Woods v. Commissioner of Social Security
Filing
31
OPINION AND ORDER: The decision of the Commissioner is AFFIRMED. The Clerk is directed to enter a judgment in favor of the Commissioner and against Woods. Signed by Magistrate Judge Susan L Collins on 9/29/2017. (jss)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
FORT WAYNE DIVISION
DENVER E. WOODS, JR.,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY, sued as Nancy A. Berryhill,
Acting Commissioner of SSA,1
Defendant.
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CAUSE NO. 1:16-cv-00108-SLC
OPINION AND ORDER
Plaintiff Denver E. Woods, Jr., appeals to the district court from a final decision of the
Commissioner of Social Security (“the Commissioner”) denying his application under the Social
Security Act (the “Act”) for disability insurance benefits (“DIB”).2 (DE 1). For the following
reasons, the Commissioner’s decision will be AFFIRMED.
I. PROCEDURAL HISTORY
Woods applied for DIB in October 2012, alleging disability as of June 1, 2012. (DE 12
Administrative Record (“AR”) 121-22). The Commissioner denied Woods’s application initially
and upon reconsideration. (AR 64-71). A hearing was held on April 24, 2014, before
Administrative Law Judge Maryann S. Bright (“the ALJ”), at which Woods, who was
represented by counsel, and a vocational expert, Marie Kieffer (the “VE”), testified. (AR 29-
1
Nancy A. Berryhill is now the Acting Commissioner of Social Security, see Casey v. Berryhill,
853 F.3d 322 (7th Cir. 2017), and thus, she is automatically substituted for Carolyn W. Colvin in this
case, see Fed. R. Civ. P. 25(d).
2
All parties have consented to the Magistrate Judge. (DE 15); see 28 U.S.C. § 636(c).
60).
On October 20, 2014, the ALJ rendered an unfavorable decision to Woods, concluding
that he was not disabled because he could perform a significant number of unskilled, sedentary
jobs in the economy despite the limitations caused by his impairments. (AR 15-23). The
Appeals Council denied Woods’s request for review (AR 1-11), at which point the ALJ’s
decision became the final decision of the Commissioner. See 20 C.F.R. § 404.981.
Woods filed a complaint with this Court on March 30, 2016, seeking relief from the
Commissioner’s decision. (DE 1). Woods alleges two material flaws in the Commissioner’s
decision: (1) that the ALJ failed to adequately account for Woods’s mental limitations in the
residual functional capacity (“RFC”) and in the hypothetical questions posed to the VE at step
five; and (2) that the ALJ improperly discounted Woods’s symptom testimony. (DE 20 at 4-9).
II. FACTUAL BACKGROUND3
At the time of the ALJ’s decision, Woods was 53 years old (AR 23, 62); had a high
school education (AR 180); and possessed past relevant work experience as a machine operator
in a manufacturing setting (DE 181). Woods alleges disability due to a history of colorectal
cancer surgery, radiation, and chemotherapy; a mood disorder due to medical conditions; and
peripheral neuropathy. (DE 20 at 2).
A. Woods’s Testimony at the Hearing
At the hearing, Woods testified as follows: Woods, who was six feet, one inch tall and
weighed 235 pounds, testified that he is married with an adult child; Woods’s wife is employed
outside the home. (AR 32-33). Although Woods had obtained health insurance on or about
3
In the interest of brevity, this Opinion recounts only the portions of the 336-page administrative
record necessary to the decision.
2
February 2014, but he did not have health insurance in 2013. (AR 33). He is independent with
his self care, but he does not do many household tasks. (AR 53). He drives a car once a week to
run errands; his wife had driven him to the hearing. (AR 34). He stopped working because his
employer closed the plant where he worked; he did not feel that he could start another job at the
time due to his pain and other symptoms. (AR 35-36).
Woods asserted that he could no longer work due to pain in his stomach from his history
of colon cancer and his frequent bathroom needs; difficulty standing or sitting for extended
periods; and medication side effects of fatigue, dizziness, and difficulty concentrating. (AR 3940, 47, 49). He stated that he has had abdominal pain for 12 years and that he takes pain
medication for the pain. (AR 42, 44). The pain, which is constant, feels like “fullness” in his
stomach area. (AR 49). He conceded, however, that he had worked for 10 years after his cancer
treatment, even when he was taking high doses of pain medication. (AR 40). He also
complained that he could “hardly stand” due to knee pain, which started a year earlier and wakes
him at night. (AR 40). Woods had told his doctor about his knee pain and she had
recommended testing, but he declined to do so due to his financial limitations. (AR 41, 54-55).
He estimated that he could walk one block before needing to rest. (AR 23).
Woods testified that in a typical day, he has to use the bathroom “on and off all day
long.” (AR 44). Up to three days a week, for six to eight-hour periods, he has to use the
bathroom every 15 minutes. (AR 45, 52). He takes pain medication, Tramadol, because his
bowel movements are painful, and the medication is helpful, though it makes him drowsy. (AR
44, 51-52). He has to lay around a lot because of the pain, and often he lies in a hot bath to ease
the pain. (AR 44). He does not do many household tasks because it is hard for him to get away
3
from the bathroom. (AR 46). He stated that he has little warning before needing to use the
bathroom, and sometimes he remains there for hours at a time. (AR 49-50, 52). He also takes
two naps each day, each lasting one to two hours. (AR 21). He has difficulty sleeping at night,
so he sometimes lies in a recliner, which helps ease his pain. (AR 51). He also complained of
feeling depressed and irritable all the time, but he had not discussed these symptoms with his
doctor or received any treatment for depression. (AR 23-24, 54).
B. Summary of the Relevant Medical Evidence
In 2002, Woods was diagnosed with advanced stage III colorectal cancer. (AR 271). He
underwent chemotherapy, radiation, and resection. (AR 271). He returned to full-time work that
same year. (AR 35-36, 39). In 2004, Woods had scar tissue surgically removed from his colon.
(AR 275). In 2009, a CT scan was negative for any recurrence of cancer, and a later
colonoscopy and sigmoidoscopy were negative. (AR 271).
On January 9, 2013, Woods underwent a mental status examination by Ceola Berry,
Ph.D., for purposes of his disability application. (AR 279-81). Woods presented with a
dysthymic mood; his attention and concentration were adequate. (AR 279). He denied any
suicidal or homicidal ideation. (AR 279). He was independent with his daily living skills, but he
reported frequent muscle spasms of his colon and frequent bowel movements. (AR 279-80).
The mental status examination did not reveal any significant problems with concentration,
memory, mental calculations, abstracting ability, general knowledge, or judgment. (AR 280).
Woods’s energy level waned during the examination, but “he presented as a persister in a
stressful environment.” (AR 280). Dr. Berry concluded that Woods’s ability to work would be
primarily affected by his perceived physical limitations and secondarily by his mood states. (AR
4
280). Dr. Berry diagnosed Woods with a mood disorder due to medical conditions and assigned
him a Global Assessment of Functioning (“GAF”) score of 60.4
Several days later, on January 15, 2013, Woods was examined by Dr. James Chan for
purposes of his disability application. (AR 271-74). Woods complained of decreased energy,
difficulty sleeping, and loss of appetite. (AR 271). Woods was diagnosed with depression by
his general practitioner, but he was not taking any medications for it. (DE 274). He related a 10year history of fatigue upon waking, which worsened throughout the day. (DE 271). The
examination revealed no abnormalities in musculoskeletal or neurological systems, strength,
sensation, fine fingering, or physical movement. (DE 273). Dr. Chan noted Woods’s history of
treatment for colon cancer and opined that Woods likely had some constipation due to postsurgical fibrosis with muscle spasms and fatigue causing hypogastric pain. (DE 274). He
recommended that Woods add dulcolax/miralax to help regulate his bowel movements, flexeril
to help with spasms, and fiber supplements; he also advised Woods to continue follow-up checks
for colon cancer. (DE 274). Dr. Chan further noted that Woods had a six-month history of
vertigo; Dr. Chan advised Woods to consider ceasing Lyrica temporarily due to possible
neurological side effects, and to switch to Neurontin instead. (AR 274).
That same day, January 15, 2013, Dr. R. Fife, a state agency physician, reviewed
4
GAF scores reflect a clinician’s judgment about the individual’s overall level of functioning. Am.
Psychiatric Ass’n, Diagnostic & Statistical Manual of Mental Disorders 32 (4th ed., Text Rev. 2000). A GAF score
of 51 to 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or
moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). Id. “The American Psychiatric Association no longer uses the GAF as a metric.” Spencer v. Colvin, No.
13-cv-1487, 2015 WL 684545, at *17 n.5 (C.D. Ill. Feb. 17, 2015) (citing Am. Psychiatric Ass’n, Diagnostic &
Statistical Manual of Mental Disorders 16 (5th ed. 2013)). However, Dr. Berry used a GAF score in assessing
Woods, so the GAF is relevant to the ALJ’s decision. See id. (citing Bates v. Colvin, 736 F.3d 1093, 1099 (7th Cir.
2013)).
5
Woods’s record. (AR 283-90). Dr. Fife concluded that Woods could lift 10 pounds frequently
and 20 pounds occasionally; stand or walk six hours in an eight-hour workday; sit about six
hours in an eight-hour workday; occasionally balance, stoop, kneel, crouch, crawl, and climb
ramps and stairs, but never climb ladders, ropes, or scaffolds; and must avoid wetness and
hazards, such as slippery, uneven surfaces or heights. (AR 283-90). Dr. Fife’s opinion was later
affirmed by Dr. J.V. Corcoran, another state agency physician. (AR 305).
The next day, January 16, 2013, Benetta E. Johnson, Ph.D., a state agency psychologist,
reviewed Woods’s record and completed a psychiatric review technique form. (AR 291-304).
Dr. Johnson concluded that Woods had mild difficulties in maintaining concentration,
persistence, or pace, but no restrictions in activities of daily living or maintaining social
functioning. (AR 301). In her narrative, Dr. Johnson observed that Woods had an adequate
attention span and that he could finish what he started, follow instructions, and get along with
authority. (AR 303). Dr. Johnson opined that Woods’s mental impairment did not appear to be
severe. (AR 303). Dr. Johnson’s opinion was later affirmed by Joelle J. Larsen, Ph.D., another
state agency psychologist. (AR 306).
On September 8, 2014, Woods visited Dr. Eric Wallisa of MedExpress Marion for
complaints of chronic abdominal pain.5 (AR 318-20). Tenderness and guarding were “noted
diffusely” in the abdominal exam. (AR 319). However, Woods’s abdomen was normal to
percussion and not distended, normally active bowel sounds were present, and an obturator sign
was negative. (AR 319). There was no rigidity or rebound tenderness noted diffusely, and no
5
As will be discussed infra, Woods submitted Dr. Wallisa’s report to the Appeals Council for review after
the ALJ issued her decision. It is unclear whether Dr. Wallisa’s report was before the ALJ at the time of her
decision.
6
evidence of hernia, a mass, or enlargement of the liver or spleen. (AR 319). An abdominal Xray revealed increased retained stool density throughout the colon, but no obstruction or
impaction. (AR 320, 322). Dr. Wallisa assessed general abdominal pain, indicating that
Woods’s symptoms appeared to be “neuropathic pain related from chemotherapy and radiation
treatments for colon cancer.” (AR 320). Dr. Wallisa prescribed Neurontin and instructed Woods
to increase his fluids. (AR 320, 324).
III. STANDARD OF REVIEW
Section 405(g) of the Act grants this Court “the power to enter, upon the pleadings and
transcript of the record, a 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). The
Court’s task is limited to determining whether the ALJ’s factual findings are supported by
substantial evidence, which means “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2005)
(citation omitted). The decision will be reversed only if it is not supported by substantial
evidence or if the ALJ applied an erroneous legal standard. Clifford v. Apfel, 227 F.3d 863, 869
(7th Cir. 2000) (citation omitted).
To determine if substantial evidence exists, the Court reviews the entire administrative
record but does not reweigh the evidence, resolve conflicts, decide questions of credibility, or
substitute its judgment for the Commissioner’s. Id. Rather, if the findings of the Commissioner
are supported by substantial evidence, they are conclusive. Jens v. Barnhart, 347 F.3d 209, 212
(7th Cir. 2003) (citation omitted). “In other words, so long as, in light of all the evidence,
reasonable minds could differ concerning whether [the claimant] is disabled, we must affirm the
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ALJ’s decision denying benefits.” Books v. Chater, 91 F.3d 972, 978 (7th Cir. 1996).
IV. ANALYSIS
A. The Law
Under the Act, a claimant is entitled to DIB if he establishes an “inability to engage in
any substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to . . . last for a continuous period of not less than 12
months.” 42 U.S.C. §§ 416(i)(1), 423(d)(1)(A). A physical or mental impairment is “an
impairment that results from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C.
§ 423(d)(3).
The Commissioner evaluates disability claims pursuant to a five-step evaluation process,
requiring consideration of the following issues, in sequence: (1) whether the claimant is
currently unemployed; (2) whether the claimant has a severe impairment; (3) whether the
claimant’s impairment meets or equals one of the impairments listed by the Commissioner, see
20 C.F.R. § 404, Subpt. P, App’x 1; (4) whether the claimant is unable to perform his past work;
and (5) whether the claimant is incapable of performing work in the national economy.6 See
Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001) (citations omitted); 20 C.F.R. §
404.1520. An affirmative answer leads either to the next step or, on steps three and five, to a
finding that the claimant is disabled. Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001)
(citation omitted). A negative answer at any point other than step three stops the inquiry and
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Before performing steps four and five, the ALJ must determine the claimant’s RFC or what tasks the
claimant can do despite his limitations. 20 C.F.R §§ 404.1520(e), 404.1545(a). The RFC is then used during steps
four and five to help determine what, if any, employment the claimant is capable of. 20 C.F.R. § 404.1520(e).
8
leads to a finding that the claimant is not disabled. Id. (citation omitted). The burden of proof
lies with the claimant at every step except the fifth, where it shifts to the Commissioner.
Clifford, 227 F.3d at 868 (citation omitted).
B. The Commissioner’s Final Decision
On October 20, 2014, the ALJ issued the decision that ultimately became the
Commissioner’s final decision. (AR 15-23). At step one, the ALJ concluded that Woods had
not engaged in substantial gainful activity after his alleged onset date of June 1, 2012. (AR 17).
At step two, the ALJ found that Woods had the following severe impairments: a history of
colorectal cancer surgery, radiation, and chemotherapy in 2002; and a mood disorder due to
medical conditions. (AR 17).
At step three, the ALJ concluded that Woods did not have an impairment or combination
of impairments severe enough to meet or equal a listing. (AR 17-19). Before proceeding to step
four, the ALJ determined that Woods’s symptom testimony was “not entirely credible” (AR 20),
and assigned him the following RFC:
[T]he claimant has the [RFC] to perform light work . . . .
Specifically, he is capable of lifting, carrying, pushing, pulling 20
pounds occasionally and 10 pounds frequently; standing and/or
walking approximately 6 hours per 8-hour work day, and sitting
for approximately 6 hours per 8-hour work day, with normal
breaks; occasionally climbing ramps and stairs, balancing,
stooping, crouching, kneeling and crawling; never climbing
ladders, ropes or scaffolds; and avoid concentrated exposure to
wetness and hazards of slippery, uneven surfaces, unprotected
heights and dangerous unguarded machinery. He is unable to
engage in complex or detailed tasks, but can perform simple,
routine and repetitive tasks consistent with unskilled work and is
able to sustain and attend to task throughout the 8-hour workday.
(AR 19). The ALJ found at step four that Woods could not perform any of his past relevant
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work. (AR 21). At step five, based on the assigned RFC and the VE’s testimony, the ALJ
concluded that Woods could perform a significant number of unskilled, light exertional jobs in
the economy, including cashier, small products assembler, and rental clerk. (AR 22). Therefore,
Woods’s application for DIB was denied. (AR 23).
C. The ALJ Adequately Accounted for Woods’s Mental
Limitations in the RFC and in the Step-Five Hypotheticals
Woods first argues that the ALJ failed to adequately account for his mental limitations in
the RFC and in the hypotheticals posed to the VE at step five. More specifically, Woods argues
that the ALJ erred by failing to incorporate into the RFC and into the hypotheticals her step-three
finding that he had moderate deficits in maintaining concentration, persistence, or pace.
Contrary to Woods’s assertion, the assigned RFC and the step-five hypotheticals adequately
account for his mental limitations, and thus, Woods’s argument does not warrant a remand of the
Commissioner’s final decision.
At steps two and three of the sequential evaluation, the ALJ determines the severity of a
claimant’s mental impairment by assessing his degree of functional limitation in categories
identified in the “paragraph B” and “paragraph C” criteria of the adult mental disorders listings.
SSR 96-8p, 1996 WL 374184, at *4 (July 2, 1996). Relevant to this appeal, the “paragraph B”
criteria consist of four “broad functional areas”: activities of daily living; social functioning;
concentration, persistence, or pace; and episodes of decompensation. 20 C.F.R. §
404.1520a(c)(3); see, e.g., Jones v. Massanari, No. 01-C-0024-C, 2001 WL 34382025, at *13
(W.D. Wis. Oct. 18, 2001). “[T]he limitations identified in the ‘paragraph B’ criteria . . . are not
an RFC assessment but are used to rate the severity of mental impairment(s) at steps 2 and 3 of
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the sequential evaluation process.” SSR 96-8p, 1996 WL 374184, at *4.
“The mental RFC assessment used at steps 4 and 5 of the sequential evaluation process
requires a more detailed assessment by itemizing various functions contained in the broad
categories found in paragraphs B and C . . . .” SSR 96-8p, 1996 WL 374814, at *4; see Virden v.
Astrue, No. 11-0189-DRH-CJP, 2011 WL 5877233, at *9 (S.D. Ind. Nov. 4, 2011). “RFC is
what an individual can still do despite his or her limitations.” SSR 96-8p, 1996 WL 374184, at
*2; see 20 C.F.R. § 404.1545(a)(1). “The RFC assessment must be based on all of the relevant
evidence in the case record . . . .” SSR 96-8p, 1996 WL 374184, at *5; see 20 C.F.R. §
404.1545(a)(3). That is, “[i]n assessing RFC, the adjudicator must consider limitations and
restrictions imposed by all of an individual’s impairments, even those that are not ‘severe.’”
SSR 96-8p, 1996 WL 374184, at *5; see Paar v. Astrue, No. 09 C 5169, 2012 WL 123596, at
*13 (N.D. Ill. Jan. 17, 2012).
Here, when assessing the “paragraph B” criteria at steps two and three, the ALJ
concluded that Woods had moderate difficulties in maintaining concentration, persistence, or
pace, but no difficulties in activities of daily living or in maintaining social functioning. (AR
18). When proceeding to step four, the ALJ then assigned Woods the following mental RFC:
“[Woods] is unable to engage in complex or detailed tasks, but can perform simple, routine and
repetitive tasks consistent with unskilled work and is able to sustain and attend to tasks
throughout the 8-hour workday.” (AR 19).
Woods asserts that the foregoing restriction is inadequate because it did not expressly
include the ALJ’s finding at step three that he had moderate difficulties in maintaining
concentration, persistence, or pace. Specifically, Woods argues that in most cases, incorporating
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terms like “simple, repetitive tasks” or “unskilled work” on their own will not necessarily
exclude from the VE’s consideration those jobs that present significant problems of
concentration, persistence, or pace. (DE 20 at 5).
Indeed, the Seventh Circuit Court of Appeals has instructed that “for most cases, the ALJ
should refer expressly to limitations on concentration, persistence, and pace in the hypothetical
in order to focus the VE’s attention on these limitations and assure reviewing courts that the
VE’s testimony constitutes substantial evidence of the jobs a claimant can do.” O’ConnorSpinner v. Astrue, 627 F.3d 614, 620-21 (7th Cir. 2010); see, e.g., Miller v. Colvin, No. 1:11-cv1186, 2013 WL 796722, at *4 (S.D. Ind. Mar. 1, 2013) (concluding that the case fell within the
scope of “most cases” and that the restrictions on concentration, persistence, and pace should
have been included in the hypothetical). However, in this particular instance, the assigned RFC
and the hypotheticals posed by the ALJ to the VE adequately accounted for Woods’s mental
limitations and the ALJ’s step-three finding that Woods had moderate deficits in concentration,
persistence, or pace.
To explain, in assigning Woods the RFC, the ALJ gave “[g]reat weight” to the
assessment of Dr. Berry. (AR 21). The mental status examination administered by Dr. Berry
“d[id] not reveal any significant problems with concentration, short-term memory, mental
calculations, abstracting ability, general knowledge or judgment,” and she found that Woods’s
“concentration and attention to task was adequate.” (AR 279-80). Dr. Berry concluded that
Woods’s “ability to work would be primarily affected by his perceived physical limitations and
secondarily by mood states.” (AR 280); see Dixon, 270 F.3d at 1177 (appreciating that in
contrast to a treating physician’s opinion, “a consulting physician’s opinion might have the
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advantage of both impartiality and expertise” (citation omitted)).
Additionally, the ALJ gave “partial weight” to the opinion of Dr. Johnson, the state
agency psychologist, who concluded that Woods had just mild limitations in maintaining
concentration, persistence, or pace, and no limitations in activities of daily living and
maintaining social functioning. (AR 21). Dr. Johnson opined that Woods could finish what he
starts, follow instructions, and get along with authority. (AR 303). Dr. Johnson’s opinion was
later affirmed by Dr. Larsen. (AR 306). “The regulations, and this Circuit, clearly recognize
that reviewing physicians and psychologist[s] are experts in their field and the ALJ is entitled to
rely on their expertise.” Ottman v. Barnhart, 306 F. Supp. 2d 829, 839 (N.D. Ind. 2004) (citing
20 C.F.R. § 404.1527(e)(2)(i); Scott v. Sullivan, 898 F.2d 519, 524 (7th Cir. 1990)).
In O’Connor-Spinner, 627 F.3d at 620, the Seventh Circuit stated that when an ALJ
translates a step-three finding of limitations into concentration, persistence, or pace to the RFC,
the ALJ should address not only the complexity of the tasks the claimant can perform, but also
the “[t]he ability to stick with a given task over a sustained period[.]” See also Warren v. Colvin,
565 F. App’x 540, 544 (7th Cir. 2014). Here, the RFC and the step-five hypotheticals did just
that. The ALJ, relying on the opinions of Drs. Berry, Johnson, and Larsen, crafted an RFC and
step-five hypotheticals that were even more accommodating that the medical source opinions of
these doctors, addressing both the complexity of the tasks that Woods could perform and his
ability to complete such tasks over a sustained period.
To address complexity, the ALJ stated that Woods “is unable to engage in complex or
detailed tasks, but can perform simple, routine, and repetitive tasks consistent with unskilled
work.” (AR 19). And to address the ability to stick with a given task over a sustained period,
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the ALJ stated that Woods “is able to sustain and attend to task throughout the 8-hour workday.”
(AR 19). Thus, the ALJ did not run afoul of the Seventh Circuit’s instruction in O’ConnorSpinner to address both the complexity of the tasks the claimant can perform and the claimant’s
ability to stick with the tasks over a sustained period. See Milliken v. Astrue, 397 F. App’x 218,
222 (7th Cir. 2010) (concluding that the assigned RFC for unskilled work adequately accounted
for the claimant’s difficulties in concentration, persistence, or pace, where a medical source
opined that the claimant could perform unskilled work despite her deficits in concentration,
persistence, or pace); Johnson v. Barnhart, 314 F.3d 283, 288-89 (7th Cir. 2002) (affirming the
ALJ’s RFC where he relied on a medical source opinion who found that despite the claimant’s
limitations in the ability to maintain a regular schedule and complete a normal workday, the
claimant could still perform low-stress, repetitive work); Marley v. Colvin, No. 1:14- cv-157,
2015 WL 3999484, at *4-6 (N.D. Ind. July 1, 2015) (finding that the ALJ adequately accounted
for the claimant’s deficits in concentration, persistence, or pace where the ALJ relied on a
medical source opinion indicating that the claimant could perform simple work and could “attend
to task for sufficient periods of time to complete tasks”).
Furthermore, in concluding at step three that Woods had moderate limitations in
concentration, persistence, or pace, the ALJ linked Woods’s concentration difficulties to his
complaints of abdominal pain and his taking pain medication. Specifically, the ALJ stated:
The claimant testified that he suffers from abdominal pain and that
he takes pain medication for the pain. He stated that he suffers
from abdominal pain and that he takes pain medication for the
pain. He stated that it is very difficult for him to concentrate when
he takes pain medications. The record fails to substantiate more
than moderate difficulties in this domain.
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(AR 18). While the ALJ considered Woods’s complaints about his abdominal pain and
medication side effects of fatigue and dizziness, the ALJ observed that despite his complaints,
Woods in the past was able to work after his cancer treatments while on high doses of pain
medications. (AR 19-20). In fact, Woods worked full time for 10 years after undergoing cancer
treatments. (AR 21 (noting Woods’s “strong work history”), 43, 181, 271). The ALJ pointed
out that Woods stopped working because the plant closed, not because of any disabling
impairments. (AR 21, 35-36). And as explained infra, although Woods testified that he took
extra breaks at work and missed one to two days of work a week (AR 46-49), he failed to
substantiate this testimony after the hearing when given an opportunity to do so (AR 21). See
Schmidt v. Astrue, 496 F.3d 833, 846 (7th Cir. 2007) (“[An ALJ is] required only to incorporate
into his hypotheticals those impairments and limitations that he accepts as credible.” (citation
omitted)).
Moreover, the record is devoid of any medical source opinion indicating that Woods has
deficits in concentration, persistence, or pace that would impact his ability to perform unskilled
work. “It is axiomatic that the claimant bears the burden of supplying adequate records and
evidence to prove their claim of disability.” Scheck v. Barnhart, 357 F.3d 697, 702 (7th Cir.
2004) (citing 20 C.F.R. § 404.1512(c); Bowen v. Yuckert , 482 U.S. 137, 146 n.5 (1987)); see
Flener ex rel. Flener v. Barnhart, 361 F.3d 442, 448 (7th Cir. 2004) (“[T]he primary
responsibility for producing medical evidence demonstrating the severity of impairments
remains with the claimant.” (citation omitted)).
Therefore, on this record, the Court concludes that the ALJ adequately accounted for
Woods’s mental limitations in the RFC and in the hypotheticals posed to the VE at step five.
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“No principle of administrative law or common sense requires us to remand a case in quest of a
perfect opinion unless there is reason to believe that the remand might lead to a different result.”
Fisher v. Bowen, 869 F.2d 1055, 1057 (7th Cir. 1989) (citations omitted).
D. The ALJ’s Consideration of Woods’s Symptom Testimony Will Not Be Disturbed
Woods also argues that the ALJ improperly discounted the credibility of his symptom
testimony. Woods cites to his testimony that his pain and other symptoms cause him to take one
to two naps a day, each lasting one to two hours, and caused him to miss one to two days of work
when he was last working. (AR 48-49). Woods emphasizes that the VE testified that an
individual who misses even one day in the 90-day probationary period would not be able to
sustain competitive work. (AR 58). For the following reasons, the ALJ’s credibility
determination will not be disturbed.
An ALJ’s credibility determination concerning a claimant’s symptom testimony is
entitled to special deference because the ALJ is in the best position to evaluate the credibility of
a witness. Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000). If an ALJ’s determination is
grounded in the record and she articulates her analysis of the evidence “at least at a minimum
level,” Ray v. Bowen, 843 F.2d 998, 1002 (7th Cir. 1988) (citation omitted), creating “an
accurate and logical bridge between the evidence and the result,” Ribaudo v. Barnhart, 458 F.3d
580, 584 (7th Cir. 2006) (citation omitted), her determination will be upheld unless it is “patently
wrong.” Powers, 207 F.3d at 435; see Carradine v. Barnhart, 360 F.3d 751, 754 (7th Cir. 2004)
(remanding an ALJ’s credibility determination because the ALJ’s decision was based on “serious
errors in reasoning rather than merely the demeanor of the witness” (citation omitted)).
“[Because] the ALJ is in the best position to observe witnesses, [the Seventh Circuit] usually
16
do[es] not upset credibility determinations on appeal so long as they find some support in the
record and are not patently wrong.” Herron v. Shalala, 19 F.3d 329, 335 (7th Cir. 1994)
(citations omitted).
Here, the ALJ found Woods’s symptom testimony “not entirely credible” for several
reasons. (AR 20). These include that: (1) the medical evidence of record does not establish the
cause of Woods’s allegations of abdominal pain; (2) the medical evidence does not support a
severe mental impairment; (3) no medical source opinions of record opined that Woods is unable
to work; (4) Woods worked for 10 years after his bout with cancer and stopped working due to
the plant closing, not because of disabling symptoms; (5) Woods failed to submit evidence after
the hearing to substantiate his assertion that he missed one to two days of work when he last
worked due to his pain and other symptoms; and (6) Woods did not appear to be in disabling
pain at the hearing. (AR 20-21). Woods challenges just two of these six reasons provided by the
ALJ.
1. Dr. Wallisa’s Report
First, Woods contends that the ALJ did not review material medical evidence of record
concerning the cause of his abdominal pain—Dr. Wallisa’s report of September 8, 2014, at
MedExpress Marion. To review, Dr. Wallisa observed that Woods had tenderness and guarding
“noted diffusely on abdominal exam,” but no other clinical signs; Dr. Wallisa assessed
generalized abdominal pain, indicating that Woods’s symptoms appeared to be neuropathic pain
related to his past chemotherapy and radiation treatments. (AR 319). Woods states that he
submitted Dr. Wallisa’s report to the Appeals Council, but the Appeals Council found that it was
not new evidence because a copy of the report was purportedly already in the record. (DE 20).
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In its Notice of Appeals Council Action, the Appeals Council stated that it considered the
additional evidence submitted by Woods—that is, it “considered Medical Records from
MedExpress Marion dated September 8, 2014 (7 pages).” (AR 2). The Appeals Council stated,
however, that the evidence was “not new because it is an exact copy of a document found in the
record at Exhibit 15F.” (AR 2). The Appeals Council further explained that it “considered
whether the [ALJ’s] actions, conclusion, or findings are contrary to the weight of the evidence
currently of record,” and it “found that this information does not provide a basis for changing the
[ALJ’s] decision.” (AR 2).
When a claimant provides additional evidence to the Appeals Council, the Council “must
determine (i) whether the proffered new evidence relates to the proper time period and (ii)
whether the evidence is ‘new’ and ‘material.’” Binzen v. Barnhart, No. 01 C 2716, 2002 WL
31324061, at *1 (N.D. Ill. Oct. 16, 2002) (quoting Perkins v. Chater, 107 F.3d 1290, 1294 (7th
Cir. 1997)); see Getch v. Astrue, 539 F.3d 473, 483-84 (7th Cir. 2008); see 20 C.F.R. §
404.970(b). “If the Appeals Council answers both of these questions in the affirmative it must
then determine whether the ALJ’s decision is contrary to all of the evidence, i.e., the evidence
before the ALJ and the new and material evidence submitted to the Appeals Council.” Binzen,
2002 WL 31324061, at *1. “If the Appeals Council denies review at this stage—essentially
reasoning that all of the evidence does not undermine the ALJ’s decision—then the Council’s
decision is unreviewable[,]” id. (citing Perkins, 107 F.3d at 1294), provided, however, that the
refusal does not rest on a mistake of law, such as a determination that the evidence newly
submitted to the Appeals Council was not material to the disability determination. See Eads v.
Sec’y of the Dep’t of Health & Human Servs., 983 F.2d 815, 817 (7th Cir. 1993).
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Here, regardless of the Appeals Council’s assertion that Dr. Wallisa’s report was already
of record, it appears that the Appeals Council reviewed Dr. Wallisa’s report. (AR 2). As
explained above, in its Notice of Appeals Council Action sent to Woods, the Appeals Council
expressly acknowledged its review of the records from MedExpress Marion, which consisted of
Dr. Wallisa’s report, and the Appeals Council further explained that the evidence does not
provide a basis for changing the ALJ’s decision. (AR 2).
“Implicit in the Appeals Council’s decision to review the additional evidence is the
[C]ouncil’s determination that [Woods’s] proffered evidence was both ‘new’ and ‘material.’”
Binzen, 2002 WL 31324061, at *6; see also Alexander v. Barnhart, No. 01 C 0168, 2003 WL
21418244, at *8 (N.D. Ill. June 18, 2003); Burling v. Barnhart, No. 01 C 3189, 2002 WL
731129, at *9 (N.D. Ill. Apr. 24, 2002). Thus, the Appeals Council’s refusal to review the case
does not rest on a mistake of law that the additional evidence was not “new” or “material.” See,
e.g., Nelson v. Bowen, 855 F.2d 503, 506 (7th Cir. 1988) (articulating that the Appeals Council’s
determination that additional evidence is not material is a legal determination and therefore is
subject to de novo review (citation omitted)); Maxwell v. Sullivan, 792 F. Supp. 582, 592 (N.D.
Ill. 1992) (stating that a district court is entitled to review an Appeals Council’s decision whether
additional evidence is “new and material”).
To the contrary, the Appeals Council refused to review the case because it concluded that
after considering the additional evidence, the new evidence was not contrary to the weight of the
evidence currently of record. (AR 2); see, e.g., Perkins, 107 F.3d at 1294. As explained supra,
“[t]he [C]ouncil’s subsequent determination that the additional evidence did not provide a basis
to disturb the ALJ’s decision is unreviewable.” Binzen, 2002 WL 31324061, at *6 (citing
Perkins, 107 F.3d at 1294). That is, the Appeals Council’s conclusion that the new evidence
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“did not tip the scales in favor of the [p]laintiff’s claim for benefits” is a “factual determination
which may not be disturbed on review.” Asberry-Whitt v. Barnhart, No. IP 02-0377-C-T/L,
2003 WL 21696543, at *5 (S.D. Ind. July 5, 2003) (citing Perkins, 107 F.3d at 1294); see also
Lopez v. Massanari, No. 01 C 1426, 2002 WL 531404, at *7-8 (N.D. Ill. Apr. 9, 2002); Nitz v.
Massanari, No. 00 C 3850, 2001 WL 929759, at *10 (N.D. Ill. Aug. 15, 2001) (explaining that
where “the Appeals Council considered this new evidence, its discretionary decision that the
evidence did not warrant further action is not reviewable”); Lee v. Chater, No. 95 C 3326, 1996
WL 478913, at *2 (N.D. Ill. Aug. 20, 1996) (rejecting plaintiff’s characterization of the Appeals
Council’s decision as a “mistake of law” where the Appeals Council considered the new
evidence but simply found that it did not provide a basis for changing the ALJ’s decision).
And even if the Appeals Council had not reviewed Dr. Wallisa’s report, necessitating a
de novo review of such evidence by this Court, Dr. Wallisa’s report does not create a “reasonable
probability that the Commissioner would have reached a different conclusion had the evidence
been considered.” Perkins, 107 F.3d at 1296 (citation and internal quotation marks omitted); cf.
Stepp v. Colvin, 795 F.3d 711, 725 (7th Cir. 2015) (finding that the new evidence contradicted
the ALJ’s conclusion that the claimant’s condition was on an upward trajectory at the end of the
adjudicative period); Farrell v. Astrue, 692 F.3d 767, 771 (7th Cir. 2012) (finding that the new
evidence filled an evidentiary gap identified in the ALJ’s decision). In assessing the severity of
Woods’s abdominal pain complaints, the ALJ cited numerous pieces of evidence to support her
conclusion that “[t]he medical evidence does not establish the cause of the claimant’s allegations
of abdominal pain.” (AR 20). The ALJ referred to the results of Woods’s colonoscopy on
January 24, 2012; the results of a flexible sigmoidoscopy on July 15, 2012; the consultative
20
examination by Dr. Chan on January 5, 2013; and a CT scan of Woods’s abdomen on February
24, 2014—none of which identified “a clear explanation” for Woods’s complaints of abdominal
pain. (AR 20).
Dr. Wallisa’s examination, too, was unremarkable in clinical findings, aside from
abdominal tenderness and guarding “noted diffusely.” (AR 319); 20 C.F.R. § 404.1529(c)(2)
(“Objective medical evidence . . . is a useful indicator to assist [the Commissioner] in making
reasonable conclusions about the intensity and persistence of [the claimant’s] symptoms and the
effect those symptoms, such as pain, may have on [the claimant’s] ability to work.”). Dr.
Wallisa diagnosed Woods with “[a]bdominal pain, generalized,” stating that his pain appeared to
be neuropathic pain relating to his past cancer treatments. (AR 320). But this is far from “a
clear explanation” for Woods’s abdominal pain complaints (AR 20), as Dr. Chan, too, generally
attributed Woods’s abdominal pain to his past cancer treatments (AR 274). Significantly, Dr.
Wallisa did not impose any physical restrictions, opine about any limitations, or assert that
Woods is unable to work. As the ALJ correctly observed, “neither the medical evidence of
record, nor the medical opinions, support the claimant’s allegations of a complete inability to
work” (AR 21), and the addition of Dr. Wallisa’s report would not change that conclusion.
Consequently, Woods’s arguments concerning Dr. Wallisa’s report do not necessitate a
remand of the ALJ’s credibility determination regarding Woods’s symptom testimony. See
Berger v. Astrue, 516 F.3d 539, 546 (7th Cir. 2008) (affirming the ALJ's credibility
determination because it was not “patently wrong” or “divorced from the facts contained in the
record”).
2. Woods’s Work History
Woods also challenges, at least in part, the ALJ’s consideration of his work history in
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connection with the ALJ’s credibility determination. While Woods admits that the ALJ was
correct in considering that he stopped working because the plant closed, he contends that his
earnings report is not inconsistent with his assertion that he missed one to two days a week when
he last worked.
With respect to Woods’s work history, the ALJ reasoned:
The claimant has a strong work history. At age 51, he stopped
working when the plant closed, not due to any disabling
impairments. The undersigned gave the claimant an opportunity
after the hearing to substantiate testimony regarding days off
work and need for breaks. Unfortunately, the efforts were
unsuccessful. The evidence submitted post hearing showed
consistent earnings.
(AR 21). Woods argues that the ALJ’s conclusion “is not entirely true,” at least with respect to
2011, as in March 2011 he earned just $620.35, he earned nothing in May 2011, and the months
of February, April, and July were also far below normal. (DE 20 at 9 (citing AR 169)). Woods
also suggests that his more consistent earnings in 2012 could include vacation pay or severance
pay, which would not reflect his days off. (DE 20 at 9).
In asserting this argument, Woods seems to ignore a basic premise of Social Security
law—that it is his burden, not the Commissioner’s, to produce “adequate records and evidence to
prove [his] claim of disability.” Scheck, 357 F.3d at 702; see Clifford, 227 F.3d at 868
(explaining that the burden of proof lies with the claimant at every step except the fifth, where it
shifts to the Commissioner). As the ALJ explained, after the hearing she gave Woods an
opportunity to substantiate his testimony about his alleged days off work and need for breaks by
submitting additional information from his past employer. (AR 21). Woods concedes, however,
that his “employer did not answer the specific questions about absences, but instead only
provided wage information.” (DE 20 at 8). That the wage information did not substantiate
22
Woods’s claim of excessive absences and need for breaks results in Woods’s failure to bear his
burden to substantiate his testimony. As such, the ALJ’s credibility determination is supported
by her consideration of Woods’s work history. See Simila v. Astrue, 573 F.3d 503, 519 (7th Cir.
2009) (considering the claimant’s work history when discounting his credibility); SSR 96-7p,
1996 WL 374186, at *5 (July 2, 1996) (directing the ALJ to consider a claimant’s prior work
record and efforts to work as part of the credibility determination).
In sum, the ALJ provided at least six reasons for discounting the severity of Woods’s
symptom testimony. Woods challenges just two of these reasons, and neither of his challenges
provide a basis upon which to upset the ALJ’s credibility determination, which is entitled to
special deference. Powers, 207 F.3d at 435. As such, the Court has no difficulty upholding the
ALJ’s credibility determination in this instance because when assessing Woods’s symptom
testimony, the ALJ built an adequate and logical bridge between the evidence and her
conclusion, see Ribaudo, 458 F.3d at 584, and her conclusion is not “patently wrong,” Powers,
207 F.3d at 435. Consequently, the ALJ’s credibility determination will stand, and the final
decision of the Commissioner will be affirmed.
V. CONCLUSION
For the foregoing reasons, the decision of the Commissioner is AFFIRMED. The Clerk
is directed to enter a judgment in favor of the Commissioner and against Woods.
SO ORDERED.
Entered this 29th day of September 2017.
/s/ Susan Collins
Susan Collins
United States Magistrate Judge
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