COFFEY v. ASTRUE

Filing 27

ENTRY ON JUDICIAL REVIEW - For the reasons set forth, this final decision of the Commissioner of the Social Security Administration is AFFIRMED. Final judgment shall be entered accordingly. Signed by Judge Tanya Walton Pratt on 3/27/2012.(JD)

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
INDIANAPOLIS DIVISION
STACEY JO COFFEY,

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Plaintiff,
v.
MICHAEL J. ASTRUE,
COMMISSIONER OF THE SOCIAL
SECURITY ADMINISTRATION,
Defendant.

Case No. 1:11-cv-0159-TWP-TAB

ENTRY ON JUDICIAL REVIEW
Plaintiff, Stacey Jo Coffey (“Ms. Coffey”) filed this action seeking judicial review of the
final decision of the Commissioner of the Social Security Administration (“Commissioner”)
denying her Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. 42
U.S.C. § 416(i). For the reasons set forth below, the Commissioner’s decision is AFFIRMED.
I. BACKGROUND
Ms. Coffey was born on December 24, 1969, making her 37 years old at the time she
filed her application for Social Security Disability and 40 years old at the time the
Administrative Law Judge rendered his decision. R. at 18, 227. She has an eleventh grade
education. R. at 43.
A.

Procedural History
Ms. Coffey filed applications for Social Security Disability Insurance and for Social

Security Supplemental Security Income Disability Benefits on August 23, 2007. R. at 99-103,
104-107. She claimed to have symptoms including irregular heart rate, high blood pressure,
panic attacks and depression. R. at 57. Her applications were denied both initially and after
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reconsideration. R. at 54-57, 63-65. On January 4, 2010, Ms. Coffey appeared with counsel and
testified at a hearing before Administrative Law Judge Albert Velasquez (“the ALJ”). R. at 2647. On May 28, the ALJ issued his decision finding that Ms. Coffey was not disabled because
she was able to perform jobs that existed in significant numbers in the national economy. R. at
10-19. On December 8, 2010, the Appeals Council denied review of the ALJ’s decision. R. 1-3.
At that point, the ALJ’s decision became the final decision of the Commissioner. See 20 C.F.R.
§ 404.981. Subsequently, Ms. Coffey filed the appeal which is before the Court today.
B.

Medical History
The first medical event on the record revolves around Ms. Coffey’s visit to Dr. Teresita

Ramilo, M.D. (“Dr. Ramilo”), on July 27, 1997. R. at 365-370. Ms. Coffey visited Dr. Ramillo
after overdosing on Excedrin PM because of depression. R. at 365. She was diagnosed with an
episode of major depression and said to have a Global Assessment of Functioning (“GAF”) of 25
at admission – but 55 at discharge.1 R. at 370. On January 10, 2006, and again on April 29,
2006, Ms. Coffey visited Dr. Anthony P. Gannon, M.D. (“Dr. Gannon”), with complaints of
lower and right side back pain. R. at 214.
On September 14, 2006, Ms. Coffey visited Dr. Gannon after nearly having a syncopal
episode. R. at 215. Dr. Gannon concluded that she likely suffered an acute anxiety episode or
panic attack. R. at 215. He prescribed Ativan. R. at 215. On July 11, 2007, Dr. Gannon noted
that Ms. Coffey’s panic attacks persisted and the Ativan was not working. R. at 219. He then
prescribed Paxil as a substitute. R. at 219. On August 6, 2007, Dr. Gannon noted that Ms.
Coffey continued to suffer panic attacks and added Xanax to her regime of medication. R. at
219. On September 24, 2007, Ms. Coffey was examined by Dr. Shah, M.D. (“Dr. Shah”). R. at

1

GAF is a numerical scale that is used by mental health physicians. American Psychiatric Association, Diagnostic
and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) 34 (4th ed. 2000).

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254-257. Dr. Shah opined that Ms. Coffey suffered from generalized anxiety disorder and panic
attacks. R. at 256. On October 15, 2007, Dr. Bettye L. Pate (“Dr. Pate”), a psychologist,
examined Ms. Coffey. R. at 258-262. Dr. Pate found that Ms. Coffey was able to bathe, groom,
cook and dress herself without assistance. R. at 259. Further, Dr. Pate found that Ms. Coffey
was able to visit her family frequently. R. at 259. However, Ms. Coffey was unable to shop by
herself. R. at 260.
When evaluating her mental capacity, Dr. Pate found that Coffey was oriented to time,
place, and person. R. at 259. Coffey reported no suicidal tendencies. R. at 260. She could
correctly complete serial threes, but not serial sevens.2 R. at 261. After the examination, Dr.
Pate opined that Coffey suffered from panic disorder with agoraphobia, generalized anxiety
disorder, and dysthymia. R. at 261. Further, Dr. Pate opined that Coffey was unlikely to require
assistance managing her funds. R. at 261. Finally, Dr. Pate placed Coffey’s GAF score at 51.
R. at 262.
On October 23, 2007, state agency examiner Dr. F. Kladder, Ph.D. (“Dr. Kladder”),
reviewed Ms. Coffey’s case file and signed a Psychiatric Review Technique Form (“PRTF”). R.
at 266-283. Dr. Kladder opined that although Ms. Coffey suffered from anxiety-related and
affective disorders, her condition did not meet or equal any listed impairment. Further, Dr.
Kladder opined that Ms. Coffey suffered from dysthymia, generalized persistent anxiety, and
recurrent severe panic attacks. R. at 269, 271. Dr. Kladder concluded that Ms. Coffey was
mildly limited in daily living activities; moderately limited in her social functioning abilities;
mildly limited in maintaining concentration and pace; moderately limited in her ability to
maintain attention for extended periods of time; and moderately limited in her ability to function
2

The serial threes and serial sevens test is a test where the patient starts at a number (usually thirty and one hundred
respectively) and subtracts 3 or 7 from that number until he or she reaches the lowest whole number attainable. See
R. at 264. The test is timed and scored to measure the patient’s mental capacity. See R. at 263-64.

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properly among the public. R. at 276, 280-81. Overall, Dr. Kladder opined that Ms. Coffey’s
disorder was very treatable and that she was able to work at a reasonable pace in an environment
with few people. R. at 282. Dr. Kladder’s opinion was later affirmed by Dr. B. Randall Horton
on January 3, 2008. R. at 285.
On May 27, 2008, Glenda Wendling, RN, FPN (“Nurse Wendling”), examined Ms.
Coffey.

R. at 306-07.

Ms. Coffey complained of back and foot pain.

R. at 306.

An

examination found that Ms. Coffey could bend eighty degrees and stoop with light difficulty and
pain in the left lumbar muscle area. R. at 306. Ms. Coffey was diagnosed with general
lumbosacral neuritis, general panic disorder and primary insomnia. R. at 306. On August 6,
2008, Nurse Wendling examined Ms. Coffey again. R. at 310. During the examination, Ms.
Coffey exhibited tenderness in her back and left sciatic area of her buttocks.

R. at 310.

However, her knees showed no swelling or redness. R. at 310. Nurse Wendling concluded that
Ms. Coffey suffered from anxiety disorder, bilateral knee pain, general lumbralsacral neuritis and
general degenerative disc disease. R. at 310. On September 3, 2008, Ms. Coffey reported that
her back had improved due to physical therapy. R. at 312. Additionally, Nurse Wendling
planned to wean Ms. Coffey off of Xanax. R. at 312.
On October 6, 2008, Ms. Coffey visited Nurse Wendling after an emergency room visit
complaining of severe joint pain. R. at 313. However, Ms. Coffey exhibited full range of
motion in her wrists and elbows with no tenderness or swelling. R. at 313. She also exhibited no
tenderness, redness or swelling in her knees or ankles; however, she exhibited pain with range of
motion. R. at 313.
On November 15, 2008, Ms. Coffey met with Glenn Ballengee (“Mr. Ballengee”) for an
initial evaluation at the Pain Management Center in Columbus, Indiana.

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R. at 300.

Mr.

Ballengee opined that although Ms. Coffey’s neck, lungs, gait and extremities were fine, she did
suffer from mild tenderness in her low back. R. at 300. Ms. Coffey received MRI results of her
back on December 3, 2008. R. at 315. The results showed some arthritic facet changes and
hypertrophy of the ligamenta flava in the L-3, L-4 and L-5 vertebrate. R. at 315. Otherwise, the
results were unremarkable. R. at 315.
On December 31, 2008, Ms. Coffey reported to the emergency room complaining of
sciatica pain. R. at 375. Dr. Pamela K. Peak, M.D. (“Dr. Peak”), the examining physician,
found that Ms. Coffey exhibited no pain to the midline of the lower lumbar spine or the thoracic
or cervical spine; normal gait; no stepoff or deformities; no leg shortening; normal straight leg
raise; and pain along the left lower buttocks into the left hip. R. at 375. Dr. Peak diagnosed Ms.
Coffey with radicular lower back pain. R. at 375. The next day, Ms. Coffey was prescribed
Vicodin and Deltasone before being released. R. at 380.
On January 22, 2009, Dr. Bradley Strausberg, M.D. (“Dr. Strausberg”), a pain specialist,
examined Ms. Coffey. R. at 292. Dr. Strausberg opined that Ms. Coffey suffered from low back
pain and lumbar facet arthropathy. R. at 292. To combat this, Dr. Strausberg provided Ms.
Coffey with Marcaine, Lidocaine, and Kenalog injections in her back. R. at 293.
On February 22, 2009, Ms. Coffey returned to the emergency room. R. at 383. She
complained of neck, back and trunk pain. R. at 383. Dr. Peak opined that Ms. Coffey continued
to suffer from lower back pain and issued her a prescription for Norco and Ultram. R. at 386.
Ms. Coffey returned to the emergency room on February 25, 2009 complaining of further back
pain. R. at 388. The treating physician, Dr. Bogmila Kopczynski, M.D. (“Dr. Kopczynski”),
opined that Ms. Coffey exhibited symptoms of chronic back pain.

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R. at 390.

After the

examination, Ms. Coffey left without signing her discharge papers because she did not like the
doctor. R. at 390.
On March 15, 2009, Ms. Coffey reported to the emergency room after suffering a
headache. R. at 394. Dr. Kopczynski opined that Ms. Coffey was suffering from migraines and
prescribed her a hydrocortisone base. R. at 397. On March 25, 2009, Ms. Coffey followed up
with Dr. Strausberg. R. at 291. Again, Dr. Strausberg injected Ms. Coffey with Marcaine,
Lidocaine and Kenalog. R. at 291. Ms. Coffey returned to the emergency room on May 25,
2009 complaining of leg pain. R. at 400. Dr. Robert Donathan, M.D. prescribed Verapamil,
Cymbalta, and Atarax in order to ease her pain. R. at 402. On June 6, 2009, Ms. Coffey
presented to the emergency room with complaints of chest pain. R. at 406. Dr. Kopczynski
opined that she had suffered a panic attack. R. at 409. He ordered x-rays of Ms. Coffey’s lungs.
The results were unremarkable. R. at 412. On June 9, 2009, Dr. Strausberg injected Ms.
Coffey’s back with Bupivacaine, Lidocaine and Kenolag. R. at 289.

Ms. Coffey continued

these injections on July 7, 2009. R. at 434.
On July 15, 2009, Ms. Coffey returned to the emergency room after experiencing more
chest pains. R. at 417. She claimed to have suffered a severe anxiety attack two weeks prior to
her visit. R. at 416. Dr. Kopczynski ordered x-rays of her chest; the results were normal. R. at
433.
On July 17, 2009, Dr. Sherif Shamaa, M.D. (“Dr. Shamaa”), a Disability Determination
Bureau physician, examined Ms. Coffey. R. at 345. Dr. Shamaa opined that Ms. Coffey
suffered from lower back pain, a history of irregular heart rate, and a history of panic attacks.
On August 6, 2009, Ms. Coffey received x-ray results on her knees, thoracic spine and lumbar
spine. R. at 349-51. The results concluded that although her knees were normal, she suffered

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from a mild curvature in her thoracic spine and minimal degeneration of her lumbar spine. R. at
349-51.
On August 26, 2009, Dr. Russ Rasmussen (“Dr. Rasmussen”), a psychologist, examined
Ms. Coffey. R. at 354-58. After a thorough examination, Dr. Rasmussen found that her mental
residual functional capacity to be moderately impaired. R. at 357. Further, Dr. Rasmussen
opined that Ms. Coffey suffered from major depression and panic disorder with agoraphobia. R.
at 357. He placed her GAF at 54. R. at 357. On August 27, 2009, Dr. Debra Marshino, M.D.,
examined Ms. Coffey’s mental capacity. R. at 360-62. She also opined that Ms. Coffey suffered
from panic disorder with agoraphobia and generalized anxiety disorder. R. at 362. Dr. Marshino
placed Ms. Coffey’s GAF at 52. R. at 362.
On September 8 and October 13, 2009, Ms. Coffey received more injections from Dr.
Strausberg. R. at 438, 440. Ms. Coffey returned to the emergency room on October 12, 2009
complaining of back pain. R. at 430. As a result, Dr. John M. Scandrett, M.D. opined that Ms.
Coffey suffered chronic back pain and ordered her to continue with her Vicodin regimen. R. at
432. On November 11, 2009, Dr. Strausberg noted that, although injections relieved Ms. Coffey
of pain, the relief does not last long enough. R. at 443. He recommended that she undergo
lumber radiofrequency. R. at 443.
C.

The Administrative Hearing
1.

Coffey’s Testimony

At the hearing on January 4, 2010, Ms. Coffey testified that she had worked at an auto
center and in several warehouses in the past. R. at 30-32. However, she was dismissed from
nearly all of her jobs due to anxiety. R. at 32-34. She also testified that she has severe panic
attacks when around others. R. at 32. The attacks caused her to either abruptly quit her job or

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take unscheduled breaks. R. at 32. Further, she testified that her anxiety keeps her from going to
the grocery store, or Wal-Mart, or even a psychiatrist. R. at 35-36. According to Ms. Coffey,
her panic attacks include clamminess, difficulty breathing and tightness in the chest. R. at 32.
Additionally, she testified that she feels that other people are staring at her or coming after her.
R. at 36. Finally, she testified that she suffers from depression. According to her testimony, she
cries and sleeps all the time and is often forgetful. R. at 37-38.
Ms. Coffey testified that she suffers from back and leg pain. R. at 38. She claimed to
feel the pain constantly, from her back to her knees. R. at 38-39. She testified that she is only
able to stand for ten to fifteen minutes at a time before having to rest and reported that she could
walk no more than a quarter of a block. R. at 39. Ms. Coffey testified that because of leg pain,
she was unable to sit for more than fifteen minutes at a time. R. at 39. Additionally, she testified
that she was unable to lift more than ten pounds. R. at 39.
2.

The Vocational Expert’s Testimony

Robert Barber, the vocational expert, (“the VE”), classified Ms. Coffey’s previous jobs.
R. at 44. He testified that Ms. Coffey had previously worked as a detailer, a medium, unskilled
position with a Service Vocational Preparation (“SVP”): 2; a warehouse worker, a medium,
unskilled position with a SVP: 2, and a press operator, a medium, unskilled position with an
SVP: 2. R. at 44. Next, the ALJ asked the VE a hypothetical question: whether a person of Ms.
Coffey’s age, education and work experience who is able to lift and carry twenty pounds – ten
pounds frequently – stand and walk for six of eight hours, and sit for six of eight hours; is unable
to climb ropes, ladders or scaffolds, crawl or kneel, work at unprotected heights, work near
dangerous moving machinery, operate a motor vehicle, work around open flames or large bodies
of water, work in an environment requiring more than superficial interaction with the general

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public, supervisors or co-workers is able perform substantial gainful activity in the national
economy. R. at 44-45. The VE answered affirmatively. He testified that this hypothetical
person could work as a packing line worker, a stock clerk, or an assembler. R. at 45.
Upon cross-examination, Coffey’s attorney asked the VE if the ALJ’s hypothetical
person would still be able to perform substantial gainful activity if that person has panic attacks
around others that would cause her to take unscheduled breaks, is limited to standing no more
than fifteen minutes, cannot walk more than one fourth of a block, cannot sit more than twenty
minutes at a time or lift more than ten pounds. R. at 45. The VE answered this question
negatively. R. at 45.
II. STANDARD OF REVIEW
To be eligible for DIB, a claimant must have a disability under 42 U.S.C. § 423.
“Disability” means the “inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment….” 42 U.S.C. § 423(d)(1)(A). The ALJ
applies a five step process in determining whether a claimant is disabled. This process is
evaluated as follows:
1. The Court considers the claimant’s work activity, if any. If he/she is doing
substantial gainful activity, the Court will find that he/she is not disabled.
2. The Court considers the medical severity of the claimant’s impairment(s). If
he/she does not have a severe medically determinable physical or mental
impairment that meets the duration requirement in § 404.1509, or a
combination of impairments that is severe and meets the duration requirement,
the Court will find that the claimant is not disabled.
3. The Court also considers the medical severity of the claimant’s impairment(s).
If he/she does have an impairment(s) that meets or equals one of the Court’s
listings in appendix 1 of this subpart and meets the duration requirement, the
Court will find that the claimant is disabled.

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4. The Court considers an assessment of the claimant’s residual functional
capacity and his/her past relevant work. If he/she can still do her past relevant
work, the Court will find that the claimant is not disabled.
5. The Court considers an assessment of the claimant’s residual functional
capacity and his/her age, education, and work experience to see if he/she can
make an adjustment to other work. If the claimant can make an adjustment to
other work, the court will find that he/she is not disabled. If the claimant
cannot make an adjustment to other work, the Court will find that he/she is
disabled.
20 C.F.R. § 404.1520(a)(4). Although the burden of proof is on the claimant for the first four
steps, it shifts to the Commissioner for the fifth. Knight v. Chater, 55 F.3d 309, 313 (7th Cir.
1995).
The Court will sustain the ALJ’s findings if they are supported by substantial evidence.
42 U.S.C. § 405(g); Nelson v. Apfel, 131 F.3d 1228, 1234 (7th Cir. 1997); Knight, 55 F.3d at
313. In reviewing the ALJ’s findings, the Court may not “decide facts anew, reweigh the
evidence, or substitute our judgment for that of the ALJ.” Nelson, 131 F.3d at 1234. The ALJ’s
decision will be reversed only if his findings are not supported by substantial evidence or if the
ALJ “applied an erroneous legal standard.” Id. Although a mere scintilla of evidence is
insufficient to affirm the ALJ’s findings, only "such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion" is required. Scivally v. Sullivan, 966 F.2d
1070, 1075 (7th Cir. 1992) (quoting Pitts v. Sullivan, 923 F.2d 561, 654 (7th Cir. 1991)). Where
reasonable minds may differ as to whether the claimant is disabled, the court will defer to the
ALJ. Binion ex rel. Binion v. Chater, 108 F.3d 780, 782 (7th Cir. 1997).
Although the ALJ need not evaluate every piece of testimony and evidence submitted, he
must articulate some legitimate reason for his decision based on relevant evidence. Clifford v.
Apfel, 227 F.3d 863, 872 (7th Cir. 2000). Further, “[an] ALJ may not select and discuss only that
evidence that favors his ultimate conclusion, but must articulate, at some minimum level, his
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analysis of the evidence [must] allow the [Court] to trace the path of his reasoning.” Diaz v.
Chater, 55 F.3d 300, 307 (7th Cir. 1995).

The Court will “give the [ALJ’s] opinion a

commonsensical reading rather than nitpicking at it." Shramek v. Apfel, 226 F.3d 809, 811 (7th
Cir. 2000).
III. DISCUSSION
A.

The ALJ’s Findings
As reported in his decision, the ALJ found that Ms. Coffey met the insured status

requirements of the Social Security Act through May 31, 2012. R. at 10. Additionally, the ALJ
found that Ms. Coffey had not engaged in substantial gainful activity since March 6, 2007. R. at
12.
The ALJ concluded that Ms. Coffey suffered from the following severe impairments:
anxiety/depression; gastroesophageal reflux disease; hypertension; obesity; tobacco addiction;
low back pain/lumbar facet arthropathy; and SI joint dysfunction. R. at 12. However, he found
that these impairments did not meet or medically equal any of the listed impairments in 20
C.F.R. 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d),
416.925, and 416.926).

R. at 15.

The ALJ reasoned that Ms. Coffey’s musculoskeletal

impairment was insufficient because she presented no evidence of nerve root compression with
neuro-anotomic distribution of pain. R. at 15. Furthermore, he reasoned that Ms. Coffey’s
cardiovascular disorder did not satisfy listings in the appendix. He also found that her digestive
disorder was responsive to treatment. R. at 15.
Additionally, the ALJ reasoned that Ms. Coffey’s mental impairments are not paired with
the necessary ancillary findings. R. at 15. The ALJ pointed to evidence that Ms. Coffey was
able to drive, meet her father and take her son to school. R. at 15. Further, the ALJ gave

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substantial weight to the opinions of state examiners Dr. Kladder and Dr. Horton. R. at 15.
Relying on those opinions, the ALJ concluded that Ms. Coffey merely possessed moderate
difficulties maintaining concentration and social functioning; mild restriction of daily living
activities; and no decompensatory episodes of extended duration. R. at 15.
Next, the ALJ evaluated Coffey’s residual functional capacity (“RFC”). R. at 15-16. The
ALJ found that Ms. Coffey was able to perform light work that included lifting up to twenty
pounds occasionally and carrying ten pounds frequently. R. at 15. He found that she could stand
or walk for a total of six hours out of an eight hour work day and also sit for six of eight hours.
R. at 15. However, the ALJ determined that she could not climb ropes, ladders or scaffolds;
crawl or kneel; work around unprotected heights, dangerous machinery, open flames or large
bodies of water; or operate a motor vehicle. R. at 16. Additionally, the ALJ found that Ms.
Coffey was only able to complete simple repetitive tasks and was limited to only superficial
interaction with the general public, managers and co-workers. R. at 16.
Although the ALJ found that Ms. Coffey’s disabilities could reasonably be expected to
produce the symptoms she claimed to suffer in her testimony, he found her testimony to be not
fully credible because it was inconsistent with the RFC assessment. R. at 17. The ALJ reasoned
that Ms. Coffey’s pain symptoms were not credible because they were not consistent with the
medical evidence. R. at 17. Further, the ALJ reasoned that her panic attacks improved with the
use of medication; additionally, she was not seeking any emergency medical help as would be
expected by someone who experienced weekly panic attacks. R. at 17. Finally, the ALJ
determined that Ms. Coffey was able to perform household chores, take her son to school, and
meet with family members. R. at 17.

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The ALJ found that Ms. Coffey was unable to return to her previous job, but could still
perform substantial gainful activity in the national economy. R. at 17-18. Because Ms. Coffey’s
ability to do the full range of light work was impeded by additional limitations, the ALJ relied on
the VE’s testimony that a person sharing Ms. Coffey’s skills, experience, age and limitations
would be able to work as a packing line worker, stock clerk, or assembler. R. at 18. By contrast,
the ALJ ruled out the hypothetical posed by Ms. Coffey’s attorney because there was “no
foundation” for his question. R. at 18. Accordingly, the ALJ found that Ms. Coffey was not
disabled. R. at 19.
B.

Analysis
1.

The ALJ’s Step Three Analysis

Ms. Coffey contends that the ALJ erred in finding that her combined impairments did not
meet or medically equal Listing 12.06 or Listing 12.04 of 20 C.F.R. 404 Subpart P, Appendix 1.
Ms. Coffey claims that her combined impairments meet or equal the listed disorders of Section
12: Mental Disorders. 20 C.F.R. 404 Subpart P, Appendix 1. Appendix 1 listed mental disorders
consist of seven broad mental disorder classifications. Id. Within each classification, there is a
list of required medical findings (Paragraph A criteria), impairment-related functional limitations
(Paragraph B criteria), and, in some categories, additional functional criteria (Paragraph C
criteria). Id. In order to meet or medically equal a listed disability in this category, a claimant
must show that he or she meets a category’s Paragraph A criteria, and its Paragraph B or
Paragraph C criteria. Id.
Ms. Coffey contends that her combined impairments meet or equal Listing 12.06:
Anxiety Related Disorders or Listing 12.04: Affective Disorders. Under 12.06, the claimant

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must show that he or she suffers from at least one medically documented impairment. 20 C.F.R.
404 Subpart P, Appendix 1. Ms. Coffey claims that she suffers from two:
A persistent irrational fear of a specific object, activity, or situation which results
in a compelling desire to avoid the dreaded object, activity, or situation; or
Recurrent severe panic attacks manifested by a sudden unpredictable onset of
intense apprehension, fear, terror and sense of impending doom occurring on the
average of at least once a week.
Id. Under Listing 12.06, the claimant must also show that his or her medically documented
finding results in at least two listed behaviors. Id. Ms. Coffey claims that her impairments cause
three of these behaviors:

(1) marked restriction of activities of daily living; (2) marked

difficulties in maintaining social functioning; and (3) marked difficulties in maintaining
concentration, persistence, or pace.
In order to meet the requirements under Listing12.04, the claimant must show that he or
she suffers from at least one medically documented impairment. 20 C.F.R. 404 Subpart P,
Appendix 1. Ms. Coffey claims that she suffers from depressive syndrome characterized by
sleep disturbance, decreased energy, difficulty concentrating or thinking, thoughts of suicide, and
delusion. Additionally, the claimant must also show that his or her listed impairment results in at
least two listed behaviors. Id. Ms. Coffey claims that her impairments result in (1) marked
restriction in activities of daily living; (2) marked difficulties in maintaining social functioning;
and (3) marked difficulties maintaining concentration, persistence, or pace.
In support of this argument, Ms. Coffey contends that the ALJ erroneously failed to (1)
acknowledge medical evidence that supported her Step 3 claim and (2) summon a medical
examiner to testify whether Coffey’s impairments meet or medically equal the listed disabilities.
Both arguments will be considered in turn.

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a. Acknowledging Contrary Medical Evidence
Coffey contends that the ALJ failed to consider medical evidence contrary to his Step
Three analysis. An ALJ must consider all relevant evidence when making his or her decision.
See Smith v. Apfel, 231 F.3d 433, 437-38 (7th Cir. 2000) (holding the ALJ must develop a “full
and fair record”). Additionally, the ALJ may not “cherry-pick” medical opinions that support his
or her opinion while ignoring opinions that do not. Scott v. Astrue, 647 F.3d 734, 740 (7th Cir.
2011). If the ALJ fails to acknowledge evidence supporting the claimant’s disability, then he or
she fails to build a logical bridge from the evidence to his or her conclusion. Godbey v. Apfel,
238 F.3d 803, 807-08 (7th Cir. 2000).
Ms. Coffey relies on testimony from Drs. Ramilo, Gannon, Pate, Rasmussen and
Marshino.

Specifically, she claims that the testimony from the above mentioned doctors

provides evidence contrary to the ALJ’s Step Three conclusion, but was ignored by the ALJ.
The Court disagrees. Although, the ALJ did not acknowledge certain evidence from these
doctors’ conclusions, the doctors’ conclusions supported the ALJ’s Step Three conclusion that
Ms. Coffey’s combined impairments do not meet or medically equal any listed impairments.
The ALJ did not err in summarizing Dr. Gannon’s opinions. On the contrary, the ALJ
fully acknowledged Dr. Gannon’s opinion that Ms. Coffey suffered an acute anxiety episode or
panic attack. Additionally, the ALJ acknowledged Ms. Coffey’s treatment history under Dr.
Gannon starting from when she began taking Antivan to when she was prescribed an increased
dosage of Paxil and Xanax.
Drs. Pate, Rasmussen and Marshino all conducted psychiatric evaluations on Ms. Coffey.
In doing so, the doctors noted all of Ms. Coffey’s subjective complaints and made their own
objective observations. As a result, the doctors unanimously opined that Ms. Coffey possessed a

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GAF score of above fifty. GAF scores of fifty and above indicate moderate difficulty in social or
occupational functioning. DSM-IV-TR 34. As mentioned previously, in order to show that he or
she has a listed impairment under 12.06 or 12.04, the claimant must show that he or she exhibits
marked limitations. However, Ms. Coffey’s GAF scores signal that she suffers from moderate
limitations; this falls a step below what the limitations require in Part B of 12.06 and 12.04 of 20
C.F.R. 404 Subpart P, Appendix 1. See 20 C.F.R. 404.1520(c)(4) (“We will use the following
five-point scale: None, mild, moderate, marked, and extreme.”).

Therefore, these doctors’

examinations reasonably supported the ALJ’s Step Three analysis and did not need to be
specifically acknowledged in his opinion as contrary evidence.
It is true that Dr. Ramilo assessed Ms. Coffey’s GAF at 25 for three days at Valle Vista
Hospital in 1997. However, the Court finds that this evidence is too dated to be relied on
individually. See Smith, 231 F.3d at 433 (ALJ erred in relying on outdated x-rays); Thompson v.
Sullivan, 933 F.2d 581, 587 (7th Cir. 1991) (ALJ erred in relying on outdated medical evidence).
Ms. Coffey makes no attempt to describe how this GAF score is linked to the others. In Dr.
Ramilo’s assessment, Ms. Coffey attributed her suicide attempt to a failed relationship. R. at
365. However, she has attributed her most recent bout with agoraphobia and depression to her
mother’s death in 2004 on several occasions. R. at 30, 254, 260, 354, 360. In fact, Ms. Coffey
admitted to feeling fine before 2002. R. at 354. There is absolutely no link between her 1997
hospital visit and her current mental limitations. See Knox v. Astrue, 327 Fed. Appx. 652, 65657 (7th Cir. 2009) (claimant must link evidence to current limitations). Additionally, Ms. Coffey
only retained her low GAF score for three days. When she was discharged from the Valle Vista
Hospital, her GAF score was 55. Therefore, the ALJ did not need to specifically acknowledge
Dr. Ramilo’s evaluation.

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Although Ms. Coffey’s GAF scores may indicate a more severe condition than the ALJ
acknowledged,3 this analysis concerns only whether the ALJ ignored evidence contrary to his
Step Three conclusion. Accordingly, the ALJ appropriately acknowledged the medical evidence
on the record in finding that Ms. Coffey’s impairments did not meet or medically equal the listed
impairments at 12.04 or 12.06 of 20 C.F.R. 404 Subpart P, Appendix 1.
b. Consulting a Medical Examiner
Ms. Coffey contends that the ALJ erred in refusing to allow a medical examiner to testify
whether her combined impairments medically equaled a Subpart P, Appendix 1 Listed
impairment. “An ALJ has a duty to solicit additional information to flesh out an opinion for
which the medical support is not readily discernable.” Barnett v. Barnhart, 381 F.3d 664, 669
(7th Cir. 2004). An ALJ must rely on a medical expert’s opinion when finding a claimant does
not meet or equal a listed impairment. SSR 96-6p, 61 Fed. Reg. 34466, 34468 (July 2, 1996). In
some situations, this requires that the ALJ hear additional evidence from a medical examiner.
See Green v. Apfel, 204 F.3d 780, 781 (7th Cir. 2000) (ALJ incorrectly made medical
conclusions instead of consulting medical examiner). However, when the medical evidence in
the record is sufficient to make a decision, the ALJ may rely on it alone. See Simila v. Astrue,
573 F.3d 503, 516 (7th Cir. 2009) (holding that the record was sufficient to forgo use of a
medical examiner). Particularly, “[w]hen an [ALJ] … finds that an individual's impairment(s)
[are] not equivalent in severity to any listing, the requirement to receive expert opinion evidence
into the record may be satisfied by [a SSA-831-U5 or SSA-832-U5 or SSA-833-U5] signed by a
State agency medical or psychological consultant.” SSR 96-6p, 61 Fed. Reg. 34466, 34468 (July
2, 1996). The Court finds that the ALJ met his burden in this case.

3

The ALJ gave substantial weight to medical opinions that found some of Ms. Coffey’s impairments to be mild.

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Here, the record contained sufficient evidence for the ALJ to hold that Ms. Coffey’s
combined impairments did not meet or medically equal Listing 12.04 or Listing 12.06. It
contained medical reports from multiple psychologists who examined Ms. Coffey over a period
of three years. Specifically, the ALJ relied on state examiners Dr. Kladder and Dr. Horton. Both
opined Ms. Coffey’s impairments did not meet or equal any listed impairments. In doing so, the
doctors completed Disability Determination Transmittal Forms similar to the SSA-831-U5.
Ms. Coffey relies heavily on Barnett, but her reliance is misplaced.

See Barnett, 381

F.3d at 664. In Barnett, the ALJ did not consult any medical expert at all in holding that the
claimant’s impairments did not meet or equal a listed impairment. Id. at 670-71. Instead, the
ALJ grounded his findings based on his own layman opinion. Id. at 671. By contrast, the ALJ in
this case grounded his findings in medical opinions written by certified state physicians. R. at 15.
Ms. Coffey contends that Dr. Kladder’s and Dr. Horton’s opinions are outdated. She
argues that the ALJ should have heard updated testimony from a medical expert. However,
when making a Step Three decision, an ALJ is not required to request an updated medical
opinion from a medical expert unless (1) “[N]o additional medical evidence is received, but in
the opinion of the [ALJ] the symptoms, signs, and laboratory findings reported in the case record
suggest that a judgment of equivalence may be reasonable”; or (2) “When additional medical
evidence is received that in the opinion of the [ALJ] may change the State agency medical or
psychological consultant's finding that the impairment(s) is not equivalent.” SSR 96-6p, 61 Fed.
Reg. 34466, 34468 (July 2, 1996); cf. Smith, 231 F.3d at 433.
In this case, additional medical evidence was received after Dr. Kladder and Dr. Horton
examined Ms. Coffey, but the evidence further affirmed their opinions that her impairments do
not meet Listing 12.04 or Listing 12.06. For example, Dr. Rasmussen opined that her remaining

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functional capacity was moderately impaired. Although this is a degree higher than the state
physicians’ opinions, it is not enough to meet or equal the listed conditions. Further, it seems
obvious that the ALJ did not feel that updated medical evidence would change the state
examiners’ minds. Therefore, the ALJ did not err in refusing to hear testimony from a medical
expert.
2.

Ms. Coffey’s Credibility

Ms. Coffey contends that the ALJ erred in finding her testimony not fully credible. The
Court defers to an ALJ’s credibility determination and shall overturn it only if it is “patently
wrong.” Getch v. Astrue, 539 F.3d 473, 483 (7th Cir. 2008); Prochaska v. Barnhart, 454 F.3d
731, 738 (7th Cir. 2006); see also Sims v. Barnhart, 442 F.3d 536, 538 (7th Cir. 2006) (“Only if
the trier of fact grounds his credibility finding in an observation or argument that is unreasonable
or unsupported … can the finding be reversed.”). The ALJ’s “decision [must be made] in a
rational manner, logically based on [his] specific findings and the evidence in the record.”
McKinzey v. Astrue, 641 F.3d 884, 890 (7th Cir. 2011). Thus, the ALJ’s opinion will be reversed
"only if [he] grounds his credibility finding in an observation or argument that is unreasonable or
unsupported.” Prochaska 454 F.3d at 738 (quoting Sims, 442 F.3d at 538).
The ALJ’s credibility determination was not patently wrong. Each assertion the ALJ
made was supported by a fact in the record. For example, the ALJ noted that Ms. Coffey
complained of debilitating back pain, but images of her lumbar spine were mostly unremarkable.
Additionally, the ALJ noted that Ms. Coffey claimed to suffer from debilitating anxiety, but she
is able to visit family, take her son to school and prepare meals. All of the ALJ’s reasons for
finding that Ms. Coffey’s testimony was not credible were supported by specific findings and

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evidence in the record. Therefore, the ALJ’s opinion with respect to his credibility determination
was not patently wrong.
3.

The ALJ’s Step Five Analysis

Ms. Coffey contends that the ALJ erred in his Step Five analysis. Specifically, she
claims that the ALJ omitted all evidence of her mental limitations. Additionally, she claims that
the ALJ’s hypothetical was flawed for the same reasons. Each argument will be considered in
turn.
a. Ms. Coffey’s Residual Function Capacity
Ms. Coffey contends that the ALJ erred in assessing her RFC. She contends that the
ALJ’s analysis omits important medical evidence concerning her work limitations. The Court
disagrees.
An ALJ “is not required to address every piece of evidence but is instead required to
build a logical bridge from the evidence to [his] conclusion.”

Similia, 573 F.3d at 516.

However, “an ALJ may not ignore an entire line of evidence contrary to [his] findings.”
Zurawski v. Halter, 245 F.3d 881, 888 (7th Cir. 2001) (quoting Henderson v. Apfel, 179 F.3d
507, 514 (7th Cir. 1999)). Doing so renders a court unable to determine whether the ALJ
considered the record as a whole. Id.
Ms. Coffey relies on her GAF scores to show that her impairments are “quite severe.”
However, as mentioned previously, her GAF scores show that she exhibits moderate
impairments. Accordingly, in his opinion, the ALJ found that Ms. Coffey suffered “moderate
functional limitations from [her] medically determinable impairments.” The ALJ incorporated
those impairments into Ms. Coffey’s RFC. Because the ALJ’s RFC analysis afforded Ms.
Coffey the same limitations as the GAF scores that she relies on, substantial evidence supports

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his decision. See Wilkins v. Barnhart, 69 Fed. Appx. 775, 780 (7th Cir. 2003) (GAF scores may
be useful in a claimant’s RFC assessment but are not essential); see also Howard v. Comm'r of
Soc. Sec., 276 F.3d 235, 241 (6th Cir. 2002) (although GAF scores are not essential to an ALJ’s
accuracy, they may be of “considerable help” when formulating a claimant’s RFC).
In addition, Ms. Coffey contends that the ALJ omitted evidence that all of her former
employment opportunities had been terminated due to panic attacks. However, the ALJ found
that Ms. Coffey had trouble with the public and, in order to maintain employment, required no
more than superficial contact with people. Additionally, the ALJ heard Ms. Coffey’s testimony
that she was terminated because of her panic attacks and found her to be not fully credible.
Therefore, the ALJ considered this evidence.
b. The ALJ’s Hypothetical
Lastly, Ms. Coffey contends that the ALJ failed to give full consideration to her
impairments in his hypothetical. In her argument, Ms. Coffey relies on O'Connor-Spinner v.
Astrue, 627 F.3d 614 (7th Cir. 2010). In O’Connor-Spinner, the ALJ failed to pose any phrase
that stipulated the claimant’s concentration, persistence and pace limitations in his hypothetical
to the vocational expert. Id. at 618-19. Similarly, Ms. Coffey claims that the ALJ omitted
information concerning her anxiety and depression in his hypothetical. She argues that omission
deprived the VE of important information that is necessary in determining whether she could
perform substantial gainful activity in the national economy. The Court disagrees.
“If the ALJ relies on testimony from a vocational expert, the hypothetical question he
poses to the VE must incorporate all of the claimant's limitations supported by medical evidence
in the record.” Indoranto v. Barnhart, 374 F.3d 470, 474 (7th Cir. 2004). However, "the ALJ is
required only to incorporate into his hypotheticals those impairments and limitations that he

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accepts as credible." Simila, 573 F.3d at 521 (quoting Schmidt v. Astrue, 496 F.3d 833, 846 (7th
Cir. 2007)).

Finally, the ALJ is not required to use specific terminology in his or her

hypothetical so long as the phrasing “specifically exclude[s] those tasks that someone with the
claimant's limitations would be unable to perform.” O’Connor-Spinner, 627 F.3d at 619.
Although the ALJ agreed that Ms. Coffey had some problems with groups of people, he
did not accept the notion that her anxiety prevented her from having any contact with people.
Instead, the ALJ relied on Dr. Kladder’s evaluation finding that Ms. Coffey could work in a
setting that required little interaction with groups of people. Accordingly, the ALJ determined
her employment required no more than superficial interaction with the general public, coworkers, or supervisors in his hypothetical.
The Court finds that the ALJ’s language “suppl[ied] the VE with information adequate to
determine whether [Coffey] could perform jobs in the national economy.” O’Connor-Spinner,
627 F.3d at 618-19. The ALJ’s hypothetical was reasonably consistent with Dr. Kladder’s
opinion that Ms. Coffey can maintain only little interaction with groups of people. It excludes
work that requires any meaningful conversation or interaction with others during work time. In
fact, the hypothetical arguably goes further than Dr. Kladder’s evaluation by limiting interaction
with all people, not just the public. Therefore, substantial evidence supports the language of the
ALJ’s hypothetical.
IV. CONCLUSION
For the reasons set forth above, this final decision of the Commissioner of the Social
Security Administration is AFFIRMED. Final judgment shall be entered accordingly.

SO ORDERED.

03/27/2012

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________________________
Hon. Tanya Walton Pratt, Judge
United States District Court
Southern District of Indiana

DISTRIBUTION:
Patrick Harold Mulvany
[e-mail]
Thomas E. Kieper
United States Attorney’s Office
[e-mail]

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