Wilson v. Commissioner of Social Security
Filing
35
OPINION AND ORDER: The ALJ's decision is not supported by substantial evidence and therefore warrants remand. Accordingly, the Commissioner's decision is REVERSED AND REMANDED. The Clerk is instructed to enter judgment in favor of Plaintiff, Randi R. W. Signed by Magistrate Judge Michael G Gotsch, Sr on 10/28/19. (ksp)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
SOUTH BEND DIVISION
RANDI R. W. 1,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
)
)
)
)
)
)
)
)
)
)
CASE NO. 3:18-CV-392-MGG
OPINION AND ORDER
Plaintiff, Randi R. W. (“Ms. W.”) seeks judicial review of the Social Security
Commissioner’s decision denying her application, dated September 6, 2014, for
Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. This Court
may enter a ruling in this matter based on parties’ consent pursuant to 28 U.S.C.
§ 636(b)(1)(B) and 42 U.S.C. § 405(g). For the reasons discussed below, the Court
REVERSES AND REMANDS the decision of the Commissioner of the Social Security
Administration (“SSA”).
I.
OVERVIEW OF THE CASE
Ms. W. is a nurse and mother of three who was 36 years old on October 4, 2013,
the date she alleges he became disabled as the result of her multiple sclerosis (“MS”),
cervical spine pain, depression and anxiety disorders, headaches, vision disturbance in
To protect privacy interests, and consistent with the recommendation of the Judicial Conference, the
Court refers to the plaintiff by first name and last initial only.
1
her right eye, and memory difficulties. Having completed a nursing degree, Ms. W.
worked from 2010 until 2013 as a registered nurse. She had previously worked as a fast
food manager. Her date last insured is December 31, 2014. Ms. W. began experiencing
MS-related symptoms in 2010 that were exacerbated during her last pregnancy in 2013.
She was diagnosed with multiple sclerosis June 2014 after treating for headaches, back
and body pain, and neuropathy.
On August 16, 2017, an administrative law judge (“ALJ”) found Ms. W. not to be
disabled as defined by the Social Security Act (“Act”) and denied her requested DIB. On
February 26, 2018, the Appeals Council denied Ms. W.’s timely request for review
making the ALJ’s August 2017 decision the final decision of the Commissioner. See Fast
v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005). Now ripe 2 before this Court is Ms. W.’s
complaint for judicial review of the Commissioner’s unfavorable decision under 42
U.S.C. § 405(g).
II.
DISABILITY STANDARD
In order to qualify for DIB, a claimant must be “disabled” under Sections 223(d)
of the Act. A person is disabled under the Act if “he or she has an inability to engage in
any substantial gainful activity by reason of a medically determinable physical or
mental impairment which can be expected to last for a continuous period of not less
than twelve months.” 42 U.S.C. § 423(d)(1)(A).
Plaintiff’s complaint became ripe on April 3, 2019, without any reply brief being filed. See N.D. Ind. L.R.
7-3(d).
2
2
The Commissioner’s five-step inquiry in evaluating claims for disability benefits
under the Act includes determinations as to: (1) whether the claimant is doing
substantial gainful activity (“SGA”); (2) whether the claimant’s impairments are severe;
(3) whether any of the claimant’s impairments, alone or in combination, meet or equal
one of the Listings in Appendix 1 to Subpart P of Part 404; (4) whether the claimant can
perform her past relevant work based upon her residual functional capacity (“RFC”);
and (5) whether the claimant is capable of making an adjustment to other work. 20
C.F.R. §§ 404.1520; see also 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).
III.
STANDARD OF REVIEW
This Court has authority to review a disability decision by the Commissioner
pursuant to 42 U.S.C. § 405(g). However, this Court’s role in reviewing Social Security
cases is limited. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). A court reviews the
entire administrative record, but does not reconsider facts, re-weigh the evidence,
resolve conflicts of evidence, decide questions of credibility, or substitute its judgment
for that of the ALJ. Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005). The Court must
give deference to the ALJ’s decision so long as it is supported by substantial evidence.
Thomas v. Colvin, 745 F.3d 802, 806 (7th Cir. 2014) (citing Similia v. Astrue, 573 F.3d 503,
513 (7th Cir. 2009)). The deference for the ALJ’s decision is lessened where the ALJ’s
findings contain errors of fact or logic or fail to apply the correct legal standard. Schomas
v. Colvin, 732 F.3d 702, 709 (7th Cir. 2013).
3
Additionally, an ALJ’s decision cannot be affirmed if it lacks evidentiary support
or an inadequate discussion of the issues. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir.
2003). An ALJ’s decision will lack sufficient evidentiary support and require remand if
it is clear that the ALJ “cherry-picked” the record to support a finding of non-disability.
Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010); see also Wilson v. Colvin, 48 F. Supp. 3d
1140, 1147 (N.D. Ill. 2014). At a minimum, an ALJ must articulate his analysis of the
record to allow the reviewing court to trace the path of his reasoning and to be assured
the ALJ has considered the important evidence in the record. Scott v. Barnhart, 297 F.3d
589, 595 (7th Cir. 2002). While the ALJ need not specifically address every piece of
evidence in the record to present the requisite “logical bridge” from the evidence to his
conclusions, the ALJ must at least provide a glimpse into the reasoning behind his
analysis and the decision to deny benefits. O’Connor-Spinner v. Astrue, 627 F.3d 614, 618
(7th Cir. 2010); see also Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015).
Thus, the question upon judicial review is not whether the claimant is, in fact,
disabled, but whether the ALJ used “the correct legal standards and the decision [was]
supported by substantial evidence.” Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2007).
Substantial evidence must be “more than a scintilla but may be less than a
preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th. Cir. 2007). Thus, substantial
evidence is simply “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971);
Summers v. Berryhill, 864 F.3d 523, 526 (7th Cir. 2017).
4
IV.
ANALYSIS
Ms. W. challenges the ALJ’s RFC determination alleging errors of law and lack of
the necessary logical bridge from the evidence to the RFC. The ALJ defined Ms. W.’s
RFC as being capable of performing light work
except for the following limitations: the claimant can lift or carry ten
pounds occasionally and ten pounds frequently . . . . operate foot controls
with her right foot occasionally, . . . handle or finger items frequently with
the right hand . . . .occasionally climb ramps and stairs . . . never climb
ladders, ropes or scaffolds; frequently balance; frequently kneel;l and
heights or moving mechanical parts. Additionally, due to moderate limits
in concentration, persistence, or pace, she can understand, remember and
carryout simple, routine and repetitive tasks; . . . engage in no more than
occasional decision-making [and] be exposed to no more than occasional
changes in job setting.
[DE 12 at 33].
A claimant’s RFC is the most activity in which she can engage in a work setting
despite the physical and mental limitations that arise from her severe and non-severe
impairments and related symptoms. 20 C.F.R. § 404.1545(a)(1); see also SSR 96-8p; Villano
v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009). In crafting an RFC, the ALJ must consider
“all of the relevant medical and other evidence” in the record. 20 C.F.R. § 404.1545(a)(3);
see also Craft v. Astrue, 539 F.3d 668, 676 (7th Cir. 2008).
Here, Ms. W. specifically alleges that the ALJ’s RFC, and consequently his
hypothetical to the vocational expert at the hearing, were flawed because he improperly
weighed medical opinion evidence based upon a misinterpretation of the ramifications
of medical reports of stability in her MS. Similarly, Ms. W. argues that the ALJ
improperly discounted her subjective symptom allegations by relying only upon
5
objective medical evidence, including the same “stability” analysis. Ms. W. also
contends that the ALJ failed to explain his inconsistent assessments of the severity of
her limitations in concentration, persistence, and pace (“CPP”) within his decision,
which lacked a logical bridge from the evidence of Ms. W.’s deficiencies in CPP to the
restrictions incorporated into the RFC. Based on these shortcomings, Ms. W. asks the
Court to remand the ALJ’s decision. Ms. W.’s arguments, considered together, reveal a
pattern of analysis by the ALJ that is not supported by substantial evidence.
A.
Insufficient Stability Rationale
In his RFC analysis, the ALJ began by using 2-1/2 pages to thoroughly recite Ms.
W.’s hearing testimony regarding her symptoms and limitations then simply concluded
that Ms. W.’s “statements about the intensity, persistence, and limiting effects of her
symptoms are not entirely consistent with the medical evidence and other evidence in
the record for the reasons explained in this decision.” [DE 12 at 36].
The ALJ then presented selected objective medical evidence from the record
reflecting the sequence of Ms. W.’s medical care from about February 2014 through
February 2015. In discussing each piece of cited medical evidence, the ALJ recited the
substance of the evidence almost verbatim, including examination observations and
findings, test results, and Ms. W.’s self-reported symptoms, followed by a brief,
conclusory statement regarding the effect of that evidence on Ms. W.’s disability
analysis. On multiple occasions, the ALJ’s “recitation plus conclusion” analysis led him
to conclude that certain evidence should be discounted based upon treating source
assessments that Ms. W.’s condition is stable.
6
In support, the ALJ consistently references by citation only parts of records from
Ms. W.’s 2014–2015 office visits to nurse practitioners, Jennifer Evans and Dineke
Francis, and her June and July 2014 visits to neurologist, Dr. Arkadiy Konyukhow. In
the cited records, Evans and Francis assessed Ms. W.’s “overall condition” as “stable”
(“the Stability Assessments”) at three separate office visits. Dr. Konyukhow’s progress
notes, test results, and findings cited by the ALJ reflect assessments that preceded Ms.
W.’s MS diagnosis, but do not use any form of the word “stable.” The ALJ’s only other
reference to medical evidence explicitly using the word “stable” was his separate
recitation—almost verbatim—of Ms. W.’s MRI results from cervical spine, brain, and
lumbar spine MRIs in 2014, 2015, and 2016 finding “stable overall demyelinating plaque
burden compared to four months prior,” “stable, overall mild plaque burden compared
to an MRI from one year prior,” or “stable lumbar spondylosis.” [Id. at 39–40].
As shown below, the ALJ’s conclusions based on this stability evidence are not
supported by substantial evidence because he failed to build the requisites logical
bridges from the evidence of record, including the stability evidence, to his conclusions
leading to his final RFC determination.
1.
Ignoring Contradictory Evidence
“An ALJ cannot rely only on the evidence that supports her opinion.” Bates v.
Colvin, 736 F.3d 1093, 1099 (7th Cir. 2013) (internal citation omitted). “And while an ALJ
need not mention every piece of evidence in her opinion, she cannot ignore a line of
evidence that suggests a disability.” Id. In other words, an ALJ cannot cherry-pick
evidence to support his conclusion. Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011); see
7
also Denton, 596 F.3d at 425. Review of the medical records cited by the ALJ and
referenced in Ms. W.’s instant briefing shows exactly this.
There is no dispute that the ALJ correctly recited positive or “normal” findings
from Ms. W.’s various examinations and medical testing in his presentation of medical
evidence. Similarly, no one disputes that the ALJ properly recited the Stability
Assessments, the stable MRI results, and Dr. Konyukhow’s notes leading to her Ms.
W.’s MS diagnosis. However, the ALJ prioritized these particular records as evidence of
stability without reference to other evidence relevant to a disability determination.
For instance, the same medical records that include stability assessments and
other normal findings also include Ms. W.’s own reports of ongoing pain, decreased
sensation and weakness on her right side, difficulty walking, memory issues, and other
physical limits. They also reveal the treating sources’ diagnoses and treatment plans,
which included continuing prescriptions for exercise and narcotic drug therapy. While
the ALJ recited some of this presumably competing evidence, he offers no explanation
as to what role this evidence played in his conclusions. Instead, he focuses on the
Stability Assessments without reconciling the positive findings in the objective medical
evidence with Ms. W.’s diagnoses, ongoing treatments, and repots of continuing,
possibly deteriorating symptoms. In so doing, the ALJ appears to have ignored entirely
evidence that contradicts his RFC analysis without adequate explanation.
2.
Stability vs. Disability
The ALJ’s repeated emphasis on the stability evidence without adequate
explanation of potentially competing evidence is also concerning because stability does
8
not equate to a lack of disability. A stable condition is one that is unchanged rather than
improved or non-severe. See Seruya v. Berryhill, No. 16-C-10896, 2017 WL 4650886, at *5
(N.D. Ill. Oct. 17, 2017). One can be both stable and disabled. See, e.g., Goffron v. Berryhill,
17 C 3169, 2018 WL 2364891, at *3 (N.D. Ill. May, 2018); Shell v. Colvin, 1:11-CV-301-PRC,
2013 WL 5257830, at *13 (N.D. Ind. Sept. 16, 2013). Nevertheless, the ALJ uses the
stability evidence as his rationale, albeit brief and imprecise, for discounting Ms. W.’s
symptom testimony and assessing the weight of the medical opinion evidence. With no
further explanation, the ALJ’s emphasis on the stability of Ms. W.’s MS implies a
misunderstanding that stability precludes a finding of disability. At the very least, the
ALJ’s emphasis on stability exposes a gap in his logic from the evidence of the record to
his cursory conclusions related to Ms. W.’s RFC.
3.
Subjective Symptom Analysis
The ALJ’s emphasis on the stability evidence without further explanation also
suggests that the ALJ relied solely on objective medical evidence in evaluating the
alleged subjective symptoms arising from Ms. W.’s pain. When evaluating a claimant’s
subjective complaints, an ALJ first determines whether the claimant has a medically
determinable impairment capable of causing the alleged symptoms before evaluating
the intensity and persistence of the claimant’s symptoms to determine the extent to
which they limit the claimant’s ability to perform work-related activities. 20 C.F.R.
§ 404.1529(b)–(c). When evaluating the intensity and persistence of a claimant’s alleged
symptoms, the ALJ considers the totality of the evidence, including (1) the claimant’s
daily activities; (2) the location, duration, frequency, and intensity of the claimant’s pain
9
or other symptoms; (3) precipitating and aggravating factors; (4) the type, dosage,
effectiveness, and side effects of any medication the claimant takes; (5) treatment, other
than medication, the claimant receives; (6) any measures used to relieve pain or other
symptoms; and (7) other factors regarding the claimant’s functional limitations and
restrictions due to pain or other symptoms. 20 C.F.R. § 404.1529(c)(3).
An “ALJ may not discredit a claimant’s testimony about her pain and limitations
solely because there is no objective medical evidence supporting it.” Vanprooyen v.
Berryhill, 864 F.3d 567, 572 (7th Cir. 2017) (quoting Villano v. Astrue, 556 F.3d 558, 562
(7th Cir. 2009)); see also Carradine v. Barnhart, 360 F.3d 751, 754 (7th Cir. 2004) (“Pain is
always subjective in the sense of being experienced in the brain.”). “[P]ain alone can be
disabling [therefore testimony] of severe pain cannot be disregarded simply because it
is not supported by objective medical evidence.” Stark v. Colvin, 813 F.3d 684, 688 (7th
Cir. 2016).
Here, the ALJ’s subjective symptom analysis provides no connection between
Ms. W.’s symptom testimony and the objective medical evidence in the record to
support his conclusion discounting her statements about the intensity, persistence, and
limiting effects of her symptoms. The ALJ recited considerable testimonial and medical
evidence that may fit into the Section 1529 categories listed above but failed to discuss
all the factors clearly. Moreover, the ALJ’s only evident rationales for discounting Ms.
W.’s symptom statements are revealed through his statement that Ms. W. “reported that
she was exercising regularly” and that her “treating sources assessed [her] multiple
sclerosis was stable with treatment.” [DE 12 at 43]. In support, the ALJ again cited
10
Nurse Practitioner Evans’s office visit notes stating: “Habits: Last saw a dentist 2013.
Exercising regularly” [DE 12 at 417], the same Stability Assessments by the nurse
practitioners, and Dr. Konyukhow office visit records.
In challenging the ALJ’s subjective symptom analysis, Ms. W. directs the Court’s
attention to the recommendation of one of her treating doctors, Dr. George Achufusi, on
July 17, 2014, to increase aerobic activity, or exercise. [See DE 12 at 410]. In light of this
apparent prescription for exercise, the Court cannot discern why the ALJ found Ms.
W.’s regular exercise in compliance with her doctor’s recommendation sufficient to
discount her symptom statements. Additionally, the ALJ’s reliance, once again, upon
the same stability evidence without further explanation leaves this Court unable to trace
the path of his reasoning or determine exactly what evidence he considered in
discounting her statements. See Scott, 297 F.3d at 595. Taken together, the ALJ’s stated
rationales for discounting Ms. W.’s symptom statements focus on objective medical
evidence without any connection to her subjective symptom allegations. Accordingly,
the ALJ’s subjective symptom analysis is not supported by substantial evidence.
4.
Medical Opinion Evidence
The ALJ also improperly favored the opinions of State Agency reviewing
consultants regarding Ms. W.’s physical limitations over the opinions of an examining
consultant and Ms. W.’s own treating physicians.
“An ALJ can reject an examining physician’s opinion only for reasons supported
by substantial evidence in the record; a contradictory opinion of a non-examining
physician does not, by itself, suffice.” Gudgel v. Barnhart, 345 F.3d 467, 470 (7th Cir.
11
2003). Yet “an ALJ is not required to credit the agency’s examining physician in the face
of a contrary opinion from a later reviewer or other compelling evidence.” Beardsley v.
Colvin, 758 F.3d 834, 839 (7th Cir. 2014). Nevertheless, “rejecting or discounting the
opinion of the agency’s own examining physician that the claimant is disabled . . . can
be expected to cause a reviewing court to take notice and await a good explanation for
this unusual step.” Id.
Moreover, treating source opinions are generally given more weight because
treating sources are more familiar with a claimant’s conditions and circumstances.
Gudgel v. Barnhart, 345 F.3d 467, 470 (7th Cir. 2003). For claims filed before March 27,
2017, like Ms. W’s, a treating source’s opinion is to be given controlling weight if it is
“well-supported by medically acceptable clinical and laboratory diagnostic techniques
and is not inconsistent with other substantial evidence” in the record. 20 C.F.R.
§ 404.1527(c)(2). When a treating source’s opinion is not given controlling weight, the
ALJ must consider the following factors: (1) the examining relationship, (2) the
treatment relationship, specifically its length, nature, and extent, of the treatment
relationship, (3) the supportability of the opinion, (4) its consistency with the record as a
whole, and (5) the specialty of the treating source. Id.; see also Moss v. Astrue, 555 F.3d
556, 561 (7th Cir. 2009); Bauer v. Astrue, 532 F.3d 606, 608 (7th Cir. 2008). Additionally,
the ALJ must provide good reasons in his decision for the weight given to the treating
source’s opinion and must not substitute his own judgment for the physician’s opinion
without relying on other medical evidence or authority in the record. See Sharbeck v.
Barnhart, 390 F.3d 500, 503 (7th Cir. 2004); Clifford, 22 F.3d at 869.
12
Here, the ALJ gave great weight to the opinions of State Agency reviewing
consultants, Drs. B. Whitley and J. V. Corcoran, who opined—without examining Ms.
W.—that she can perform light work with some limitations. Before reporting this
conclusion, the ALJ recited the physical limitations identified by Drs. Whitley and
Corcoran then stated that the consultants “are familiar with the Administrations’ [sic]
disability programs, rules and regulations [and their opinions are] consistent with the
claimant’s treating sources’ assessments that the claimant’s multiple sclerosis was stable
with treatment.” [DE 12 at 41 (citing once again the nurse practitioners’ Stability
Assessments and Dr. Konyukhow’s June and July 2014 office visit records)]. 3
The ALJ’s consideration of the medical assessment of State Agency consultative
examiner, neurologist Dr. J. Smejkal, started with recitation of his examination
observations, findings, and diagnoses—consistent with the presentation of other
evidence from examining medical sources—before according “some weight” to his
assessment explaining in one sentence that “it is partially consistent with the evidence
of record, including Dr. Whitley’s and Dr. Corcoran’s opinions.” [DE 12 at 41].
Following the same pattern, the ALJ recited the opinions of Ms. W.’s treating doctors,
Dr. John Kelly and Dr. Syed Quadri, as to her physical limitations before according
Similarly, the ALJ gave great weight to the opinions of State Agency psychological and psychiatric
consultants, Dr. Donna Unversaw and Dr. Joelle Larsen, after reporting their general opinions that Ms.
W. suffers from mild psychological and psychiatric symptoms. He then concluded that they “are familiar
with the Administrations’ [sic] disability programs, rules and regulations” and that their “opinions are
consistent with the claimant’s course of treatment for her psychiatric symptoms, and her reported
activities of daily living, which included driving regularly and caring for her children.” [DE 12 at 41–42].
However, Ms. W. does not challenge the ALJ’s handling of their opinions, so they need not be discussed
further here.
3
13
them only little weight. The ALJ reasoned that Dr. Kelly’s opinion was worthy of less
weight because he did not start treating Ms. W. until after her date last insured. The ALJ
further reasoned separately, using identical language and citations, that both Dr. Kelly’s
opinion and Dr. Quadri’s opinion “is not consistent with the objective evidence of
record including Dr. Whitley’s and Dr. Corcoran’s opinions or with the claimant’s
treating sources’ assessments that the claimant’s multiple sclerosis was stable with
treatment.” [DE 12 at 42 (citing the nurse practitioners’ Stability Assessments and Dr.
Konyukhow’s June and July 2014 office visit records one more time)].
In granting the opinions of Drs. Whitley and Corcoran great weight, the ALJ
relies almost exclusively on the Stability Assessments and Dr. Konyukhow’s records
without explaining how these limited records support the reviewing doctors’ opinions.
Even more grievous, however, is the ALJ’s error in favoring Drs. Whitley and
Corcoran’s opinions over Dr. Smejkal’s opinion, without sufficient explanation, when
Dr. Smejkal examined Ms. W. and Drs. Whitley and Corcoran did not. Moreover, the
ALJ’s decision that the opinions of Ms. W.’s treating physicians, Drs. Kelly and Quadri,
were not worthy of controlling weight is also based almost exclusively on the stability
evidence without further explanation. Having discounted Dr. Kelly’s and Dr. Quadri’s
opinions, which included the most restrictive limitations on work for Ms. W., the ALJ
arguably considered most of the Section 1527 factors. However, he did not explain how
the stability evidence, or any other evidence for that matter, failed to support Dr. Kelly’s
and Dr. Quadri’s opinions.
14
Therefore, the ALJ’s medical opinion analysis also lacks the requisite logical
bridge between the evidence and his conclusions on the opinion evidence such that they
and the resulting RFC are not supported by substantial evidence.
As to Dr. Kelly, the ALJ also reported that he did not start treating Ms. W. until
after her date last insured implying an additional rationale for discounting his opinion.
Yet the ALJ does not offer any authority or analysis to explain why this justifies
discounting Dr. Kelly’s opinion. Indeed, Ms. W.’s briefing before this Court presents an
argument that the opinion of Dr. Kelly, as Nurse Practitioner Evans’s supervisor, may
nevertheless qualify for consideration as a treating source opinion. Given the other
flaws in the ALJ’s decision, the Court need not determine whether Dr. Kelly’s opinion
should or should not have been considered, but suggests the ALJ on remand carefully
consider the proper role of Dr. Kelly’s opinion in this case.
B.
Limitations on Concentration, Persistence, and Pace
Ms. W. also contends that the ALJ improperly failed to explain his inconsistent
assessments of the severity of her limitations in concentration, persistence, and pace
(“CPP”) within his decision. Additionally, Ms. W. alleges that the ALJ’s decision lacks a
logical bridge from the evidence of her deficiencies in CPP to the restrictions the ALJ
incorporated into the RFC. The Court agrees.
In assessing the severity of Ms. W.’s mental impairments at Step Two, the ALJ
found that Ms. W. had mild limitation in the functional area of concentrating,
persisting, or maintaining pace. In support, the ALJ recited parts of Ms. W.’s own
Function Report dated October 14, 2014. The ALJ noted Ms. W.’s statement that “she
15
had difficulty with memory, understanding, and concentration, and that she could not
pay bills, or balance a checkbook due to memory problems related to her multiple
sclerosis.” [DE 12 at 31]. The ALJ then reported other statements from Ms. W. that she
could drive, transport her children, take care of her personal hygiene and medications,
count change, sew when her hand cooperated, pay attention for hours at a time, and
follow spoken instructions. [Id. at 31–32]. The ALJ then concluded that “[t]he medical
evidence during the relevant time period remains devoid of the claimant’s alleged
limits during the relevant time period.” [Id. at 32].
The ALJ also recited from the records of Dr. Jeffrey Samelson, the consultative
psychologist who examined Ms. W. in October 2014. The ALJ reported that Dr.
Samelson assessed Ms. W. with “unimpaired comprehension, judgment, and
understanding.” [Id.] The ALJ then acknowledged Dr. Samelson’s finding that Ms. W.
“had memory issues and problems with sustained concentration and persistence,” but
then found that Dr. Samelson’s “findings [were] not consistent with this opinion, and
the claimant’s actual functioning, including driving and handling responsibilities of the
home and her children, supports only mild limitations.” [Id.]. The ALJ concluded his
Step Two CPP analysis by stating that he considered Ms. W.’s “potential deficiencies in
this area based on her multiple sclerosis, as discussed in Finding 5, infra [i.e., the RFC
analysis that followed].” [Id.]. 4
Notably, the ALJ’s Step Two analysis of Ms. W.’s functional ability to understand, remember, or apply
information was identical to this analysis of Ms. W.’s CPP limitations up through the recitation of Dr.
Samelson’s assessment that Ms. W. had “unimpaired comprehension, judgment, and understanding.”
[Compare DE 12 at 31 (“first functional area” analysis), with id. at 31–32 (“third functional area” analysis)].
4
16
In the RFC, the ALJ stated that “due to moderate limits in concentration,
persistence, or pace, [Ms. W.] can understand, remember and carryout simple, routine
and repetitive tasks; she is able to engage in no more than occasional decision-making;
and she can be exposed to no more than occasional changes in job setting.” [Id. at 33].
The ALJ’s analysis in support of that RFC, however, did not explicitly mention
moderate limitations in CPP or the specific limitations the ALJ included in the RFC.
Instead, the ALJ’s RFC analysis in relation to Ms. W.’s limitations in CPP
followed the same pattern of “recitation plus conclusion” discussed above. The ALJ
acknowledged Ms. W.’s own assessment of her memory, concentration, and persistence
issues by reciting pretty thoroughly her subjective symptom testimony. The ALJ also
considered Dr. Samelson’s opinion dated October 20, 2014. Most relevant was the ALJ’s
recitation of Dr. Samelson’s (1) allegedly inconsistent assessments that Ms. W.’s
“sustained concentration and persistence were predicted to be problematic” but that she
was “capable of being around people in work-related settings, her understanding,
comprehension and judgment appeared intact” and (2) his allegedly inconsistent
opinions that she “did not appear capable of work-related activities due to memory
issues and problems with sustained concentration and persistent” but that her
“comprehension, judgment, understanding and social interaction appeared relatively
unimpaired.” [Id. at 40]. The ALJ then afforded Dr. Samelson’s opinion only some
weight with the simple, on-sentence explanation that “the objective evidence of record
fails to support that [Ms. W.] is not capable of work due to memory issues.”[Id.].
17
Overall, the ALJ’s assessment of Ms. W.’s limitations in CPP is confusing because
he finds mild limitation in CPP at Step Two but incorporates an apparent finding of
moderate limitations in CPP into his RFC. In his brief, the Commissioner attempts to
distinguish the two analyses by arguing that the ALJ’s Step Two finding was only
related to his mental impairments while the RFC also accounted for limitations arising
from Ms. W.’s MS. While the Commissioner’s suggestion is plausible, the ALJ did not
actually make that distinction clear in his opinion. Furthermore, the RFC analysis does
not demonstrate how, or from what evidence, the ALJ derived his conclusion of
moderate limitations in CPP or what evidence supports the limitations of simple,
routine and repetitive tasks, occasional decision-making, and occasional changes in job
setting he included in RFC presumably accounting for moderate limitations in CPP.
While it is possible that the ALJ’s differing conclusions as to Ms. W.’s limitation
in CPP may be supportable, the ALJ’s decision does not articulate how these potentially
conflicting conclusions jibe. More importantly, the ALJ’s failure in the RFC analysis to
connect evidence of Ms. W.’s limitations in CPP that allegedly account for the full range
of her limitations is problematic given authority that “simple tasks” restrictions do not,
on their own and without further explanation, account for moderate limitations in CPP.
See Varga v. Colvin, 794 F.3d 809, 814 (7th Cir. 2015); Yurt v. Colvin, 758 F.3d 850, 857 (7th
Cir. 2014) (citing O’Connor-Spinner, 627 F.3d at 619 ; Stewart v. Astrue, 561 F.3d 679, 684–
85 (7th Cir. 2009).
In summary, the ALJ has failed to provide the Court with sufficient connective
rationale, or logical bridge, to discern whether the purported CPP restrictions in the
18
RFC account fully for Ms. W.’s unique limitations in the ability to maintain
concentration, persistence, and pace. Therefore. the Court cannot be certain that the
vocational expert’s reliance on the ALJ’s RFC assessment effectively provided enough
information from which to determine accurately what jobs Ms. W., with her unique
limitations, may be able to perform. See Winsted v. Berryhill, 915 F.3d 466, 471 (7th Cir.
2019). As a result, the ALJ has not supported his RFC with substantial evidence to
support his RFC related to her limitations in concentration, persistence, and pace.
V.
CONCLUSION
For the reasons stated above, the ALJ’s decision is not supported by substantial
evidence and therefore warrants remand. Accordingly, the Commissioner’s decision is
REVERSED AND REMANDED. The Clerk is instructed to enter judgment in favor of
Plaintiff, Randi R. W.
SO ORDERED this 28th day of October 2019.
s/Michael G. Gotsch, Sr.
Michael G. Gotsch, Sr.
United States Magistrate Judge
19
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?