk and/or sit up to six
hours in an eight-hour workday, frequently climb ramp/stairs, balance, stoop, kneel, crouch, and
crawl, and occasionally climb ladders/ropes/scaffolds. (R. 60-61, 70-71). On reconsideration by
Rohini Mendonca, M.D., on April 30, 2020, the previous physical RFC was upheld but additional
environmental limitations, i.e., avoid concentrated exposure to extreme cold, heat, and vibration,
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were assessed. Id. at 82-85, 94-97. The ALJ found the state agency physical consultants’
assessments generally persuasive as they were “supported by the overall conservative treatment of
record, including only medication management” and “consistent with the limited objective
findings of record, including those of the consultative examination.” Id. at 21. However, the ALJ
assessed additional exposure to hazards and climbing ladders, ropes and scaffolds limitations than
those assessed in the reviewing state agency consultants’ opinions considering Rodolfo’s gout
According to Rodolfo, the ALJ failed to explain why a walking limitation of six hours out
of an eight-hour workday was supported by substantial evidence in light of Dr. Castellon’s opinion
that Rodolfo is limited to standing/walking for five hours in an eight-hour workday and Dr.
Hawkins finding that he would have “some difficulty in prolonged walking due to chronic bilateral
knee pain from gout.” (R. 353). The ALJ adequately explained why she discounted Dr. Castellon’s
five-hour stand/walk limitation with a sit/stand option. Instead, the ALJ credited the view of the
state agency physicians who reviewed the record, including Dr. Hawkins’ report, and opined that
Rodolfo can stand and/or walk for six hours in an 8-hour workday. Id. at 21. In reaching that
conclusion, the state agency physicians specifically relied on Dr. Hawkins’ report showing: no
anatomic abnormality of the cervical, thoracic or lumbar spine, no limitation of motion of any
spinal segment, normal gait without limp or staggering, no use of an assisted device, capable of
walking more than fifty feet without assistive device, no anatomic abnormality of either lower
extremity, no evidence of redness, warmth, thickening or effusion of any joint, complaints of
moderate knee pain but ankles, knees and hips all have full range of motion, straight leg raises are
90 degrees in sitting and supine positions, no cyanosis, clubbing, or edema, capillary refill is
immediate, and muscle strength is 5/5 bilaterally. Id. at 61, 71, 85, 96. The ALJ reasonably
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credited the state agency physicians’ opinions as to Rodolfo’s ability to stand and/or walk over Dr.
Castellon’s view that Rodolfo could stand/walk five hours in an 8-hour workday and needed a
sit/stand option. Under the applicable regulations, the ALJ was permitted to credit the state agency
physicians’ opinion over Dr. Castellon’s given her finding that former opinions were more
consistent with the limited objective findings in the record, including those of the consultative
examination by Dr. Hawkins, and supported by the overall conservative treatment record,
including primarily medication management. Id. at 21; Prill, 23 F.4th at 751.
Turning to Rodolfo’s mental impairments, the ALJ similarly concluded that Dr. Castellon’s
opinions were inconsistent with his conservative treatment for his mental impairments. In
rejecting certain of Dr. Castellon’s opinions as to Rodolfo’s mental limitations, the ALJ found that
Dr. Castellon’s opinions were inconsistent with Rodolfo’s lack of treatment from a mental health
specialist. Although there was no treatment from a mental health specialist, the ALJ considered
that “[t]he evidence showed only medication management by the claimant’s primary care
provider.” 2 (R. 18). The ALJ’s explanation reflects her consideration of the consistency factor.
The ALJ properly considered that Rodolfo’s lack of formal mental health treatment was
Rodolfo’s mental health treatment history is limited. On December 20, 2019, Rodolfo’s mood was
anxious and depressed and NP Holmes recommended Zoloft 25 mg daily and a behavioral health clinic
(BHC) consult which she wrote that she facilitated for December 23, 2019. (R. 382-83). There is no
evidence of a BHC appointment in the record. On January 20, 2020, Rodolfo reported that he had not
picked up his Zoloft prescription. Id. at 390. At the hearing, Rodolfo explained that he did not fill the
prescription because could not afford the medication. Id. at 42. NP Holmes advised Rodolfo to take Zoloft
and continue to pursue intensive therapy options. Id. at 395. She noted that Rodolfo was resistant to therapy
at that time because he “feels better.” Id. The record shows no evidence of therapy appointments. On
September 15, 2020, Rodolfo complained of depression. Id. at 435. However, on examination, Dr.
Castellon noted that Rodolfo exhibited: proper orientation, “no depression, anxiety, or agitation,” and intact
insight and judgment and she recommended no treatment for his depression complaint. Id. at 436. Two
weeks later, Rodolfo reported decreased energy, some mild memory impairment, and difficulty
concentrating, which began six months prior. Id. at 428, 430. Rodolfo also stated that he sometimes got
startled with loud noises and flashbacks of an attack by gang members near his house a few years earlier.
Id. Dr. Castellon noted that Rodolfo could be suffering from PTSD and she referred him to Behavioral
Health for further assessment and management. Id. at 430-31. A mental exam that day was normal. Id. at
430. The record includes no later treatment records.
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inconsistent with the moderate limitations in understanding and carrying out very short and simple
instructions and in interacting with others opined by Dr. Castellon.
The ALJ also placed significance on the September 2020 findings of the psychological
consultative examiner, Dr. Gil. (R. 18, 337-40). The ALJ pointed out that Rodolfo reported
considerable activities of daily living to Dr. Gil, including being able to dress and care for his
hygiene independently, use public transportation independently, drive short distances, spend time
with friends, and pay bills. Id. at 18. In particular, the ALJ noted that on examination, Rodolfo
was alert and fully oriented with logical thought process, exhibited the ability to perform simple
mathematic calculations, and had only mild impairments in his immediate memory. Id. The ALJ
emphasized that Dr. Gil assessed Rodolfo with adjustment disorder with depressed mood, only
mild in severity. Id. at 18, 340. The ALJ adequately explained that these limited findings did not
support finding that Rodolfo’s mental impairments resulted in more than minimal functional
limitations. Id. at 18.
Moreover, Dr. Castellon’s opinions conflicted with the conclusions of the state agency
reviewing psychologists, who considered Dr. Gil’s consultative examination findings. Ray v. Saul,
861 F. App’x 102, 106 (7th Cir. 2021). While the ALJ found Dr. Castellon’s opinions about
Rodolfo’s mental impairments were not consistent or supported by the record as a whole, she found
that the state agency psychological reviewers’ opinions were consistent and supported by the
record. Specifically, the ALJ found that Drs. Rozenfeld’s and Robicheau’s opinions that Rodolfo’s
mental impairments were not severe and caused no more than mild limitations were consistent
with the limited mental status examination findings of record, including those of the psychological
consultative examination, and supported by the lack of formal psychiatric treatment which showed
only medication management by Rodolfo’s primary care provider. (R. 18). The ALJ was entitled
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to rely on Drs. Rozenfeld’s and Robicheau’s opinions as reviewing state agency consultants, given
that they are experts in Social Security disability evaluation and she determined that their opinions
were consistent with the limited mental status examination findings in the record, including those
of the psychological examination. Prill, 23 F.4th at 751.
The Court also notes that Rodolfo’s overall conservative treatment record was not the only
factor the ALJ considered in evaluating Dr. Castellon’s opinions. For her third reason for finding
Dr. Castellon’s opinions to be unpersuasive, the ALJ noted that Dr. Castellon’s examinations of
Rodolfo were limited—both in frequency and the length of the examinations. As the ALJ noted,
Dr. Castellon had treated Rodolfo only two times at the time of her physical RFC assessment on
September 15, 2020. (R. 22, 406-09). Dr. Castellon saw Rodolfo three times—on September 1,
2020, September 15, 2020, and September 29, 2020—before issuing her psychological opinions.
Id. at 427-43. The ALJ noted that Rodolfo testified that his visits with Dr. Castellon were brief,
lasting about 15 minutes. Id. at 22, 42-43. The length of the treatment relationship, frequency of
examinations, and extent of the treatment relationship is a relevant factor in determining the
persuasiveness of an opinion because they “may help demonstrate whether the medical source has
a longitudinal understanding of your impairment(s)” and “the level of knowledge the medical
source has of your impairments.” 20 C.F.R. §§ 404.1520c(3)(i)-(iii), 416.920c(3)(i)-(iii). Thus,
the ALJ reasonably discounted Dr. Castellon’s opinions on the basis of her limited treatment
history with Rodolfo.
Rodolfo contends that it inconsistent for the ALJ to credit the opinions of Drs. Rozenfeld
and Robicheau who did not examine Rodolfo, but to discount the Dr. Castellon’s opinions because
they are based on a limited treatment relationship. Doc. 14 at 13. This argument is not persuasive.
Under the new regulatory scheme for evaluating medical opinions, the opinions of treating
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physicians are not entitled to any particular deference. See 20 C.F.R. §§ 404.1520c(a),
416.920(c)(a). While the ALJ is entitled to consider the number of times that a treating physician
has seen a claimant in evaluating the opinion, a treating relationship is only a secondary factor to
the supportability and consistency criteria. See 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).
Moreover, “[i]t is appropriate for an ALJ to rely on the opinions of [non-examining] physicians
and psychologists who are also experts in social security disability evaluation.” Flener ex rel.
Flener v. Barnhart, 361 F.3d 442, 448 (7th Cir. 2004); See also 20 C.F.R. §§ 404.1520c(c)(5),
416.920c(c)(5) (The ALJ “will consider other factors that tend to support or contradict a medical
opinion or prior administrative medical finding,” including, but not limited to “evidence showing
a medical source has familiarity with the other evidence in the claim or an understanding of our
disability program's policies and evidentiary requirements.”).
Here, the records reviewed by the state agency psychological consultants provided a more
longitudinal picture of Rodolfo’s condition than did Dr. Castellon who saw Rodolfo for only
month. “The fact that these [psychologists] reviewed the entire record strengthens the weight of
their conclusions.” Flener, 361 F.3d at 448. The ALJ explained that Dr. Castellon’s opinions were
not consistent with the overall treatment record. (R. 21-22). Conversely, the ALJ found the state
agency psychological consultants’ opinions were consistent with the longitudinal record, including
the psychological consultative examination. Given Dr. Castellon’s limited treatment history with
Rodolfo, the ALJ reasonably concluded that the state agency consultants had a better longitudinal
perspective to evaluate Rodolfo’s condition. The ALJ’s analysis shows that she considered the
regulatory factors of supportability and consistency in weighing Dr. Castellon’s opinions, and it
was within her discretion to find them less persuasive than other opinions that were based on a
broader view of the medical record.
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Additionally, Rodolfo has not shown that the ALJ’s decision to find the opinions of Drs.
Rozenfeld and Robicheau persuasive was unsupported. Although Drs. Rozenfeld and Robicheau
did not examine Rodolfo, they relied on the psychological consultative examination performed by
Dr. Gil when reviewing and analyzing Rodolfo’s medical record. (R. 57-59, 67-69, 80-81, 92-93).
In reaching their conclusions, Drs. Rozenfeld and Robicheau relied on Dr. Gil’s findings that
Rodolfo had a sad and restricted affect and mildly depressed mood, but his eye contact was good,
his behavior was relaxed and calm, he was fully oriented, polite, engaging, and related well, he
denied suicidal and homicidal ideation and auditory and visual hallucinations, he repeated 6 digits
forward and 4 backward, he recalled 3/3 items on delay, he performed calculations but declined
serial 7s, his fund of knowledge was adequate as was his reasoning ability, his judgment was
variable, and there was no evidence of psychosis or a thought process disorder. Id. at 58, 68, 81,
93. Based on their review of the evidence, including Dr. Gil’s report, Drs. Rozenfeld and
Robicheau determined that Rodolfo’s mental impairment was non-severe, imposing no more than
mild limitations in functioning. Id. That was a reasonable interpretation of the findings from the
psychological consultative examination.
Because the evidence supports the state agency
psychological reviewers’ opinions, the ALJ did not err in finding those opinions persuasive.
Overall, the nature of the treatment that Rodolfo received, the limited objective findings,
including the examination findings by the consultative physician and psychiatrist and a spine xray, the contrary opinions by the reviewing state agency physicians and psychologists, and the
limited treatment relationship between Rodolfo and Dr. Castellon were enough to support a logical
bridge from the evidence to the ALJ’s conclusion to discount Dr. Castellon’s physical and mental
RFC opinions. Thus, there is substantial evidence to support the ALJ’s first and third reasons for
discrediting Dr. Castellon’s opinions.
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The ALJ’s second reason for dismissing Dr. Castellon’s mental limitation opinions—that
those limitations were unsupported by Dr. Castellon’s evaluation—is more problematic. In
particular, the ALJ rejected Dr. Castellon’s opinions that Rodolfo was moderately limited in
understanding and carrying out very short and simple instructions and in interacting with others. 3
(R. 21-22). The ALJ stated that Dr. Castellon’s opinions were not well supported because “she
relie[d] at least in part on the claimant’s subjective symptoms when formulating the opinion.” Id.
at 22. Arguably, this reason—that Dr. Castellon’s opinion rested “at least in part” on subjective
complaints—is likely an inadequate basis for dismissing Dr. Castellon’s psychological opinions.
As the Seventh Circuit has explained, “[m]ental-health assessments normally are based on what
the patient says, but only after the doctor assesses those complaints through the objective lens of
her professional expertise.” Mischler v. Berryhill, 766 F. App’x 369, 375 (7th Cir. 2019); see also
Price v. Colvin, 794 F.3d 836, 840 (7th Cir. 2015) (“psychiatric assessments normally are based
primarily on what the patient tells the psychiatrist.”). “Further, the trained physician, not the ALJ,
is better positioned to discern ‘true’ complaints from exaggerated ones.” Mischler, 766 F. App’x
at 375; Price, 794 F.3d at 840.
In this case, Dr. Castellon’s opinion does indicate that she assessed Rodolfo’s complaints
through the “objective lens of her professional expertise.” For example, Dr. Castellon explicitly
noted that her assessment of Rodolfo’s abilities to understand, remember or apply information and
concentrate, persist, or maintain pace were supported by the results of Rodolfo’s Mini-Mental
The ALJ’s finding that Rodolfo had no more than mild limitations in the functional areas of
understanding, remembering or applying information, concentrating, persisting or maintaining pace, and
adapting or managing oneself is consistent with Dr. Castellon’s opinions that Rodolfo was mildly limited
in his abilities to understand, remember, or apply information and concentrate, persist, or maintain pace and
not limited in his ability to adapt or manage himself. (R. 18, 420).
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State Examination (“MMSE”). 4 (R. 420-21). Dr. Castellon explained that the MMSE showed
mildly limited remembering ability, mild concentration impairment, and that Rodolfo could not
recall three objects. Id. Thus, Dr. Castellon’s report is not largely lacking in objective support. Cf.
Winsted v. Berryhill, 923 F.3d 472, 478 (7th Cir. 2019) (ALJ properly rejected state agency
psychologist’s opinion because it “largely reflect[ed] [the claimant’s] subjective reporting.”). In
other words, her opinion does not “merely transcribe [Rodolfo’s] subjective symptoms” without
adequately assessing them through the “objective lens” of her professional experience. Regarding
Rodolfo’s ability to interact with others, Dr. Castellon wrote: “Patient says he has lost interest and
energy to interact as he used to.” (R. 420). While this assessment is based on Rodolfo’s subjective
reports, “[by] necessity . . . patient self-reports often form the basis for psychological assessments,”
Knapp v. Berryhill, 741 F. App’x 324, 328 (7th Cir. 2018), and there is no indication that Dr.
Castellon was being “too uncritical” in interpreting Rodolfo’s self-reported symptoms in this
regard. Shannon M. v. Saul, 2020 WL 264522, at *12 (N.D. Ill. Jan. 17, 2020). Thus, on this
record, it is not clear that the ALJ properly discounted Dr. Castellon’s moderate mental health
limitations because they relied in part on subjective reporting.
However, the ALJ did not discount Dr. Castellon’s moderate mental limitations solely
because she relied in part on Rodolfo’s subjective complaints. As discussed above, the ALJ
properly viewed Dr. Castellon’s opinions as inconsistent with the overall record, including the lack
of treatment by a mental health specialist, only medication management by Rodolfo’s primary care
Dr. Castellon’s September 29, 2020 treatment notes indicate the MMSE was normal and Rodolfo
reported no paranoia or suicidal or homicidal ideations. (R. 428 430). Overall, Rodolfo scored “28/30
(normal)” on the MMSE. Id. at 430. Further, Dr . Castellon’s examination showed appropriate mood and
affect with “no depression, anxiety, or agitation.” Id. He was also noted to be “oriented to time, place, and
person” and his judgment and insight were “intact.” Id.
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provider, the limited mental status examination findings, including by Dr. Gil, and Dr. Castellon’s
short previous relationship with Rodolfo. Thus, any error regarding the rejection of Dr. Castellon’s
mental opinion limitations as based in part on subjective reporting was harmless because the other
reasons the ALJ gave for discounting the opinions were valid and supported. Simila v. Astrue, 573
F.3d at 516 (“[A]ny error here was harmless given the other reasons the ALJ cited for discounting
Dr. Callier's opinions.”).
Moreover, any mental opinion related error would be harmless for a second reason.
Although not mentioned by the ALJ, Dr. Castellon expressly opined that Rodolfo’s mental
limitations were temporary and not expected to meet the disability durational requirement. Dr.
Castellon stated that Rodolfo’s mental symptoms and limitations began six months prior to the
date of her opinion and were not expected to last for at least 12 months. (R. 418); see also id. at
428 (9/29/2020 office visit note stating “[Rodolfo] is asking for temporal psychological disability
and would like these forms filled out today.”). As a result, Dr. Castellon offered a psychological
opinion covering just the period from March 29, 2020 to September 29, 2020. Stepp v. Colvin, 795
F.3d 711, 719 (7th Cir. 2015) (“Dr. Ritter’s assessment, however, was—by its own terms—
temporally limited and suggested that [claimant] would be unable to work for only a few weeks.”).
Temporary limitations which do not last 12 months or longer do not meet the durational
requirement for a disability finding. See 42 U.S.C. § 423(d)(1)(A); 20 C.F.R. §§ 404.1505(a),
416.905(a). Thus, Dr. Castellon’s opinions, even if credited, would not necessitate a finding of
disability because they do not suggest that Rodolfo’s mental symptoms were of disabling severity
for at least 12 months. Moreover, viewed cumulatively, the record does not show that Rodolfo
had an inability to work due to mental impairments that lasted or were expected to last for a period
of one year. Chambers, 861 F. App’x at 101 (claimant’s “medical records revealed fluctuating
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psychological symptoms, but her mental impairments never deteriorated to the point of disabling
within the meaning of the Social Security Act, which requires complete disability for not less than
twelve months.”). There are no other treatment records or opinions showing that the mental
limitations detailed in Dr. Castellon’s opinions lasted or could be expected to last for at least twelve
months. The medical records before March 2020 do not support disabling mental limitations (see
supra, n. 2), and there are no treatment records after September 2020. In sum, Rodolfo has not
met his burden of demonstrating a disabling mental impairment which lasted or was expected to
last for at least twelve months. Stepp, 795 F.3d at 719 (claimant “is required to demonstrate that [
]he suffers from a long-term disability, which must last or be expected to last at
least twelve months.”).
Finally, Rodolfo criticizes the ALJ for failing to discuss certain evidence which supported
Dr. Castellon’s proposed mental limitations. “The regulations do not, however, require the ALJ to
identify every piece of evidence that supports and runs counter to her assessment” of a physician’s
opinion. Denise O.-B. v. Kijakazi, 2023 WL 35179, at *2 (N.D. Ill. Jan. 4, 2023). Rather, they
simply require her “[to] explain how [she] considered the supportability and consistency factors
for a medical source's opinions,” 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2), which she did
here. Rodolfo cites a mental-status exam from December 2019 where NP Holmes noted anxious
and depressed mood, tearful affect, rapid and pressured speech, agitated behavior, reportedly
impaired memory, and impulsive judgment, which the ALJ did not expressly mention. (R. 306).
But the ALJ cited this treatment record when discussing Rodolfo’s gout, demonstrating that she
was aware of it and considered it. (R. 20). Rodolfo also emphasizes Dr. Castellon’s finding on
September 29, 2020 that he showed difficulty with concentration. Id. at 428, 430. In this regard,
Dr. Castellon opined that Rodolfo was mildly limited in his ability to concentrate, persist, or
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maintain pace based on his MMSE, which is in fact consistent with the ALJ’s finding that Rodolfo
had no more than a mild limitation in that functional area. Id. at 18, 420. Next, Rodolfo incorrectly
argues that the ALJ failed to mention Dr. Gil’s finding that Rodolfo had a mild impairment in his
immediate memory at the consultative examination. Doc. 14 at 12. However, the ALJ explicitly
recounted that Rodolfo exhibited “only mild impairment in his immediate memory” at the
psychological consultative exam. (R. 18).
Finally, Rodolfo cites evidence of reduced range of motion in his bilateral upper
extremities that was noted during Dr. Castellon’s exams. (R. 429, 435, 441). Though the ALJ was
not “required to mention every piece of evidence,” Jeske v. Saul, 955 F.3d 583, 593 (7th Cir. 2020),
she explicitly addressed the September 2020 evidence of reduced upper extremity range of motion.
(R. 22). The ALJ explained that she did not find Dr. Castellon’s opinion that Rodolfo was limited
in his ability to perform the requirements of his past work as a truck driver, including constantly
lifting over 10 pounds and a full range of motion of the neck and upper extremities, persuasive
because: (1) the corresponding examination showed normal strength in the bilateral upper and
lower extremities; (2) there was no indication Rodolfo followed-up with the referral to physical
therapy to work on range of motion or received any treatment other than pain medication; (3) there
was no imaging in the record of Rodolfo’s upper extremities or neck; and (4) the imaging of
Rodolfo’s spine showed only osteoporosis. Id. The ALJ’s finding that Rodolfo’s reduced upper
extremity range of motion was not work preclusive is supported by substantial evidence.
In sum, the ALJ applied the proper legal standard in finding certain of Dr. Castellon’s
opinions unpersuasive. The ALJ considered whether the opinions of Dr. Castellon were supported
by and consistent with the overall conservative course of treatment and limited objective findings
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as she was required to do. The ALJ also provided an accurate and logical bridge between the
evidence and her conclusions. Accordingly, reversal and remand is not warranted.
For the reason stated above, Plaintiff’s request to reverse and remand the ALJ’s decision
is denied  and the Acting Commissioner’s motion for summary judgment  is granted.
Pursuant to sentence of four of 42 U.S.C. § 405(g), the ALJ’s decision is affirmed.
Dated: January 18, 2023
Sunil R. Harjani
United States Magistrate Judge
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