Holderfield v. Saul

Filing 27

MEMORANDUM Opinion and Order: For the reasons set forth in the attached Opinion, Plaintiff's motion for summary judgment is granted, and the Commissioner's motion is denied. The Commissioner's decision is reversed, and the case is remanded for further proceedings. Civil case terminated. Signed by the Honorable Lisa A. Jensen on 7/16/2021. Mailed notice (jp, )

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
WESTERN DIVISION
Stacey H.,
Plaintiff,
v.
Kilolo Kijakazi,
Acting Commissioner of Social Security, 1
Defendant.

)
)
)
)
)
)
)
)
)
)

Case No. 3:20-cv-50112
Magistrate Judge Lisa A. Jensen

MEMORANDUM OPINION AND ORDER
Plaintiff Stacy H. brings this action under 42 U.S.C. § 405(g) seeking reversal or a remand
of the decision denying her disability insurance benefits. 2 For the reasons set forth below, the
Commissioner’s decision is reversed, and this case is remanded.
I. Background
In June 2016, Plaintiff applied for social security disability insurance benefits alleging she
became disabled on April 15, 2016. Plaintiff alleged that she was unable to work as of the date of
her disability primarily due to her chronic neck and back pain with associated numbness in her
arms and legs.
Following a hearing, an administrative law judge (“ALJ”) issued a decision on February
26, 2019, finding that Plaintiff was not disabled. The ALJ determined that Plaintiff’s impairments
did not meet or medically equal a listed impairment. The ALJ specifically found that Plaintiff’s

Kilolo Kijakazi has been substituted for Andrew Marshall Saul. Fed. R. Civ. P. 25(d).
The parties have consented to the jurisdiction of a United States Magistrate Judge for all proceedings
pursuant to 28 U.S.C. § 636(c).

1
2

1

degenerative disc disease did not meet or medically equal Listing 1.04. R. 20. The ALJ concluded
that Plaintiff had the residual functional capacity (“RFC”) to perform light work with certain
restrictions. Plaintiff was 47 years old at the time of the ALJ’s decision.
Plaintiff appeals the ALJ’s decision arguing that the ALJ erred in analyzing whether she
met or medically equaled Listing 1.04(A). 3 Therefore, although the record demonstrates that
Plaintiff sought medical treatment for a number of conditions, this Court will focus on the evidence
relevant to the ALJ’s Listing 1.04(A) analysis in the discussion below.
II. Standard of Review
A reviewing court may enter judgment “affirming, modifying, or reversing the decision of
the [Commissioner], with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). If
supported by substantial evidence, the Commissioner’s factual findings are conclusive. Id.
Substantial evidence consists of “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). Accordingly,
the reviewing court is not to “reweigh evidence, resolve conflicts, decide questions of credibility,
or substitute [its] judgment for that of the Commissioner.” Burmester v. Berryhill, 920 F.3d 507,
510 (7th Cir. 2019).
However, the Seventh Circuit has emphasized that review is not merely a rubber stamp.
Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (a “mere scintilla” is not substantial evidence).
A reviewing court must conduct a critical review of the evidence before affirming the
Commissioner’s decision. Eichstadt v. Astrue, 534 F.3d 663, 665 (7th Cir. 2008). Even when

In her opening brief, Plaintiff also challenges the ALJ’s RFC determination and subjective symptom
evaluation. However, in her reply brief Plaintiff abandons these arguments. Accordingly, the Court will not
address them. See Bonte v. U.S. Bank, N.A., 624 F.3d 461, 466 (7th Cir. 2010) (explaining that failing to
respond to an argument in a response brief results in waiver). However, Plaintiff should raise any of these
concerns with the ALJ on remand.
3

2

adequate record evidence exists to support the Commissioner’s decision, the decision will not be
affirmed if the Commissioner does not build an accurate and logical bridge from the evidence to
the conclusion. Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 2008). Moreover, federal courts
cannot build a logical bridge on behalf of the ALJ. See Mason v. Colvin, No. 13 C 2993, 2014 WL
5475480, at *5-7 (N.D. Ill. Oct. 29, 2014).
III. Discussion
Plaintiff argues that reversal or remand is proper because the ALJ failed to adequately
analyze whether her back condition, including cervical, lumbar, and thoracic disc disease with
peripheral neuropathy, meets or medically equals the criteria of Listing 1.04(A).
A claimant is eligible for benefits if she has an impairment that meets or equals an
impairment found in the listing of impairments. 20 C.F.R. § 404.1520(d). The listings specify the
criteria for impairments that are considered presumptively disabling. 20 C.F.R. § 404.1525(a). A
claimant may also demonstrate presumptive disability by showing that his impairments are
accompanied by symptoms that are equal in severity to those described in a specific listing. 20
C.F.R. § 404.1526(a). Therefore, at step three of the sequential evaluation process, in “considering
whether a claimant’s condition meets or equals a listed impairment, an ALJ must discuss the listing
by name and offer more than perfunctory analysis of the listing.” Minnick v. Colvin, 775 F.3d 929,
935 (7th Cir. 2015) (quoting Barnett v. Barnhart, 381 F.3d 664, 668 (7th Cir. 2004)).
Listing 1.04 addresses spinal disorders, including degenerative disc disease that result in
compromise of a nerve root or the spinal cord. 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.04. Listing
1.04(A) requires “evidence of nerve root compression characterized by neuro-anatomic
distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle
weakness or muscle weakness) accompanied by sensory or reflex loss and if there is involvement

3

of the lower back, positive straight-leg test (sitting and supine).” 20 C.F.R. Pt. 404, Subpt. P, App.
1 § 1.04(A).
Here, the ALJ found that Plaintiff’s degenerative disc disease of the cervical, lumbar, and
thoracic spine as well as her peripheral neuropathy constituted severe impairments. R. 17.
However, the ALJ’s listing analysis regarding whether Plaintiff met or equaled Listing 1.04(A)
consisted of the following two-sentence statement:
The claimant’s degenerative disc disease does not meet or medically equal Listing
1.04 of the Appendix 1 impairments. The record fails to demonstrate nerve root
compression characterized by neuro-anatomic distribution of pain, limitation of
motion of the spine, motor loss accompanied by sensory or reflex loss and positive
straight leg raising (1.04A).
R. 20. Plaintiff argues that this is the type of perfunctory analysis that the Seventh Circuit has
found to be inadequate. This Court agrees. In Minnick, the ALJ merely stated that the plaintiff’s
degenerative disc disease did not meet or equal Listing 1.04 because “[t]he evidence does not
establish the presence of nerve root compression, spinal arachnoiditis, or spinal stenosis resulting
in pseudoclaudication, as required by that listing.” 775 F.3d at 935. The court in Minnick noted
that this statement provided no analysis to support the ALJ’s conclusion. Id. at 935-36 (remanding
because the ALJ’s two-sentence discussion contained “no analysis whatsoever” and was “the very
type of perfunctory analysis we have repeatedly found inadequate”). The ALJ’s two-sentence
listing statement here also contains no analysis and for that reason it is cursory and deficient.
The Commissioner does not contest that the ALJ’s analysis was cursory. Instead, the
Commissioner argues that after the step three analysis the ALJ discussed the medical evidence and
this discussion supports the ALJ’s finding that Listing 1.04(A) was not met. While the Court will
not discount the ALJ’s listing analysis just because it appears elsewhere in the opinion, the
Commissioner has not explained how the medical evidence discussed later in the opinion
4

constitutes the ALJ’s listing analysis. It is true that the ALJ summarized Plaintiff’s medical
evidence. However, in her summary she makes no reference to any listing. A mere summary is not
the same as meaningful analysis. See Edmonson v. Colvin, No. 14 CV 50135, 2016 WL 946973,
at *4 (N.D. Ill. Mar. 14, 2016) (“It is true that the ALJ engaged in a fairly lengthy recitation of the
medical evidence, but this was mostly a long chronology of doctor visits with little commentary
or analysis. Even when the ALJ offered some fleeting commentary, he never connected it back to
the specific 1.04(A) requirements.”); Chuk v. Colvin, No. 14 C 2525, 2015 WL 6687557, at *8
(N.D. Ill. Oct. 30, 2015) ([S]ummarizing a medical history is not the same thing as analyzing it, in
order to build a logical bridge from evidence to conclusion.”); Alevaras v. Colvin, No. 13 C 8409,
2015 WL 2149480, at *4 (N.D. Ill. May 6, 2015) ([M]erely summarizing medical evidence is not
the same thing as analyzing it and explaining how the evidence supports the conclusion that the
claimant is not disabled.”).
Moreover, in examining the chronology that the ALJ sets forth after her step three analysis
she lists (without discussion) many findings supportive of Listing 1.04(A). For example, while she
states at step three that the record fails to demonstrate “limitation of motion of the spine,” she then
goes on in the next section to state “[e]xams showed decreased range of motion of the cervical and
lumbar spine (6F/5-6, 14F/5).” R 21. In addition, her medical record chronology reports MRI
evidence of spinal cord compression, hand/leg numbness diagnosed as peripheral neuropathy, and
abnormal EMG results in the bilateral lower extremities indicative of possible bilateral S1
radiculopathy. R. 21. While these findings could be consistent with Listing 1.04(A), the ALJ makes
no comment one way or the other as to what impact these findings had on her listing analysis.
The ALJ does note the following near the end of her medical record chronology in
conjunction with her RFC analysis: “Additionally, although the claimant has peripheral

5

neuropathy and obesity, exams frequently showed 5/5 strength in the upper and lower extremities,
normal reflexes, and can do heel, toe and tandem gait.” R. 22. However, this Court’s review of the
record reveals numerous findings of abnormal strength in the upper and lower extremities,
abnormal reflexes in the upper and lower extremities, and difficulty with heel/toe movement. For
example, Plaintiff has been diagnosed with hyperreflexia, including abnormal reflexes in the upper
and lower extremities R. 624. Dr. Arbona stated that her numbness and hyperreflexia probably
come from cord involvement. R. 624. Consultative examiner Dr. Ramchandani found decreased
strength in the lower extremities, including difficulty squatting. While he stated that Plaintiff could
walk on her heels and toes, Dr. Ramchandani noted that in doing so she had to lean on the table
for support. R. 468. Moreover, the record contains numerous findings of decreased strength in the
upper extremities as well. R. 536, 551-53, 619. An ALJ cannot cherry-pick the records by relying
on those that support her opinion and ignoring those that do not. See Denton v. Astrue, 596 F.3d
419, 425 (7th Cir. 2010) (“An ALJ has the obligation to consider all relevant medical evidence
and cannot simply cherry-pick facts that support a finding of non-disability while ignoring
evidence that points to a disability finding.”). Thus, even the limited RFC analysis that appears
later in the opinion does not accurately summarize the records or provide substantial evidence to
support the ALJ’s finding that Plaintiff does not meet or equal Listing 1.04(A). In sum, this Court
does not consider the ALJ’s subsequent medical record chronology sufficient to support her twosentence statement regarding Listing 1.04.
Next, the Commissioner argues that the ALJ relied on the opinions of the state agency
physicians that a listing was not met. There are several problems with this argument. First, there
is no evidence in the record that the ALJ in fact relied upon the state agency physician opinions to
support her step three finding. The Commissioner concedes this point but argues that this error “is

6

harmless because she subsequently considered and discussed these opinions.” Defendant’s
Response at 4, Dkt. 25. However, the ALJ’s subsequent discussion of the state agency physician
opinions was in regard to their opinion concerning Plaintiff’s RFC. Even then, she gave the state
agency physicians opinions only “some weight” because “evidence received at the hearing level
shows that the claimant is more limited than determined by the State agency consultants[.]” R. 23.
As such, this Court cannot say with great confidence that on remand the ALJ would rely on the
state agency physicians to support her step three finding. See Schomas v. Colvin, 732 F.3d 702,
707 (7th Cir. 2013) (finding an error harmless only when a court can “predict with great confidence
that the result on remand would be the same”).
Most importantly, however, this Court agrees with Plaintiff that on this record it would be
improper for the ALJ to rely on the state agency physicians’ opinions regarding whether Plaintiff
met Listing 1.04 without the benefit of various records that the state agency physicians did not
have at the time they rendered their opinions. See Moreno v. Berryhill, 882 F.3d 722, 728 (7th Cir.
2018), as amended on reh’g (Apr. 13, 2018) (“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.”).
Here, Plaintiff points out that the state agency physicians did not have the following:
-

the 2017 MRI of the cervical spine which showed an annular bulge with minimal
encroachment at C5/6; disc bulge contacting the ventral cord which is slightly
flattened at C6/7. R. 481;

-

the 2017 MRI of the thoracic spine which showed disc protrusion with mild flattening
of the right anterior cord with right lateral recess encroachment at T9/10; disc

7

protrusion with migration and contact with the ventral cord with reniform cord
morphology at T10/11. R. 482;
-

the 2017 MRI of the lumbar spine that showed annular bulge barely contacting the
ventral sac and minimal left foraminal encroachment at L4/5; annular bulge, lateral
recess encroachment, facet arthrosis, and foraminal stenosis moderate on the right and
minimal on the left at L5/S1. R. 483;

-

the July and September 2018 records of Dr. Arbona who noted “major compression”
of the spinal cord, “compression of the thoracic cord,” and impact on the “cervical
cord.” R. 612, 626.

-

The EMG of Plaintiff’s lower extremities showing absent bilateral H soleus response
consistent with bilateral S1 radiculopathy. R 512.

The above evidence is significant especially for purposes of analyzing whether a claimant meets
Listing 1.04. See Ivy v. Saul, No. 1:19-CV-380-JD, 2020 WL 4463160, at *5 (N.D. Ind. Aug. 4,
2020) (“The ALJ’s reliance on the state agency opinions fails when the state agency physicians
did not have access to the CT scan that showed a compromised spinal cord.”). 4
Finally, the Commissioner argues that the burden remains on Plaintiff to establish that her
impairment meets or equals an impairment enumerated in the listings. However, Plaintiff listed
ample evidence that could establish that she met or medically equaled Listing 1.04(A). With regard
to nerve root compression, Plaintiff points to the 2017 MRIs of the cervical, thoracic, and lumbar
spine that all show cord compression as well as Dr. Arbona’s records, which diagnose “major
compression” of the spinal cord, compression of the thoracic cord, and impact on the cervical cord.

Because the state agency physicians did not have updated and relevant medical records it was similarly
improper for the ALJ to rely on their opinions to support a finding that Plaintiff’s symptoms did not equal
Listing 1.04(A).
4

8

With regard to neuro-anatomic distribution of pain, Plaintiff points to numerous references
to radicular pain and sciatic pain. Specifically, the record reveals evidence of cervical pain with
upper extremity radiculopathy. R. 491, 532-33. Dr. Bear noted that Plaintiff’s neck pain and
radicular symptoms may be related to cervical spine abnormalities with narrowed spinal canal with
possible nerve root impingement and clear signs and symptoms of impingement syndrome. R. 53233. With regard to the lower extremities, consultative examiner Dr. Ramchandani noted pain in
the paraspinal region of the thoracolumbar spine and in the thighs, with decreased range of motion.
Plaintiff had reduced sensation to pin prick in the legs. Dr. Ramchandani diagnosed Plaintiff with
lumbar stenosis with radiculopathy of the lower extremity secondary to spondylolisthesis. R 46869. EMG of the lower extremities also confirmed findings consistent with bilateral S1
radiculopathy. R. 512.
Regarding the other required findings under Listing 1.04, Plaintiff points to evidence of
limitation of motion of the spine. R. 472. As set forth above, the ALJ affirmatively stated that
Plaintiff’s “[e]xams showed decreased range of motion of the cervical and lumbar spine (6F/5-6,
14F/5).” R. 21. The record also reveals evidence of atrophy in her left leg. R. 468. There is also
evidence of muscle weakness in the lower extremities as well as abnormal reflexes. R. 468.
Weakness in the upper extremities is also supported by the records, R. 551-53, as is abnormal
reflexes in the arms. R. 623-24. The above evidence is at the very least indicative of meeting
Listing 1.04(A).
The Commissioner does not deny that these findings could be consistent with Listing
1.04(A). The Commissioner argues only that by pointing to “various tests and notes in the record,
plaintiff has also failed to demonstrate that her degenerative disc disease met or equaled Listing
1.04 for the durational requirement of the Act.” Defendant’s Response at 4, Dkt. 25. However, the

9

ALJ did not base her finding that Plaintiff did not meet Listing 1.04 on the failure of Plaintiff to
show that she met all of the listing criteria for the durational requirement of the Act. Under the
Chenery doctrine, this Court must confine its review to the grounds on which the ALJ made her
finding. See, e.g., Jeske v. Saul, 955 F.3d 583, 587 (7th Cir. 2020) (“Our review is limited also to
the ALJ’s rationales; we do not uphold an ALJ’s decision by giving it different ground to stand
upon.”); Meuser v. Convin, 838 F.3d 905, 911 (7th Cir. 2016) (finding that where “the ALJ did not
rely on this rationale in his opinion, [] the Commissioner cannot now rely on it”). Moreover,
Plaintiff’s neck and back pain with numbness have been described as chronic and as lasting more
than 12 months. R. 414, 491, 632.
The ALJ’s finding that Plaintiff’s neck and back condition did not meet or medically equal
Listing 1.04(A) is not supported by substantial evidence. The ALJ failed to discuss her reasoning
and failed to address evidence that may support a finding that Listing 1.04(A) was met. As such,
the ALJ’s inadequate analysis requires remand.
Finally, this Court declines Plaintiff’s request for a direct award of benefits. A direct award
of benefits is a “rare step.” Martin v. Saul, 950 F.3d 369, 371 (7th Cir. 2020). Such an award of
benefits is appropriate “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). Here, because the
ALJ did not adequately analyze all of the evidence to determine if Plaintiff’s condition meets
Listing 1.04(A) and did not have the benefit of state agency physicians opinions based on updated
medical records this Court cannot say that there is only one conclusion that can be drawn here.
This Court finds that remand is the more appropriate course so that the ALJ can reach her
conclusions after proper consideration and analysis of all of the relevant evidence.

10

IV. Conclusion
For the foregoing reasons, Plaintiff’s motion for summary judgment is granted, and the
Commissioner’s motion is denied. The decision of the Commissioner is reversed, and the case is
remanded for further proceeding consistent with this opinion.
Date: July 16, 2021

By:

11

______________________
Lisa A. Jensen
United States Magistrate Judge