Cofield v. Commissioner of Social Security

Filing 22

OPINION AND ORDER: The decision of the Commissioner is REMANDED for further proceedings consistent with this opinion. Signed by Magistrate Judge Andrew P Rodovich on 9/5/2018. (jss)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION
MICHAEL A. COFIELD,
Plaintiff,
v.
NANCY A. BERRYHILL,
Deputy Commissioner for Operations,
Social Security Administration,
Defendant.

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Case No. 2:17-cv-317

OPINION AND ORDER
This matter is before the court on petition for judicial review of the decision of the
Commissioner filed by the plaintiff, Michael A. Cofield, on July 25, 2017. For the following
reasons, the decision of the Commissioner is REMANDED.
Background
The plaintiff, Michael A. Cofield, filed an application for Disability Insurance Benefits
on March 28, 2014, alleging a disability onset date of July 8, 2013. (Tr. 25). The Disability
Determination Bureau denied Cofield’s application on June 17, 2014, and again upon
reconsideration on October 8, 2014. (Tr. 25). Cofield subsequently filed a timely request for a
hearing on October 28, 2014. (Tr. 25). A video hearing was held on July 21, 2016, before
Administrative Law Judge (ALJ) Karen Sayon, and the ALJ issued an unfavorable decision on
August 23, 2016. (Tr. 25-36). Cofield and Vocational Expert (VE) Glee Ann L. Kehr appeared
and testified at the hearing. (Tr. 25). The Appeals Council denied review, making the ALJ’s
decision the final decision of the Commissioner. (Tr. 1-3).
Cofield meets the insured status requirements of the Social Security Act through March
31, 2019. (Tr. 27). The ALJ issued an unfavorable decision and made findings as to each of the

steps in the five-step sequential analysis. (Tr. 25-36). At step one of the five-step sequential
analysis for determining whether an individual is disabled, the ALJ found that Cofield had not
engaged in substantial gainful activity since July 8, 2013, the alleged onset date. (Tr. 27).
At step two, the ALJ determined that Cofield had the following severe impairments:
lumbar degenerative disc disease, cervical degenerative disc disease, and mild right carpal tunnel
syndrome. (Tr. 27). The ALJ considered Cofield’s medically determinable mental impairments
of depression and anxiety, singly and in combination. (Tr. 28). The ALJ determined that
Cofield’s mental impairments did not cause more than minimal limitation on his ability to
perform basic mental work activities and therefore were non-severe. (Tr. 28).
At step three, the ALJ concluded that Cofield did not have an impairment or combination
of impairments that met or medically equaled the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1. (Tr. 28). The ALJ indicated that she considered Listings
1.04 and 11.14. (Tr. 29). However, she found that the medical evidence did not document
listing-level severity and that no acceptable medical source mentioned findings were equivalent
in severity to the criteria of any listed impairment, individually or in combination. (Tr. 29).
After consideration of the entire record, the ALJ then assessed Cofield’s residual
functional capacity (RFC) as follows:
[T]he claimant has the residual functional capacity (RFC) to perform light
work as defined in 20 CFR 404.1567(b). He is limited to no climbing ladders,
ropes, or scaffolding. He is limited to occasional balancing, stooping,
kneeling, crouching, and climbing ramps and stairs. He is limited to
occasional overhead reaching bilaterally.
(Tr. 29). The ALJ explained that in considering Cofield’s symptoms she followed a two-step
process. (Tr. 30). First, she determined whether there was an underlying medically determinable
physical or mental impairment that was shown by a medically acceptable clinical or laboratory

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diagnostic technique that reasonably could be expected to produce Cofield’s pain or other
symptoms. (Tr. 30). Then, she evaluated the intensity, persistence, and limiting effects of the
symptoms to determine the extent to which they limited Cofield’s functioning. (Tr. 30).
The ALJ found that after consideration of the evidence, Cofield’s medically determinable
impairments reasonably could be expected to cause the alleged symptoms. (Tr. 30). However,
the ALJ found that Cofield’s statements concerning the intensity, persistence, and limiting
effects of his symptoms were not entirely consistent with the medical evidence and other
evidence in the record. (Tr. 32).
At step four, the ALJ found that Cofield was unable to perform any past relevant work.
(Tr. 34). Considering Cofield’s age, education, work experience, and RFC, the ALJ concluded
that there were jobs in the national economy that he could perform, including mail room clerk
(99,100 jobs exist), information clerk (973,500 jobs exist), and office helper (74,060 jobs exist).
(Tr. 35). The ALJ found that Cofield had not been under a disability, as defined in the Social
Security Act, from July 8, 2013 through August 23, 2016, the date of this decision. (Tr. 35-36).
Discussion
The standard for judicial review of an ALJ’s finding that a claimant is not disabled within
the meaning of the Social Security Act is limited to a determination of whether those findings are
supported by substantial evidence. 42 U.S.C. § 405(g) (“The findings of the Commissioner of
Social Security, as to any fact, if supported by substantial evidence, shall be conclusive.”);
Moore v. Colvin, 743 F.3d 1118, 1120–21 (7th Cir. 2014); Bates v. Colvin, 736 F.3d 1093, 1097
(7th Cir. 2013) (“We will uphold the Commissioner’s final decision if the ALJ applied the
correct legal standards and supported his decision with substantial evidence.”). Courts have
defined substantial evidence as “such relevant evidence as a reasonable mind might accept to

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support such a conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S. Ct. 1420, 1427, 28
L. Ed. 2d 852 (1972) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S. Ct. 206,
217, 83 L. Ed. 2d 140 (1938)); see Bates, 736 F.3d at 1098. A court must affirm an ALJ’s
decision if the ALJ supported her findings with substantial evidence and if there have been no
errors of law. Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (citations omitted). However,
“the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues.”
Lopez ex rel Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003).
Disability insurance benefits are available only to those individuals who can establish
“disability” under the terms of the Social Security Act. The claimant must show that he is unable
“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).
The Social Security regulations enumerate the five-step sequential evaluation to be followed
when determining whether a claimant has met the burden of establishing disability. 20 C.F.R.
§§ 404.1520. The ALJ first considers whether the claimant is presently employed and “doing . . .
substantial gainful activity.” 20 C.F.R. §§ 404.1520(b). If he is, the claimant is not disabled and
the evaluation process is over. If he is not, the ALJ next addresses whether the claimant has a
severe impairment or combination of impairments that “significantly limits . . . physical or
mental ability to do basic work activities.” 20 C.F.R. §§ 404.1520(c); see Williams v. Colvin,
757 F.3d 610, 613 (7th Cir. 2014) (discussing that the ALJ must consider the combined effects of
the claimant’s impairments). Third, the ALJ determines whether that severe impairment meets
any of the impairments listed in the regulations. 20 C.F.R. § 401, pt. 404, subpt. P, app. 1. If it
does, then the impairment is acknowledged by the Commissioner to be conclusively disabling.

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However, if the impairment does not so limit the claimant’s remaining capabilities, the ALJ
reviews the claimant’s “residual functional capacity” and the physical and mental demands of his
past work. If, at this fourth step, the claimant can perform his past relevant work, he will be
found not disabled. 20 C.F.R. § 404.1520(e). However, if the claimant shows that his
impairment is so severe that he is unable to engage in his past relevant work, then the burden of
proof shifts to the Commissioner to establish that the claimant, in light of his age, education, job
experience, and functional capacity to work, is capable of performing other work and that such
work exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1520(f).
Cofield has requested that the court reverse the ALJ’s decision and award benefits, or in
the alternative remand for additional proceedings. In his appeal, Cofield has argued that: (1) the
ALJ erred in evaluating the medical opinions of record; (2) the ALJ’s RFC assessment was not
supported by substantial evidence; and (3) the ALJ failed to appropriately evaluate Cofield’s
subjective allegations.
Cofield has argued that the ALJ erred in evaluating the medical opinions of record.
Cofield contends that the ALJ improperly gave no weight to the opinion of his treating specialist,
Dr. Michael Spence, M.D. A treating source’s opinion is entitled to controlling weight if the
“opinion on the issue(s) of the nature and severity of [the claimant’s] impairment(s) is
well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence” in the record. 20 C.F.R. ' 404.1527(d)(2); see
Bates v. Colvin, 736 F.3d 1093, 1099 (7th Cir. 2013); Punzio v. Astrue, 630 F.3d 704, 710 (7th
Cir. 2011); Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007). The ALJ must “minimally
articulate his reasons for crediting or rejecting evidence of disability.” Clifford v. Apfel, 227
F.3d 863, 870 (7th Cir. 2000) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1076 (7th Cir.

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1992)); see 20 C.F.R. ' 404.1527(d)(2) (“We will always give good reasons in our notice of
determination or decision for the weight we give your treating source’s opinion.”).
“[O]nce well-supported contradicting evidence is introduced, the treating physician’s
evidence is no longer entitled to controlling weight and becomes just one more piece of evidence
for the ALJ to consider.” Bates, 736 F.3d at 1100. Controlling weight need not be given when a
physician’s opinions are inconsistent with his treatment notes or are contradicted by substantial
evidence in the record, including the claimant’s own testimony. Schmidt, 496 F.3d at 842 (“An
ALJ thus may discount a treating physician’s medical opinion if the opinion is inconsistent with
the opinion of a consulting physician or when the treating physician’s opinion is internally
inconsistent, as long as he minimally articulates his reasons for crediting or rejecting evidence of
disability.”); see, e.g., Latkowski v. Barnhart, 93 F. App’x 963, 970–71 (7th Cir. 2004); Jacoby
v. Barnhart, 93 F. App’x 939, 942 (7th Cir. 2004). If the ALJ was unable to discern the basis for
the treating physician’s determination, the ALJ must solicit additional information. Moore v.
Colvin, 743 F.3d 1118, 1127 (7th Cir. 2014) (citing Similia v. Astrue, 573 F.3d 503, 514 (7th
Cir. 2009)). Ultimately, the weight accorded a treating physician’s opinion must balance all the
circumstances, with recognition that, while a treating physician “has spent more time with the
claimant,” the treating physician may also “bend over backwards to assist a patient in obtaining
benefits . . . [and] is often not a specialist in the patient’s ailments, as the other physicians who
give evidence in a disability case usually are.” Hofslien v. Barnhart, 439 F.3d 375, 377 (7th
Cir. 2006) (internal citations omitted); see Punzio, 630 F.3d at 713.
If the ALJ decides that the treating physician’s opinion should not be given controlling
weight, the ALJ is “required by regulation to consider certain factors in order to decide how
much weight to give the opinion.” Scrogham v. Colvin, 765 F.3d 685, 697 (7th Cir. 2014).

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These factors are set forth in 20 C.F.R. § 404.1527(c)(1)-(5) and include: 1) the length of the
treatment relationship and the frequency of examination; 2) the nature and extent of the treatment
relationship; 3) supportability; 4) consistency with the record as a whole; and 5) whether the
treating physician was a specialist in the relevant area. An ALJ need not explicitly mention
every factor, so long as her decision shows that she “was aware of and considered many of the
factors.” Schreiber v. Colvin, 519 Fed.Appx. 951, 959 (7th Cir. 2013).
Dr. Spence, a specialist in physical medicine and rehabilitation, was Cofield’s treating
doctor. He diagnosed Cofield with right C6-6 radiculopathy, disc bulge at L4-5 central spinal
stenosis, L3-4-5 misalignment with L4-5 disc protrusion, right carpal tunnel syndrome, and C6-7
disc bulge with decompression. (Tr. 502-03, 505, 614). Dr. Spence prescribed Cofield Norco
and referred him for further physical therapy. (Tr. 503). He noted that Cofield’s neck pain
radiated down his right arm, as well as ongoing numbness in his right fingers. (Tr. 576).
Cofield’s pain was aggravated by walking. (Tr. 580). On November 18, 2014, Cofield had a L4L5 right-sided laminectomy, foraminotomy, partial facetectomy, and discectomy for his back
pain. (Tr. 621). The surgery did not alleviate Cofield’s lower back pain, and prolonged sitting
made it worse. (Tr. 652, 661). In 2015, an MRI showed degenerative changes most marked at
L4-5, and Cofield continued to complain about ongoing radiating neck pain. (Tr. 676, 709, 729).
Dr. Spence repeatedly placed Cofield off work. The ALJ found that the issue of Cofield
being off work was reserved to the Commissioner. Therefore, the ALJ concluded that Dr.
Spence’s opinion was entitled to no weight. (Tr. 33). Dr. Spence’s treatment notes ended with
the same work status statement: “off work until otherwise prescribed by orthopedics.” (Tr. 34).
However, the ALJ noted that Cofield was not being treated by an orthopedist. (Tr. 34). The
court agrees with the ALJ that this statement was an issue reserved for the Commissioner. 20

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C.F.R. § 404.1527(d)(1). The ability to work was not the kind of “medical opinion” that the
ALJ must evaluate under 20 C.F.R. § 404.1527(b), (c). The agency's regulations assign the
decision about ability to work to the Commissioner. See 20 C.F.R. § 404.1527(d)(1); Johansen
v. Barnhart, 314 F.3d 283, 288 (7th Cir. 2002); Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir.
2000). “Although a medical opinion on an ultimate issue such as whether the claimant is
disabled is not entitled to controlling weight, the ALJ must consider the opinion and should
recontact the doctor for clarification if necessary.” Barnett v. Barnhart, 381 F.3d 664, 669 (7th
Cir. 2004). The ALJ cannot simply reject a doctor's report on that basis. See Garcia v. Colvin,
741 F.3d 758, 760 (7th Cir. 2013). Moreover, if the ALJ was unable to discern the basis for the
treating physician’s determination, the ALJ must solicit additional information. Moore v.
Colvin, 743 F.3d 1118, 1127 (7th Cir. 2014).
Even if the ALJ had legitimate reasons to discount Dr. Spence’s medical opinion, she
ultimately did not apply the correct legal standard in determining what weight the opinion should
be given. See 20 C.F.R. § 404.1527(d)(2); Moss v. Astrue, 555 F.3d 556, 561 (7th Cir. 2009);
Bauer v. Astrue, 532 F.3d 606, 608 (7th Cir. 2008). If the ALJ does not give the treating
physician’s opinion controlling weight, the ALJ cannot simply disregard it without further
evaluation. Campbell v. Astrue, 627 F.3d 299, 308 (7th Cir. 2010); see also Bjornson v. Astrue,
671 F.3d 640, 647 (7th Cir. 2012) (finding that a statement that you are “disabled” or “unable to
work” does not mean that the Agency will determine a claimant is disabled, yet such a statement
is not improper and therefore to be ignored). Instead the ALJ must specifically determine what
weight, if any, the opinion should be given. Campbell, 627 F.3d at 308.
The ALJ’s decision noted that Dr. Spence was board certified in physical medicine and
rehabilitation. It also stated that “surgeons repeatedly document better functioning on

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examinations, and the claimant is not a surgical candidate.” The Commissioner has clarified that
the statement referred to the earlier portion of ALJ’s decision. The ALJ noted that although Dr.
Spence repeatedly found decreased sensation and strength, it appeared that his findings were
repeated after every visit. (Tr. 29). Also, the ALJ noted that two different doctors had
concluded that Cofield was not a surgical candidate noting few abnormal examination findings,
as well as normal neurological findings. (Tr. 29). However, the ALJ must provide sufficient
details to allow the court to trace the path of her reasoning. Diaz v. Chater, 55 F.3d 300, 307
(7th Cir. 1995); Green v. Shalala, 51 F.3d 96, 101 (7th Cir. 1995). The ALJ did not articulate in
her decision what she was referring to when she indicated that “surgeons repeatedly document
better functioning” and how that finding discounted Dr. Spence’s opinion.
If the ALJ decides that the treating physician’s opinion should not be given controlling
weight, the ALJ is “required by regulation to consider certain factors in order to decide how
much weight to give the opinion.” Scrogham v. Colvin, 765 F.3d 685, 697 (7th Cir. 2014). The
court has remanded where ALJ “said nothing about this required checklist of factors.” Larson v.
Astrue, 615 F.3d 744, 751 (7th Cir. 2010). In the instant matter, the ALJ has failed to consider
the required checklist of factors. Specifically, she failed to consider the length of the treatment
relationship and the frequency of examination. Cofield contends that he saw Dr. Spence at least
ten times over a two year period. Moreover, in evaluating Dr. Spence’s opinion the ALJ did not
discuss the consistency with the record or the supportability of Dr. Spence’s findings. The
Commissioner did not address this argument.
Additionally, the ALJ assigned great weight to the other medical opinions in the record,
the State agency medical consultants and Amber Hanas. Cofield contends that their opinions
were formed prior to considerable treatment, including his November 2014 laminectomy.

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Amber Hanas, physical therapist (PT), noted that Cofield had a 20 pound lifting restriction. (Tr.
34). The ALJ found that this limitation was entitled to great weight because it was consistent
with the medical records. (Tr. 34). The ALJ acknowledged that Hanas, as a physical therapist,
was not an acceptable medical source but an “other” source. (Tr. 34). Under SSR 06-03p, the
ALJ “generally should explain the weight given to the opinions” from “other sources” “or
otherwise ensure that the discussion of the evidence in the determination or decision allows the
claimant or subsequent reviewer to follow the adjudicator’s reasoning.” SSR 06-03p, 2006 WL
2329939 (Aug. 9, 2006). Cofield contends that Hanas’ lifting limitation was rendered seven
months prior to his November 2014 laminectomy. (Tr. 435).
Moreover, Cofield has argued that the ALJ improperly assigned great weight to the nonexamining State agency medical consultants. Generally, an ALJ affords more weight to the
opinion of an examining source than the opinion of a non-examining source, but the ultimate
weight given depends on the opinion’s consistency with the objective medical evidence, the
quality of the explanation, and the source’s specialty. Givens v. Colvin, 551 F. App’x 855, 860
(7th Cir. 2013); 20 C.F.R. § 404.1527(c). The consultants opined that Cofield could perform
light work with no climbing ladders, ropes, or scaffolds, occasional climbing ramps or stairs,
balancing, stooping, kneeling, crouching, or crawling, and occasional reaching overhead
bilaterally. (Tr. 33). The ALJ’s decision indicated that the State agency medical consultants’
opinions are entitled to great weight because they were supported by the medical records,
evidence subsequent to their opinions did not document a change or worsening in Cofield’s
condition, and they are highly qualified physicians who are experts in Social Security disability
programs. (Tr. 33).

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Cofield has argued that the opinions of Hanas and the State medical consultants were
outdated, and therefore improperly were assigned more weight than treating source Dr. Spence.
Cofield has pointed to evidence in the record that subsequent to his surgery he underwent two
years of additional treatment with Dr. Spence. Dr. Spence noted that Cofield’s surgery did not
alleviate his lower back pain and prolonged sitting made it worse. (Tr. 652, 661). On July 30,
2015, Cofield could not put any weight on his right leg without stabbing pains. Also, he
attempted physical therapy, pool therapy, epidural injections, facet joint injections, spinal
surgery, massage therapy, and TENS unit. (Tr. 673). An ALJ may not rely on outdated opinions
of agency consultants “if later evidence containing new, significant medical diagnoses
reasonably could have changed the reviewing physician’s opinion.” Moreno v. Berryhill, 882
F.3d 722, 728 (7th Cir. 2018).
The ALJ credited the outdated opinions from Hanas and non-examining medical
consultants over the more-recent opinion of treating source Dr. Spence without any substantive
discussion. Moreover, the ALJ has not pointed to contradictory evidence in the record to support
assigning no weight to Dr. Spence’s opinion nor has she considered the factors of 20 C.F.R. §
404.1527 in determining what weight to assign to the medical opinions. The court is not finding
that the ALJ must give great weight Dr. Spence or that the State agency medical consultants and
Amber Hanas are entitled to less weight, rather the ALJ must sufficiently explain the rationale
that underlies her decision. Thus, the ALJ’s decision is remanded on this issue.
Cofield has argued that the RFC was not supported by substantial evidence. “The RFC is
an assessment of what work-related activities the claimant can perform despite his limitations.”
Young v. Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004); see 20 C.F.R. § 404.1545(a)(1) (“Your
residual functional capacity is the most you can still do despite your limitations.”); SSR 96-8p, at

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*2 (“RFC is an administrative assessment of the extent to which an individual’s medically
determinable impairment(s), including any related symptoms, such as pain, may cause physical
or mental limitations or restrictions that may affect his or her capacity to do work-related
physical and mental activities.”). The RFC is based upon medical evidence—including
statements from medical sources about what the claimant still can do—as well as “other
evidence, such as testimony by the claimant or his friends and family.” Craft v. Astrue, 539 F.3d
668, 676 (7th Cir. 2008); 20 C.F.R. § 404.1545(a)(3).
SSR 96-8p explains how an ALJ should assess a claimant’s RFC at steps four and five of
the sequential evaluation. In a section entitled, “Narrative Discussion Requirements,” SSR 968p specifically spells out what is needed in the ALJ’s RFC analysis. This section of the Ruling
provides:
The RFC assessment must include a narrative discussion describing how the
evidence supports each conclusion, citing specific medical facts (e.g.,
laboratory findings) and nonmedical evidence (e.g., daily activities,
observations). In assessing RFC, the adjudicator must discuss the
individual’s ability to perform sustained work activities in an ordinary work
setting on a regular and continuing basis (i.e., 8 hours a day, for 5 days a
week, or an equivalent work schedule), and describe the maximum amount
of each work-related activity the individual can perform based on the
evidence available in the case record. The adjudicator must also explain how
any material inconsistencies or ambiguities in the evidence in the case record
were considered and resolved.
SSR 96-8p (footnote omitted). Thus, as explained in this section of the Ruling, there is a
difference between what the ALJ must contemplate and what she must articulate in her written
decision. “The ALJ is not required to address every piece of evidence or testimony presented,
but he must provide a ‘logical bridge’ between the evidence and his conclusions.” Getch v.
Astrue, 539 F.3d 473, 480 (7th Cir. 2008) (quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir.
2000)); see Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014). Although the ALJ does not

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need to discuss every piece of evidence, she cannot ignore evidence that undermines her ultimate
conclusions. Moore, 743 F.3d at 1123 (“The ALJ must confront the evidence that does not
support his conclusion and explain why that evidence was rejected.”) (citing Terry v. Astrue, 580
F.3d 471, 477 (7th Cir. 2009); Myles v. Astrue, 582 F.3d 672, 678 (7th Cir. 2009); Arnett v.
Astrue, 676 F.3d 586, 592 (7th Cir. 2012)). “A decision that lacks adequate discussion of the
issues will be remanded.” Moore, 743 F.3d at 1121.
At step two, the ALJ found that Cofield’s mild right carpal tunnel syndrome was a severe
impairment. (Tr. 27). Cofield has argued that the ALJ’s RFC finding failed to accommodate his
carpal tunnel syndrome. The ALJ indicated that after consideration of the entire record she
found that:
The claimant has the residual functional capacity to perform light work as
defined in 20 CFR 404.1567(b). He is limited to no climbing ladders, ropes,
or scaffolding. He is limited to occasional balancing, stooping, kneeling,
crouching, and climbing ramps and stairs. He is limited to occasional
overhead reaching bilaterally.
(Tr. 29). The ALJ indicated that the RFC was supported by “the overall evidence of the record,
including the medical findings, nature and frequency of treatment, the claimant’s activities, the
opinion evidence, the claimant’s testimony, and other factors discussed above.” (Tr. 32).
The ALJ noted that she accommodated Cofield’s mild right carpal tunnel syndrome by limiting
him to occasional overhead reaching bilaterally and lifting and carrying 10 pounds frequently
and 20 pounds occasionally. (Tr. 32). The Commissioner has indicated that the restrictions
imposed to accommodate Cofield’s carpal tunnel syndrome were consistent with the opinion of
his physical therapist, Amber Hanas, who noted that Cofield had a 20 pound lifting restriction.
(Tr. 34). Also, the ALJ’s decision stated “there is no evidence of problems reaching or with

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manipulative functioning on examination.” (Tr. 34). However, she has failed to cite to any facts
or records to support that finding.
Cofield has argued that the ALJ failed to explain how a limitation regarding overhead
reaching and limiting him to lifting and carrying 10 pounds frequently and 20 pounds
occasionally accommodated Cofield’s carpal tunnel syndrome. The State agency physicians
were not aware of Cofield’s carpal tunnel and did not mention it in their RFC assessment. (Tr.
102-104). The agency physicians’ findings were based on Cofield’s degenerative spinal
changes. (Tr. 102). Moreover, Cofield testified that his right arm had tremors when lifting, that
it ached with repetitive writing, and that he could lift less than a coffee cup. (Tr. 30).
The ALJ has failed to create a logical bridge from the evidence to her conclusion. She
did not cite evidence supporting her accommodation of Cofield’s carpal tunnel syndrome.
An ALJ always is obligated to address how she reached an RFC assessment by discussing
some reasoning behind the RFC and the evidence that supports it. SSR 96-8p stresses that
“[t]he RFC assessment must include a narrative discussion describing how the evidence supports
each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical
evidence (e.g., daily activities, observations).” The ALJ found that Cofield’s carpal tunnel
syndrome was severe. The ALJ generally discussed the medical evidence in the record.
However, the ALJ has failed to explain how the medical evidence supported the ALJ’s RFC
finding that Cofield’s mild right carpal tunnel syndrome was accommodated by limiting him to
occasional overhead reaching bilaterally and lifting and carrying 10 pounds frequently and 20
pounds occasionally.
Similarly, Cofield made an additional argument that the ALJ did not explain how the
clinical findings supported her conclusion that he had no difficulty ambulating. The ALJ

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determined that Cofield could stand and walk for 6 hours and that he could lift 20 pounds
occasionally. The regulations define light work as lifting no more than 20 pounds at a time with
frequent lifting or carrying of objects weighing up to 10 pounds. SSR 83-10, 1983 WL 31251, at
*6 (Jan. 1, 1983). Since frequent lifting or carrying requires being on one's feet up to two-thirds
of a workday, the full range of light work requires standing or walking, off and on, for a total of
approximately 6 hours of an 8-hour workday. SSR 83-10, 1983 WL 31251, at *6. On remand,
the ALJ will be afforded the opportunity to arrive at an RFC finding that is supported by
substantial evidence creating a logical bridge from the evidence to her conclusion.
Finally, Cofield has argued that the ALJ failed to appropriately evaluate his subjective
allegations. An ALJ’s evaluation of subjective symptoms will be upheld unless it is patently
wrong. Shideler v. Astrue, 688 F.3d 306, 310-11 (7th Cir. 2012). Nevertheless, an ALJ must
support her evaluation with specific reasons that are supported by the record. Pepper v.
Colvin, 712 F.3d 351, 367 (7th Cir. 2013). The SSA has issued new guidance on how the
agency assesses the effects of a claimant's alleged symptoms. On March 28, 2016, Social
Security Ruling 16-3p became effective and issued new guidance regarding the evaluation of a
disability claimant’s statements about the intensity, persistence, and limiting effects of
symptoms. See SSR 16-3p, 2016 WL 1237954 (Mar. 28, 2016). Under SSR 16-3p, an ALJ must
assess the claimant’s subjective symptoms rather than assessing his “credibility.” The Social
Security Administration clarified that Social Security Ruling 16-3p only applies when the ALJs
“make determinations and decisions on or after March 28, 2016” and that Social Security Ruling
96-7p governs cases decided before that date. See Notices, SSR 16-3p, 2017 WL 4790249 (Oct.
25, 2017).

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Under SSR 16-3, the ALJ first must determine whether the claimant has a medically
determinable impairment that reasonably could be expected to produce his symptoms. SSR 163p, 2016 WL 1119029, at *2. Then, the ALJ must evaluate the “intensity, persistence, and
functionally limiting effects of the individual's symptoms to determine the extent to which the
symptoms affect the individual's ability to do basic work activities.” SSR 16-3p, 2016 WL
1119029, at *2. An individual's statements about the intensity and persistence of the pain may
not be disregarded because they are not substantiated by objective medical evidence. SSR 163p, 2016 WL 1119029 at *5. In determining the ability of the claimant to perform work-related
activities, the ALJ must consider the entire case record, and the decision must contain specific
reasons for the finding. SSR 16-3p, 2016 WL 1119029, at *4, 9. The ALJ must weigh the
claimant’s subjective complaints, the relevant objective medical evidence, and any other
evidence of the following factors:
(1) The individual’s daily activities;
(2) Location, duration, frequency, and intensity of pain or other symptoms;
(3) Precipitating and aggravating factors;
(4) Type, dosage, effectiveness, and side effects of any medication;
(5) Treatment, other than medication, for relief of pain or other symptoms;
(6) Other measures taken to relieve pain or other symptoms;
(7) Other factors concerning functional limitations due to pain or other symptoms.
20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3).
The ALJ determined that Cofield’s medically determinable impairments reasonably could
have been expected to cause some of the alleged symptoms; however, his statements concerning
the intensity, persistence, and limiting effects of his symptoms were not entirely consistent with

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the medical evidence and other evidence in the record. (Tr. 32). The ALJ’s analysis largely is a
summary of medical evidence. Therefore, the ALJ did not explain what evidence undermined
Cofield’s specific allegations of pain.
Cofield has argued that the ALJ did not appropriately address his daily living activities in
assessing his alleged subjective complaints. The ALJ’s decision mentioned Cofield’s daily
living activities, however, it was in her discussion of whether Cofield’s mental impairments of
depression and anxiety caused more than minimal limitation in the his ability to perform basic
mental work activities. (Tr. 28). Moreover, the ALJ did not discuss Cofield’s testimony that he
could not climb stairs in his home due to his knee pain, that he wore a brace throughout the day,
that he had to put bathrooms on all levels in his home due to trouble ambulating, and that he had
to sit down to dress himself. (Tr. 51, 55, 67). Therefore, the ALJ has failed to explain how
Cofield’s ability to complete limited daily living activities undermined his allegations of pain or
equated to an ability to perform full-time work.
The ALJ’s decision must provide specific reasons for the weight given to the individual’s
symptoms, be consistent with and supported by the evidence, and must be sufficiently specific or
clearly articulated so the individual and any subsequent reviewers can assess how the adjudicator
evaluated the symptoms. SSR 16-3p, 2016 WL 1119029, at *9. The ALJ has addressed some of
the regulatory factors set forth in 20 C.F.R. §§ 404.1529(c). The ALJ cited evidence that Cofield
experience some relief with pain medications, physical therapy, and aquatic therapy. (Tr. 32).
Moreover, she provided a discussion regarding Cofield’s medications and that Cofiled reported
some positive effects from his medications. (Tr. 33). The ALJ also acknowledged Cofield’s
good work history. (Tr. 33). Therefore, the court is not concluding that the ALJ’s evaluation of

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subjective symptoms is patently wrong. However, since this matter is being remanded on a
different issues the ALJ may reevaluate Cofield’s subjective symptoms.
Cofield has requested that the court remand for an award of benefits. 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). The Seventh
Circuit has held that when an ALJ’s decision is not supported by substantial evidence,
the appropriate remedy is to remand for further proceedings unless the evidence before the court
compels an award of benefits. Briscoe v. Barnhart, 425 F.3d 345, 355 (7th Cir. 2005). The
record here does not warrant an award of benefits.
Based on the foregoing reasons, the decision of the Commissioner is REMANDED for
further proceedings consistent with this order.
ENTERED this 5th day of September, 2018.
/s/ Andrew P. Rodovich
United States Magistrate Judge

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