Caraway v. Commissioner of Social Security

Filing 29

MEMORANDUM AND OPINION. The Commissioner's final decision denying plaintiff's application for benefits is REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. §405(g). The clerk of court is directed to enter judgment in favor of plaintiff. Signed by Magistrate Judge Clifford J. Proud on 12/23/2014. (klm)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
CHRISTY C. CARAWAY,

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Plaintiff,
vs.
CAROLYN W. COLVIN,
Acting Commissioner of Social
Security,
Defendant.

Case No. 14-cv-312-CJP 1

MEMORANDUM and ORDER
PROUD, Magistrate Judge:
In accordance with 42 U.S.C. § 405(g), plaintiff Christy C. Caraway is before
the Court, represented by counsel, seeking review of the final decision of the
Commissioner of Social Security denying her Disability Insurance Benefits (DIB).
Procedural History
Plaintiff applied for DIB on August 23, 2010. She alleged disability
beginning on June 23, 2010. (Tr. 32). After holding a hearing, Administrative Law
Judge (ALJ) Stuart T. Janney denied the applications in a decision dated October
11, 2012. (Tr. 32-49). The Appeals Council denied review and the decision of the
ALJ became the final agency decision. (Tr. 1). Administrative remedies have been
exhausted and a timely complaint was filed in this court.
Issues Raised by Plaintiff
1

This case was referred to the undersigned for final disposition upon consent of the parties,
pursuant to 28 U.S.C. §636(c). See, Doc. 28.

1

Plaintiff raises the following issues:
1. The ALJ improperly weighed medical opinion evidence.
2. The ALJ improperly assessed plaintiff’s RFC.
3. The ALJ erred in his credibility determination
Applicable Legal Standards
To qualify for DIB, a claimant must be disabled within the meaning of the
applicable statutes. For these purposes, “disabled” means 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) and 1382c(a)(3)(A). A “physical or mental
impairment” is an impairment resulting from anatomical, physiological, or
psychological abnormalities which are demonstrable by medically acceptable
clinical and laboratory diagnostic techniques.

42 U.S.C. §§ 423(d)(3) and

1382c(a)(3)(C). “Substantial gainful activity” is work activity that involves doing
significant physical or mental activities, and that is done for pay or profit. 20
C.F.R. §§ 404.1572.
Social Security regulations set forth a sequential five-step inquiry to
determine whether a claimant is disabled. The Seventh Circuit Court of Appeals
has explained this process as follows:
The first step considers whether the applicant is engaging in
substantial gainful activity. The second step evaluates whether an
alleged physical or mental impairment is severe, medically
determinable, and meets a durational requirement. The third step
2

compares the impairment to a list of impairments that are
considered conclusively disabling. If the impairment meets or equals
one of the listed impairments, then the applicant is considered
disabled; if the impairment does not meet or equal a listed
impairment, then the evaluation continues. The fourth step assesses
an applicant's residual functional capacity (RFC) and ability to engage
in past relevant work. If an applicant can engage in past relevant
work, he is not disabled. The fifth step assesses the applicant's RFC,
as well as his age, education, and work experience to determine
whether the applicant can engage in other work. If the applicant can
engage in other work, he is not disabled.

Weatherbee v. Astrue, 649 F.3d 565, 568-569 (7th Cir. 2011).
Stated another way, it must be determined: (1) whether the claimant is
presently unemployed; (2) whether the claimant has an impairment or
combination of impairments that is serious; (3) whether the impairments meet or
equal one of the listed impairments acknowledged to be conclusively disabling; (4)
whether the claimant can perform past relevant work; and (5) whether the
claimant is capable of performing any work within the economy, given his or her
age, education and work experience. 20 C.F.R. §§ 404.1520; Simila v. Astrue,
573 F.3d 503, 512-513 (7th Cir. 2009); Schroeter v. Sullivan, 977 F.2d 391, 393
(7th Cir. 1992).
If the answer at steps one and two is “yes,” the claimant will automatically
be found disabled if he or she suffers from a listed impairment, determined at
step three. If the claimant does not have a listed impairment at step three, and
cannot perform his or her past work (step four), the burden shifts to the
Secretary at step five to show that the claimant can perform some other job.

Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984). See also, Zurawski v.

3

Halter, 245 F.3d 881, 886 (7th Cir. 2001)(Under the five-step evaluation, an
“affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding
that the claimant is disabled…. If a claimant reaches step 5, the burden shifts to
the ALJ to establish that the claimant is capable of performing work in the
national economy.”).
This Court reviews the Commissioner’s decision to ensure that the decision
is supported by substantial evidence and that no mistakes of law were made. It is
important to understand that the scope of judicial review is limited. “The findings
of the Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive. . . .” 42 U.S.C. § 405(g). Thus, this Court must
determine not whether plaintiff was, in fact, disabled, but whether the ALJ’s
findings were supported by substantial evidence and whether any errors of law
were made. See, Books v. Chater, 91 F.3d 972, 977-78 (7th Cir. 1996) (citing

Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995)). This Court uses the Supreme
Court’s definition of substantial evidence, i.e., “such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Richardson

v. Perales, 402 U.S. 389, 401 (1971).
In reviewing for “substantial evidence,” the entire administrative record is
taken into consideration, but this Court does not reweigh evidence, resolve
conflicts, decide questions of credibility, or substitute its own judgment for that of
the ALJ. Brewer v. Chater, 103 F.3d 1384, 1390 (7th Cir. 1997). However, while
judicial review is deferential, it is not abject; this Court does not act as a rubber

4

stamp for the Commissioner. See, Parker v. Astrue, 597 F.3d 920, 921 (7th Cir.
2010), and cases cited therein.
The Decision of the ALJ
ALJ Janney followed the five-step analytical framework described above. He
determined that plaintiff had not been engaged in substantial gainful activity since
the alleged onset date. The ALJ found that plaintiff had severe impairments of
type I diabetes mellitus with retinopathy and nephropathy, level II obesity with
coronary artery disease treated with a coronary artery bypass graft procedure,
hyperlipidemia, hypertension, obstructive sleep apnea, hypothyroidism, attentiondeficit hyperactivity disorder, and depressive reaction with anxiety.
The ALJ found that plaintiff had the residual functional capacity (RFC) to
perform work at the sedentary level with physical and mental limitations. Based
on the testimony of a vocational expert (VE), the ALJ found plaintiff was unable to
perform her past work. However, she was not disabled because she was able to do
other jobs which exist in significant numbers in the regional and national
economies. (Tr. 32-49).
The Evidentiary Record
The court has reviewed and considered the entire evidentiary record in
formulating this Memorandum and Order. The following summary of the record
is directed to the points raised by the plaintiff.
1. Agency Forms

5

Plaintiff was born in 1974 and was 35 years old on the alleged onset date of
June 23, 2010. Plaintiff was insured for DIB through December 31, 2014. (Tr.
225).
According to plaintiff, her diabetes, hypothyroidism, kidney and heart
problems, and anxiety limited her ability to work. (Tr. 229). Plaintiff previously
worked as an accounting clerk for a soda factory, administrative assistant for a
non-profit, business assistant for a dental office, and a photo laboratory
technician. (Tr. 230).
Plaintiff submitted two Function Reports, one in October 2010 and another
in February 2011. (Tr. 245-55, 289-300). Plaintiff stated she was weak and tired
all of the time. She stated that it was very painful for her to walk, sit, or stand.
(Tr. 245, 289). Plaintiff stated she spent her day eating, watching TV, going to
rehab, napping, and talking on the phone. (Tr. 246, 290). Her husband took care
of their two cats and two dogs. (Tr. 290). Plaintiff prepared simple meals weekly
and was unable to stay on her feet long enough to use the stove. She was able to
dust and do some laundry. (Tr. 247, 291).
Plaintiff could walk, drive, and ride in a vehicle. (Tr. 248, 292). She
attended church and rehab three times a week. (Tr. 249, 293). She said she had
trouble lifting, squatting, bending, standing, reaching, walking, sitting, kneeling,
stair climbing, seeing, remembering, and completing tasks. She stated she could
lift no more than five pounds and could walk two or three blocks before needing
to rest. (Tr. 250, 294). Three of plaintiff’s medications caused drowsiness or

6

dizziness. (Tr. 251, 296). She occasionally had trouble opening jars and she
needed assistance with heavy items. (Tr. 254, 298).
2. Evidentiary Hearing
Plaintiff was represented by an attorney at the evidentiary hearing on
October 1, 2012. (Tr. 58). She testified that she was 5’5” and weighed 200
pounds. She had a major increase in weight as her normal weight was 125
pounds. She lived with her husband at the time of the hearing. (Tr. 62). Her
husband was formerly a coal miner but was laid off and unemployed. She stopped
working one and one-half years earlier when she had bypass surgery on five blood
vessels. (Tr. 63, 66).
Plaintiff stated she had no insurance or medical card. She was only able to
see her endocrinologist because she had a payment plan. Her cardiologist did not
charge her for services. (Tr. 70). Plaintiff testified to being type 1 diabetic since
the age of ten. (Tr. 66). She had not undergone an A1C procedure since childhood
as it was too costly. (Tr. 68). She checked her blood sugar three to six times a
day, depending on her levels and how she felt. (Tr. 68, 80). She had been on an
insulin pump for fifteen years. (Tr. 69). Her doctor gave her samples of her
insulin and otherwise she only took low cost medications. (Tr. 72-3). Plaintiff had
retinopathy and had surgery on both of her eyes. (Tr. 69). She did not like to
drive because her vision was deteriorating. She testified that she had trouble
seeing traffic over her shoulders and had no peripheral vision. (Tr. 90).

7

Plaintiff stated she had problems with her thyroid. Her thyroid bothered
her about once every six months but was otherwise controlled well with
medications. (Tr. 69-70). Plaintiff took medications for her high cholesterol and
blood pressure. (Tr. 71). Her cholesterol medication, Lipitor, caused her to have
muscle spasms and her blood pressure medication caused her to be very tired.
(Tr. 73). She also took medication for her anxiety. (Tr. 73). It sometimes
improved her problems but she still had trouble handling stress. (Tr. 78). Plaintiff
relied on her family, friends, and pastor to help cope with her mental stressors.
(Tr. 86).
Plaintiff needed to raise her feet while resting, otherwise they became
swollen. (Tr. 85). She occasionally took a water pill to help reduce swelling. (Tr.
71). She saw a nephrologist for her stage two chronic kidney disease which
caused swelling and high blood pressure. (Tr. 71-2).
She and her husband rented their home and her husband took care of all
the yard work. (Tr. 74). Plaintiff stated that she could dust but had trouble
performing most other household chores. (Tr. 74-6). Multitasking was difficult
and she needed many breaks to check her blood sugar. (Tr. 79-80).
Three times a week plaintiff attempted to go outside and walk a mile. (Tr.
82). It took her about an hour to walk a mile and she needed occasional stops.
(Tr. 83). She needed twelve hours of sleep otherwise she became irritable. (Tr.
84). Plaintiff testified to having trouble using her hands and dropping things
frequently. (Tr. 90).

8

A vocational expert (VE) also testified. The ALJ asked the VE a hypothetical
question which comported with the ultimate RFC assessment, that is, a person of
plaintiff’s age and work history who was able to perform sedentary work limited
to never climbing ladders, ropes, or scaffolding, occasionally stoop, kneel, and
crouch, frequently reach, handle, and finger with the bilateral upper extremities.
She should avoid concentrated exposure to extreme heat and cold, hazards,
unprotected heights. Additionally, she could not work in an environment that was
stringently production or quota-based and could not work in a setting that
requires shifting between tasks more than once every fifteen minutes. (Tr. 91100).
The VE testified that the person could not perform any of plaintiff’s
previous work. However, she could do jobs that exist in significant numbers in the
national economy. Examples of such jobs are stuffer, dowel inspector, and
surveillance system monitor. (Tr. 97-102). The VE testified that additional
unscheduled breaks, needing to elevate the feet at waist height, or the inability to
work for an hour in the afternoon, would preclude all employment. (Tr. 104-5).
3. Medical Treatment
In February 2010, plaintiff underwent a coronary bypass graft procedure
which revealed severe multivessel coronary artery disease with critical stenosis.
(Tr. 344-47). She was also diagnosed with stage II chronic kidney disease. (Tr.
729). After surgery plaintiff was discharged in stable condition and was doing well

9

for several months. (Tr. 378). However, in May 2010 she got pneumonia and she
began feeling worse. (Tr. 375).
That July, plaintiff presented at the hospital with nausea, vomiting,
tightness in her chest, and high blood sugar. (Tr. 485). Doctors determined
plaintiff was in diabetic ketoacidosis and that she suffered a non-ST-elevation
myocardial infarction. (Tr. 544-47). Angiographies and a cardiac catheterization
revealed plaintiff had severe three-vessel native coronary artery disease, 60%
stenosis in the left circumflex coronary artery, and severe 90% stenosis in the
right coronary artery, among other things. (Tr. 553).
From

2006

through

2011,

plaintiff

regularly

saw

her

treating

endocrinologist, Dr. Becker. (Tr. 364-421, 562-67, 907-17). Dr. Becker
prescribed medications and monitored plaintiff’s diabetes and hypothyroidism.
(Ex. Tr. 383, 389, 375-6, 913). In September 2010, plaintiff presented to Dr.
Becker with swelling in her legs and lightheaded spells. (Tr. 563). Dr. Becker
changed her medications to help and thereafter continually noted minimal or
trace edema. (Tr. 563, 908, 918). Dr. Becker diagnosed plaintiff with proteinuria
in February 2011. He noted plaintiff did not follow her diet and she had gained
twelve pounds since her last visit. (Tr. 917). Dr. Becker’s records show that
plaintiff’s BMI ranged from a 28 to a 35 and her diabetes was not well controlled.
(Tr. 365, 375, 378, 382, 907-17).

Plaintiff frequently told Dr. Becker she

experienced fatigue, depression, and vision problems. (Tr. 565, 599-602, 907-17).

10

Plaintiff regularly saw her nephrologist, Dr. Kamran. Dr. Kamran diagnosed
plaintiff with hyperkalemia and hypercalcemia in September 2010. (Tr. 725). Dr.
Kamran determined plaintiff’s proteinuria was caused from nephropathy. (Tr.
721). He monitored her prescriptions and had her return every six months for a
check-up. (Tr. 495-98, 507-15, 868-70, 833-35).
In April 2011, plaintiff’s cardiologist noted plaintiff had generalized edema
to her hands and feet that continued throughout the day. It became more
significant when she had more salt in her diet. He prescribed a water pill to help
keep the edema under control. (Tr. 849-52).
Plaintiff began having neck, shoulder, and back pain in September 2011.
(Tr. 912). She began seeing a chiropractor weekly. (Tr. 919-37). The chiropractor
noted plaintiff’s gait was guarded and her movement was restricted. (Tr. 937). He
diagnosed plaintiff with segmental/somatic cervical, thoracic, and lumbar
dysfunction, facet’s syndrome, and thoracic outlet syndrome. (Tr. 936). The
chiropractor noted plaintiff’s progress was slow but he was hopeful she would
continue to improve. (Tr. 922-26).
In July 2010, plaintiff first presented to her family physician, Dr. Graham,
with anxiety. She stated she had apprehension and palpitations nearly every day.
(Tr. 788). Dr. Graham diagnosed plaintiff with generalized anxiety and prescribed
medications. (Tr. 789-90). Dr. Graham opined that occupational stressors caused
her anxiety and that she did not experience true panic attacks. (Tr. 785).
4. Plaintiff’s Treating Physicians’ Opinions

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In February 2011, Dr. Becker completed a medical source statement
regarding plaintiff’s impairments. (Tr. 707-10). Dr. Becker diagnosed plaintiff
with diabetes mellitus type 1, retinopathy and proteinuria. He stated plaintiff’s
symptoms included fatigue, episodic vision blurriness, retinopathy, kidney
problems, dizziness/loss of balance, and headaches. He opined plaintiff’s
impairments would last at least twelve months. (Tr. 707). Dr. Becker felt
plaintiff’s symptoms would occasionally be severe enough to interfere with
attention and concentration and she was incapable of even “low stress” jobs. She
could sit for more than two hours but could only stand for thirty minutes. In a
normal eight hour workday plaintiff could sit at least six hours and stand or walk
about four hours as long as normal breaks existed. (Tr. 708).
Dr. Becker opined that plaintiff would need to take unscheduled breaks
about every two hours in order to monitor her blood sugar and have a snack.
Plaintiff’s legs would have to be elevated into the neutral position for at least four
hours if she had to endure prolonged sitting. While she could occasionally lift less
than ten pounds, Dr. Becker felt plaintiff could never carry anything ten pounds
or heavier. She could rarely twist, stoop, or climb stairs and never crouch or
climb ladders. He felt she had a significant limitation with regard to reaching,
handling, or fingering. (Tr. 709). Plaintiff would likely have “good days” and “bad
days” and should avoid exposure to most environmental hazards. (Tr. 710).
In March 2011, plaintiff’s family practitioner Dr. Graham completed an
evaluation regarding plaintiff’s impairments. (Tr. 810-13). He diagnosed plaintiff

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with hyperlipidemia, diabetes mellitus type 1, hypothyroidism, obesity, diabetic
retinopathy, generalized anxiety, attention deficit hyperactivity disorder, acute
renal failure, and coronary artery disease. Plaintiff had appropriate eye contact,
posture, and gait. Her symptoms were primarily extreme fatigue and daytime
somnolence which caused her to have difficulty concentrating and staying on task.
(Tr. 810). Her mood was generally happy with a slightly flat affect. Dr. Graham
felt plaintiff’s thought process was logical. (Tr. 811). She was able to perform
some simple math calculations and her abstract thinking was fair. (Tr. 811-12).
Dr. Graham opined plaintiff had serious limitations in her ability to
independently initiate, sustain, or complete tasks due to her fatigue and her
difficulty coping with stress. (Tr. 812). Dr. Graham stated plaintiff could not
sustain working eight hours of work a day for five days. (Tr. 813).
5. RFC Assessment
State agency physician Dr. C. A. Gotway assessed plaintiff’s RFC in
November 2010. (Tr. 657-63). He reviewed medical records but did not examine
plaintiff. He believed plaintiff could occasionally lift twenty pounds and frequently
lift ten pounds. He opined that plaintiff could stand, walk, or sit for six hours out
of an eight hour workday. She was limited to occasional stooping, kneeling, and
crouching and could never climb ladders, ropes or scaffolds. (Tr. 657-58).
This opinion was seconded by Dr. James Madison of Disability
Determination Services (DDS) in May 2011. (Tr. 829-31).
6. Consultative Examinations

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Plaintiff underwent a psychological consultation in November 2010 with
Dollean York-Anderson, Ph.D. (Tr. 640-41). Plaintiff was cooperative and had
good eye contact and personal hygiene. Plaintiff’s responses to questions were
coherent and she was oriented to date, place, and time. She quickly and
accurately calculated serial seven subtractions and accurately solved orally
presented word problems requiring addition, subtraction, and multiplication. (Tr.
640). However, plaintiff could not perform division and she could only recall one
of five objects after five minutes. Dr. York-Anderson’s diagnosis was depression
and she assigned plaintiff a GAF 2 score of 50. Dr. York-Anderson felt plaintiff
appeared quite depressed. Dr. York-Anderson opined plaintiff’s memory,
concentration, and judgment were good and plaintiff appeared capable of
managing her own funds. (Tr. 641).
Dr. Adrian Feinerman performed a physical consultative exam in
November, 2010. Dr. Feinerman’s diagnostic impression was hypertension,
diabetes

mellitus,

arteriosclerotic

heart

disease,

hypothyroidism,

diabetic

retinopathy, and degenerative joint disease. He opined that plaintiff’s had no
limitation of motion of any joint or spinal segment. Plaintiff was able to get on and
off the exam table, tandem walk, walk on her toes, walk on her heels, squat and
rise, hear normally, and speak normally. She was able to lift, carry, and handle

1The GAF is determined on a scale of 1 to 100 and reflects the clinician’s judgment of an individual’s
overall level of functioning, taking into consideration psychological, social, and occupational functioning.
Impairment in functioning due to physical or environmental limitations are not considered. American
Psychiatric Association, Diagnostic & Statistical Manual of Mental Disorders - Fourth Edition, Text Revision
32-33 (4th ed. 2000); Although the American Psychiatric Association recently discontinued use of the GAF
metric, it was still in use during the period plaintiff’s examinations occurred.

2

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objects without difficulty and Dr. Feinerman felt she could manage her own funds.
(Tr. 819-28).
Analysis
Plaintiff argues that the ALJ improperly weighed medical opinion evidence,
improperly assessed plaintiff’s RFC, and erred in his credibility determination. As
plaintiff relies in part on her testimony, the Court will first consider her argument
regarding the ALJ’s credibility analysis.
It is well-established that the credibility findings of the ALJ are to be
accorded deference, particularly in view of the ALJ’s opportunity to observe the
witness. Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000). “Applicants for
disability benefits have an incentive to exaggerate their symptoms, and an
administrative law judge is free to discount the applicant’s testimony on the basis
of the other evidence in the case.” Johnson v. Barnhart, 449 F.3d 804, 805 (7th
Cir. 2006).
SSR 96-7p requires the ALJ to consider a number of factors in assessing
the claimant’s credibility, including the objective medical evidence, the claimant’s
daily activities, medication for the relief of pain, and “any other factors concerning
the individual’s functional limitations and restrictions due to pain or other
symptoms.” SSR 96-7p, at *3.
The ALJ is required to give “specific reasons” for his credibility findings.

Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009). It is not enough just to
describe the plaintiff’s testimony; the ALJ must analyze the evidence. Ibid. See

15

also, Terry v. Astrue, 580 F.3d 471, 478 (7th Cir. 2009)(The ALJ “must justify the
credibility finding with specific reasons supported by the record.”) If the adverse
credibility finding is premised on inconsistencies between plaintiff’s statements
and other evidence in the record, the ALJ must identify and explain those
inconsistencies. Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001).
Plaintiff argues the ALJ erred in his credibility determination by relying on
her activities of daily living and not incorporating all of plaintiff’s claimed side
effects from her medications.
The Seventh Circuit has repeatedly held it is appropriate to consider
activities of daily living but it should be done with caution. The ability to perform
daily tasks “does not necessarily translate into an ability to work full-time.” Roddy

v. Astrue, 705 F.3d 631, 639 (7th Cir. 2013). Here, the ALJ looked at plaintiff’s
function reports and testimony and determined her daily activities were not
consistent with an inability to work. He noted that plaintiff’s function reports did
not indicate problems with personal care and she was able to prepare simple
meals and go shopping. She testified to being able to perform light cooking and go
shopping.

Additionally,

her

grooming

and

hygiene

were

appropriate

at

examinations.
Plaintiff reported very limited daily activities that could all be performed at
her own pace and with significant breaks. Her daily activities did not indicate in
any way that she would have been capable of working an entire workday. If the
ALJ had relied solely upon plaintiff’s activities of daily living in determining

16

plaintiff’s credibility his analysis would have been insufficient. However, this
Court agrees with the Commissioner’s argument that ALJ Janney considered the
other appropriate factors in making his credibility determination, and therefore
his credibility determination stands.
For example, the ALJ presented a detailed analysis of plaintiff’s objective
medical history. He looked at plaintiff’s history of cardiac symptoms. He stated
plaintiff had no active cardiopulmonary disease, and doctors’ notes showed she
was improving. Additionally, he looked at plaintiff’s edema and heart rate.
Plaintiff denied edema in March and August of 2012. (Tr. 40). While plaintiff
claimed her hands experienced swelling, the records show plaintiff’s edema was
limited to her lower extremities and not global in nature. (Tr. 42). Her blood
pressure and hyperlipidemia have generally been well controlled on medications.
The ALJ noted the record showed plaintiff’s cardiac condition had not been
impacted by her obesity. He looked at plaintiff’s hypothyroidism and noted her
treating endocrinologist stated she was doing well and her energy level was good.
(Tr. 41).
The ALJ looked at plaintiff’s diabetes. He acknowledged her instance of
acidosis and renal failure but also stated she had not followed her diet
consistently. The record showed plaintiff had a history of non-compliance. Her
blood sugar levels improved when she followed a dietary plan. (Tr. 41). The ALJ
also took note of plaintiff’s mental impairments. He stated that plaintiff had

17

generally normal mental status examinations and never received inpatient or
outpatient psychiatric services. (Tr. 43).
The ALJ analyzed plaintiff’s medications and additional treatment. He
determined plaintiff was prescribed many of her medications for several years
which was indicative that the medications were effective. Plaintiff reported that
several of her medications made her tired and lethargic. However, the ALJ noted
plaintiff’s energy level was “good” in 2012 and that her medications were never
changed due to their side effects. (Tr. 44). Plaintiff’s willingness to pursue
specialized affordable care weighed in her favor. However, she had not required
hospitalization since 2010 and had not received treatment for her mental
impairments. Plaintiff argues the ALJ should have given more weight to her
testimony that Lipitor caused her to have muscle spasms. These claims are not
substantiated by the record. Plaintiff never complained of muscle spasms to a
doctor or requested to be taken off of Lipitor.
ALJ Janney finally looked at plaintiff’s work history. He determined she
had a consistent work history and that she was seemingly motivated to work.
While this factor worked in her favor, the other evidence he discussed outweighed
this in his credibility determination. (Tr. 47)
The ALJ clearly took the appropriate factors into consideration when
determining plaintiff was not entirely credible. The Seventh Circuit has held that
“not all of the ALJ’s reasons have to be sound as long as enough of them are, and
here the ALJ had multiple other reasons for discounting plaintiff’s credibility.

18

Halsell v. Astrue, 357 Fed. Appx. 717 (7th Cir. 2009). The ALJ did not just look at
negative factors but considered ones that worked in plaintiff’s favor as well. He
built the requisite logical bridge to his findings and therefore his credibility
determination stands. Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009).
Plaintiff’s next argument is that the ALJ erred in forming her RFC. An RFC
is “the most you can still do despite your limitations.” 20 C.F.R. §1545(a). In
assessing RFC, the ALJ is required to consider all of the claimant’s “medically
determinable impairments and all relevant evidence in the record.” Ibid.
Plaintiff argues that the ALJ did not identify the evidentiary basis he used in
forming his RFC assessment. Along these lines, she argues that the ALJ rejected
all the medical evidence and plaintiff’s testimony and therefore created an
“evidentiary deficit” which caused him to make an independent medical finding in
forming the RFC. This Court disagrees.
The ALJ did not “reject” all of the medical evidence on file. He analyzed the
opinions and gave them each a certain amount of weight. The ALJ did not assign
all of the medical opinions “no weight” but rather “little weight” or “reduced
weight.” He used portions of the medical opinions he found supported in the
record when he formed his RFC. For example, he included the limitations on
standing, walking, and hazards found in Dr. Becker’s opinion. The ALJ included
the limitations from the state agency doctor’s RFC regarding climbing, stooping,
kneeling, and crouching but decided to form a more restrictive RFC overall. (Tr.
39, 707-710, 657-63).

19

He then looked at the rest of the record in forming his opinion. He
considered plaintiff’s testimony as well as a function report from her and her
mother in law. He found some of plaintiff’s claims to not be credible, such as her
level of fatigue. However, he found other portions of her testimony to be credible,
like her inability to multi-task. (Tr. 44-45). He included this in his RFC with
regard to plaintiff’s inability to work in a production or quota-based environment
or in a job with frequent shifts in work tasks. (Tr. 39, 45).
The ALJ is required to assess all the evidence on file, both medical and
nonmedical, and determine an RFC. Diaz v. Chater, 55F.3d 300, 306 (7th Cir.
2005). His RFC determination was not error as it was well reasoned and
supported by the record.
Plaintiff’s final argument is that the ALJ inappropriately weighed the
opinion of Dr. Becker, plaintiff’s treating endocrinologist. The ALJ is required to
consider a number of factors in weighing a treating doctor’s opinion.

The

applicable regulation refers to a treating healthcare provider as a “treating
source.”

The version of 20 C.F.R. §404.1527(c)(2) in effect at the time of the

ALJ’s decision states:
Generally, we give more weight to opinions from your treating
sources, since these sources are likely to be the medical
professionals most able to provide a detailed, longitudinal picture of
your medical impairment(s) and may bring a unique perspective to
the medical evidence that cannot be obtained from the objective
medical findings alone or from reports of individual examinations,
such as consultative examinations or brief hospitalizations. If we find
that a treating source's opinion on the issue(s) of the nature and
severity of your impairment(s) is well-supported by medically
acceptable clinical and laboratory diagnostic techniques and is not
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inconsistent with the other substantial evidence in your case record,
we will give it controlling weight. [Emphasis added]
A treating doctor’s medical opinion is entitled to controlling weight only where it
is supported by medical findings and is not inconsistent with other substantial
evidence in the record. Clifford v. Apfel, 227 F.3d 863 (7th Cir. 2000); Zurawski

v. Halter, 245 F.3d 881 (7th Cir. 2001). Supportability and consistency are two
important factors to be considered in weighing medical opinions. In a nutshell,
“[t]he regulations state that an ALJ must give a treating physician's opinion
controlling weight if two conditions are met: (1) the opinion is supported by
‘medically acceptable clinical and laboratory diagnostic techniques[,]’ and (2) it is
‘not inconsistent’ with substantial evidence in the record.” Schaaf v. Astrue, 602
F.3d 869, 875 (7th Cir. 2010), citing §404.1527(d).
Plaintiff contends that the ALJ failed to consider the factors from 20 C.F.R.
§ 404.1527(c) in determining how much weight to give Dr. Becker’s opinion. She
argues plaintiff had seen Dr. Becker for ten years, Dr. Becker was aware of the
totality of plaintiff’s impairments, Dr. Becker was a specialist, and his opinions
were consistent with portions of the record. Contrary to plaintiff’s belief, the ALJ
need not analyze every factor. The Seventh Circuit has held that the ALJ has not
erred when discussing only two of the relevant factors in 20 C.F.R. § 404.1527(c).

Elder v. Astrue, 529 F.3d 408, 415-16 (7th Cir. 2008). Here, the ALJ opines that
Dr. Becker’s opinions are neither consistent nor supported by the records, which
are two sufficient reasons outlined in the statute. However, the ALJ erred in this

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analysis of supportability and consistency and he therefore inappropriately
weighed the doctor’s opinion.
First, the ALJ determined plaintiff’s record did not indicate an inability to
handle stress or miss more than one day of work per month. The ALJ relies upon
the mental status examination performed by the consulting psychologist, Dr.
York-Anderson, and treatment notes from plaintiff’s family physician, Dr.
Graham. (Tr. 46). This Court agrees with plaintiff that the ALJ failed to
acknowledge evidence that supported Dr. Becker’s opinion. As plaintiff points out,
Dr. Graham’s treatment notes do indicate plaintiff had difficulty with anxiety as
she experienced palpitations and apprehension. (Tr. 785, 788).
In weighing the medical opinions, the ALJ is not permitted to “cherry-pick”
the evidence, ignoring the parts that conflict with his conclusion. Myles v. Astrue,
582 F.3d 672, 678 (7th Cir. 2009). While he is not required to mention every
piece of evidence, “he must at least minimally discuss a claimant's evidence that
contradicts the Commissioner's position.” Godbey v. Apfel, 238 F.3d 803, 808
(7th Cir. 2000). The ALJ impermissibly “cherry-picks” portions of Dr. Graham’s
records focusing only on the treatment records that indicate plaintiff was doing
well.
Plaintiff also points out that the Commissioner and the ALJ cited
consultative psychologist Dr. York-Anderson in support of the notion that
plaintiff’s memory, concentration, and judgment were good. While Dr. YorkAnderson did note this, she also noted plaintiff was “quite depressed.”

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Additionally, plaintiff points out that the ALJ and the Commissioner improperly
assume Dr. York-Anderson would have determined plaintiff could perform low
stress work. This is error. The Seventh Circuit has held that when an evaluation
does not include a functional assessment the report cannot be used to support
specific limitations within an RFC. Suide v. Astrue, 371 Fed. Appx. 684, 690 (7th
Cir. 2010). Here, Dr. York-Anderson never opined as to plaintiff’s functional
capacity. Assuming she felt plaintiff could perform low stress work was
inappropriate.
The ALJ then discussed Dr. Becker’s opinion that plaintiff needed to elevate
her legs and concluded that the record did not support this claim. The ALJ
primarily relies on the fact that plaintiff normally had trace edema and one
doctor’s note indicated it may be related to diet. (Tr. 46). Plaintiff argues that
several portions of the record contain evidence that plaintiff’s edema was at times
severe, and she had pain in her legs and toes. Plaintiff also contends that the ALJ
failed to identify evidence suggesting elevating the legs was inappropriate for even
trace edema. This Court agrees. If the ALJ was unsure as to why Dr. Becker felt
plaintiff needed to elevate her legs he had a duty to contact him. The Seventh
Circuit has held that an “ALJ has a duty to solicit additional information to flesh
out an opinion for which the medical support is not readily discernable. 20 C.F.R.
§ 404.1527(c)(3).“ Barnett v. Barnhart, 381 F.3d 664, 669 (7th Cir. 2004).
The ALJ also claims plaintiff’s nephrologist classified the edema as
primarily diet-related. (Tr. 46). This is inaccurate. Plaintiff’s cardiologist referred

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to her sodium intake when discussing her edema, and stated the edema became
“pretty significant” when she had more salt in her diet. That same visit he
prescribed a medication in order to alleviate the symptoms. (Tr. 849-53). While it
was clear plaintiff needed to minimize her sodium intake, no doctor on record
determined the swelling was primarily diet-related.
The ALJ discounts Dr. Becker’s conclusion that plaintiff had difficulty
reaching, handling, or feeling stating that it inconsistent with the record as a
whole and his own treatment notes. The ALJ noted that the consulting physicians
indicated plaintiff had no difficulty in these areas. Additionally, Dr. Becker’s notes
failed to indicate plaintiff had pain, numbness, or upper extremity neuropathy.
After establishing Dr. Becker’s opinion was not supported the ALJ then
contradicts that opinion and explains how plaintiff probably does have limitations
with regard to reaching, handling, and fingering due to her bypass graft surgery
and her diabetes.
This Court agrees with plaintiff that it is unclear how the ALJ could
determine plaintiff’s residual pain from surgery and diabetes could limit her
ability to reach, handle, and finger, but Dr. Becker could not reach the same
conclusion. It is possible that Dr. Becker included the limitations regarding
reaching, handling, and fingering due to plaintiff’s surgery and diabetes as well.
Again, if the ALJ was unclear as to why Dr. Becker included this limitation, he
had a duty to contact him for clarification. Barnett, 381 F.3d at 669. The ALJ’s

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own finding that plaintiff may have difficulty reaching, handling, and fingering is
in direct opposition to his claim that Dr. Becker’s opinion is unsupported.
The ALJ is “required to build a logical bridge from the evidence to his
conclusions.” Simila v. Astrue, 573 F.3d 503, 516 (7th Cir. 2009). While the ALJ
was not required to give Dr. Becker’s opinion controlling weight, he needed to
adequately explain why the opinion was discounted. ALJ Janney simply failed to
do so here. “If a decision ‘lacks evidentiary support or is so poorly articulated as
to prevent meaningful review,’ a remand is required.” Kastner v. Astrue, 697 F.3d
642, 646 (7th Cir. 2012)., citing Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir.
2002).
The Court wishes to stress that this Memorandum and Order should not be
construed as an indication that the Court believes that plaintiff is disabled or that
she should be awarded benefits. On the contrary, the Court has not formed any
opinions in that regard, and leaves those issues to be determined by the
Commissioner after further proceedings.
Conclusion
The Commissioner’s final decision denying Christy C. Caraway’s application
for social security disability benefits is REVERSED and REMANDED to the
Commissioner for rehearing and reconsideration of the evidence, pursuant to
sentence four of 42 U.S.C. §405(g).
The Clerk of Court is directed to enter judgment in favor of plaintiff.
IT IS SO ORDERED.

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DATE: December 23, 2014.

s/ Clifford J. Proud
CLIFFORD J. PROUD
UNITED STATES MAGISTRATE JUDGE

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