McCollum v. Commissioner of Social Security

Filing 21

OPINION AND ORDER: The ALJ erred in weighing Dr. Elsamads opinion and failed to support the RFC with substantial evidence. For these reasons, the court remands the case for further consideration. Signed by Judge Joseph S Van Bokkelen on 5/28/2019. (jss)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION
KIMBERLEY DELICHA MCCOLLUM,
Plaintiff,
v.
Case No. 2:18-cv-00060-JVB-APR
NANCY A. BERRYHILL,
Acting Commissioner of
Social Security Administration,
Defendant.
OPINION AND ORDER

Plaintiff Kimberley Delicha McCollum seeks judicial review of the Social Security
Commissioner’s decision denying her disability benefits and asks this Court to remand the case.
For the reasons below, this Court remands the Administrative Law Judge’s decision.

A. Overview of the Case
In her application, Plaintiff alleged that she became disabled on May 1, 2011. (R. at 18.)
After a video hearing before an Administrative Law Judge (“ALJ”) in 2016, the ALJ found that
Plaintiff suffered from the severe impairments of degenerative disc disease of the lumbar spine,
right trigger finger, bilateral foot impairment, and obesity. (R. at 20.) The ALJ did, however, find
that a number of jobs existed which Plaintiff could perform. (R. at 27–28.) Therefore, the ALJ
found her to be not disabled. (R. at 34.) This decision became final when the Appeals Council
denied Plaintiff’s request for review. (R. at 1.)

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B. Standard of Review
This Court has authority to review the Commissioner’s decision under 42 U.S.C. §
405(g). The Court will ensure that the ALJ built an “accurate and logical bridge” from evidence
to conclusion. Thomas v. Colvin, 745 F.3d 802, 806 (7th Cir. 2014). This requires the ALJ to
“confront the [plaintiff’s] evidence” and “explain why it was rejected.” Thomas v. Colvin, 826
F.3d 953, 961 (7th Cir. 2016). The Court will uphold decisions that apply the correct legal
standard and are supported by substantial evidence. Briscoe ex rel. Taylor v. Barnhart, 425 F.3d
345, 351 (7th Cir. 2005). Evidence is substantial if “a reasonable mind might accept [it] as
adequate to support [the ALJ’s] conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S. Ct.
1420, 28 L. Ed. 2d 842 (1971).

C. Disability Standard
The Commissioner follows a five-step inquiry in evaluating claims for disability benefits
under the Social Security Act:
(1) Whether the claimant is currently employed; (2) whether the claimant has a
severe impairment; (3) whether the claimant’s impairment is one that the
Commissioner considers conclusively disabling; (4) if the claimant does not have a
conclusively disabling impairment, whether he can perform his past relevant work;
and (5) whether the claimant is capable of performing any work in the national
economy.
Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012). The claimant bears the burden of proof at
every step except step five. Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000).

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D. Analysis
Plaintiff contends that the ALJ committed four reversible errors: the ALJ erred in
weighing the medical opinion, in the RFC determination, in relying on improper VE testimony,
and in analyzing Plaintiff’s subjective symptoms.

(1) Medical Evidence
Plaintiff argues that the ALJ erred in weighing the opinion of treating podiatrist Dr.
Ahmad Elsamad, DPM. Dr. Elsamad provided a written opinion on June 3, 2013. (R. at 343.) Dr.
Elsamad opined that Plaintiff could not perform the essential elements of her job as a U.S. Postal
Carrier from February 2008 through the date of the opinion. He then described the portions of
the job that Plaintiff could no longer perform, such as standing; using her feet, ankles, and legs
throughout the day; bending, reaching, lifting, and casing mail; lifting up to seventy pounds;
being able to enter and exit a vehicle repeatedly throughout the day; loading large trays of mail
into a vehicle; and driving a vehicle throughout the day. Id. Dr. Elsamad stated that Plaintiff
suffered from “metadetcus,” chronic foot pain, swelling, foot deformity, and restriction and
limitation of movement. Id. Dr. Elsamad opined that Plaintiff’s condition is permanent, and that
“no amount of treatment modalities” would allow her to return to her job. Id.
A treating physician’s opinion is to be given controlling weight unless the ALJ provides
good reasons for setting aside that opinion. Brown v. Colvin, 845 F.3d 247, 252 (7th Cir. 2016).
When a treating physician’s opinion is not entitled to controlling weight, an ALJ must weigh it

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using factors such as examining relationship, length of treatment relationship and the frequency
of examination, the nature and extent of the treatment relationship, supportability, consistency,
specialization, and other factors. 20 C.F.R. §§ 404.1527(c)(1)-(6). The ALJ afforded Dr.
Elsamad’s opinion “some weight,” stating that the RFC supports the opinion that Plaintiff cannot
perform her past work as a mail carrier, but that his assertion that Plaintiff suffered from swelling
was not supported by exams.
First, the ALJ offered very little analysis or discussion of Dr. Elsamad’s opinion. The
ALJ must give good reasons to discount the opinion of the treating physician, but there is so little
discussion here that it is hard to find “good reasons” for giving the opinion less than controlling
weight. 20 C.F.R. §404.1527; Clifford v. Apfel, 227 F.3d 863, 869–71 (7th Cir. 2000). Although
the ALJ acknowledges that Dr. Elsamad was a treating podiatrist, he fails to address the other
factors in 20 C.F.R. § 404.1527(c). The only evidence that the ALJ finds inconsistent is that the
medical evidence does not support the foot swelling noted by Dr. Elsamad. The ALJ offers no
citations to the record that contradict Dr. Elsamad’s opinion that Plaintiff suffers from foot
swelling. Moreover, there is evidence in the record that supports Dr. Elsamad’s opinion that
Plaintiff had foot swelling. Treatment records from March 2014 noted that Plaintiff suffered
from joint swelling and muscle weakness. (R. at 315.) Dr. Elsamad’s treatment notes indicate
edema in the right leg. (R. at 351). Plaintiff also testified that her feet began to swell after
standing for an hour. The ALJ has failed to give good reasons to discount Dr. Elsamad’s opinion,
as he has failed to discuss specific evidence in the record that supports his opinion that Plaintiff
did not suffer from foot swelling. The ALJ does not otherwise discuss Dr. Elsamad’s opinion,
and therefore the Court cannot discern whether the ALJ considered the other relevant factors in
20 C.F.R. § 404.1527(c). Dr. Elsamad treated Plaintiff for at least three years and prescribed

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multiple forms of treatment and tests for Plaintiff. (R. at 348–54, 371, 376–394, 416–35.) Yet the
ALJ failed to discuss this in his analysis of Dr. Elsamad’s opinion. This is an issue that requires
remand.
(2) Residual Functional Capacity (“RFC”)
The state agency physicians found that Plaintiff’s only severe impairment was “DDD
(Disorders of Back-Discogenic and Degenerative),” and they both opined that Plaintiff could
perform light work with reduced postural activities. (R. at 60, 68.) The ALJ gave these opinions
great weight. (R. at 26.) The state agency physicians did not review Dr. Elsamad’s opinion, nor
any of the lower extremity images or imaging results. The state agency physicians, therefore, did
not consider any foot or lower limb impairments, and the RFCs provided in the opinions did not
offer any limitations to account for foot and lower extremity impairments. In fact, the ALJ found
Plaintiff suffered from severe bilateral foot impairment. (R. at 20.) Yet the ALJ followed the
state agency physicians’ RFC opinions without including any limitations regarding Plaintiff’s
severe bilateral foot impairment.
The state agency physicians found that Plaintiff could never climb ladders, ropes or
scaffolds, occasionally climb ramps and stairs, and occasionally balance, stoop, kneel, crouch,
and crawl. However, the ALJ’s hypothetical to the VE and subsequent RFC found that Plaintiff
could occasionally climb ladders, ropes or scaffolds, frequently climb ramps and stairs, and
frequently balance, stoop, kneel, crouch, and crawl. The ALJ did not explain why he rejected the
state agency’s RFC without relying on other medical evidence or opinion evidence in making the
RFC determination. The ALJ gave great weight to the state consultants, who did not have all the
medical evidence, yet concluded that Plaintiff’s limitations were less than the state agency
physician’s opinions without any discussion. The ALJ is required to explain why functional

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limitations and restrictions can or cannot reasonably be accepted as consistent with the medical
and other evidence. SSR 96-8p. The Court cannot conduct a meaningful review of the ALJ’s
RFC when the ALJ fails to explain or discuss the inconsistency between the state agency RFCs,
given great weight, and the ALJ’s final RFC with reduced limitations.
“[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 SSR
LEXIS 5 at *14, 1996 WL 374184, at *5, see Paar v. Astrue, No. 09 C 5169, 2012 U.S. Dist.
LEXIS 4948, 2012 WL 123596, at *13 (N.D. ILL. Jan. 17, 2012). Here, the ALJ failed to
consider even a severe limitation. The ALJ has labeled the foot impairments as severe yet did not
include any limitations regarding her foot impairments in the RFC or provide adequate reasons
for not including such limitations. The ALJ failed to build an accurate and logical bridge from
the evidence of Plaintiff’s severe foot impairment to the RFC.

(3) Other Issues
Plaintiff also raises issues regarding the RFC’s lack of mental limitations, the VE
testimony, and subjective complaints. Because the ALJ improperly weighed Dr. Elsamad’s
opinion and failed to support the RFC with substantial evidence, remand is appropriate. Proper
treatment of Dr. Elsamad’s opinion and the RFC may alter the rest of the ALJ’s decision. On
remand, the ALJ will have the opportunity to reexamine the RFC and all of the relevant medical
evidence.

(E) Conclusion

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The ALJ erred in weighing Dr. Elsamad’s opinion and failed to support the RFC with
substantial evidence. For these reasons, the court remands the case for further consideration.
SO ORERED on May 28, 2019.
s/ Joseph S. Van Bokkelen
JOSEPH S. VAN BOKKELEN
UNITED STATES DISTRICT JUDGE

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