SCHIFFMILLER v. SAUL
ORDER - The Court REVERSES the ALJ's decision denying the Plaintiff benefits and REMANDS this matter for further proceedings. Final judgment will issue accordingly. Signed by Magistrate Judge Doris L. Pryor on 7/28/2022.(JSR)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
JANI B. S. 1,
Plaintiff Jani B. S. requests judicial review of the denial by the Commissioner
of the Social Security Administration ("Commissioner") of her application for
Supplemental Security Income ("SSI") under Title XVI of the Social Security Act. See
42 U.S.C. §§ 423(d). For the reasons set forth below, the Court hereby REVERSES
the ALJ's decision denying the Plaintiff benefits and REMANDS this matter for
On May 30, 2017, Jani filed an application for Title XVI SSI. (Dkt. 16-2 at 52,
R. 51). Jani's application alleged disability resulting from autism, anxiety,
depression, interstitial cystitis, and polycystic ovary syndrome. (Dkt. 16-6 at 6, R.
237). The Social Security Administration ("SSA") denied Jani's claim initially on
In an effort to protect the privacy interests of claimants for Social Security benefits, the Southern
District of Indiana has adopted the recommendations put forth by the Court Administration and Case
Management Committee of the Administrative Office of the United States Courts regarding the
practice of using only the first name and last initial of any non-government parties in Social Security
opinions. The Undersigned has elected to implement that practice in this Order.
October 11, 2017, (Dkt. 16-3 at 14, R. 106), and on reconsideration on December 15,
2017. (Id. at 29, R. 121). On February 11, 2018, Jani filed a written request for a
hearing, which was granted. (Dkt. 16-4 at 13, R. 133). On November 22, 2019,
Administrative Law Judge ("ALJ") Jan Leventer conducted a hearing, where Jani
and her counsel appeared in person and vocational expert, Harry Cynowa, appeared
telephonically. (Dkt. 16-2 at 69, R. 68). On January 15, 2020, ALJ Leventer issued an
unfavorable decision finding that Jani was not disabled. (Dkt. 16-2 at 52-60, R. 5159). Jani appealed the ALJ's decision and, on September 20, 2020, the Appeals
Council denied Jani's request for review, making the ALJ's decision final. (Dkt. 16-2
at 3-5, R. 2-4). Jani now seeks judicial review of the ALJ's decision denying benefits.
See 42 U.S.C. § 1383(c)(3).
STANDARD OF REVIEW
To qualify for disability, a claimant must be disabled within the meaning of the
Social Security Act. To prove disability, a claimant must show she 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 twelve
months." 42 U.S.C. § 423(d)(1)(A). To meet this definition, a claimant's impairments
must be of such severity that she is not able to perform the work she previously
engaged in and, based on her age, education, and work experience, she cannot engage
in any other kind of substantial gainful work that exists in significant numbers in the
national economy. 42 U.S.C. § 423(d)(2)(A). The SSA has implemented these
statutory standards by, in part, prescribing a five-step sequential evaluation process
for determining disability. 20 C.F.R. § 416.920(a). The ALJ must consider whether:
(1) the claimant is presently [un]employed; (2) the claimant has a
severe impairment or combination of impairments; (3) the
claimant's impairment meets or equals any impairment listed in the
regulations as being so severe as to preclude substantial gainful
activity; (4) the claimant's residual functional capacity leaves [her]
(5) the claimant is unable to perform any other work existing in
significant numbers in the national economy.
Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351-52 (7th Cir. 2005) (citation
omitted). An affirmative answer to each step leads either to the next step or, at steps
three and five, to a finding that the claimant is disabled. 20 C.F.R. § 416.920; Briscoe,
425 F.3d at 352. If a claimant satisfies steps one and two, but not three, then she
must satisfy step four. Once step four is satisfied, the burden shifts to the SSA to
establish that the claimant is capable of performing work in the national economy.
Knight v. Chater, 55 F.3d 309, 313 (7th Cir. 1995); see also 20 C.F.R.
§ 416.920. (A negative answer at any point, other than step three and five, terminates
the inquiry and leads to a determination that the claimant is not disabled.).
After step three, but before step four, the ALJ must determine a claimant's
residual functional capacity ("RFC") by evaluating "all limitations that arise from
medically determinable impairments, even those that are not severe." Villano v.
Astrue, 556 F.3d 558, 563 (7th Cir. 2009). The RFC is an assessment of what a
claimant can do despite her limitations. Young v. Barnhart, 362 F.3d 995, 1000-01
(7th Cir. 2004). In making this assessment, the ALJ must consider all the relevant
evidence in the record. Id. at 1001. The ALJ uses the RFC at step four to determine
whether the claimant can perform her own past relevant work and if not, at step five
to determine whether the claimant can perform other work in the national economy.
See 20 C.F.R. § 416.920(a)(4)(iv)-(v).
The claimant bears the burden of proof through step four. Briscoe, 425 F.3d at
352. If the first four steps are met, the burden shifts to the Commissioner at step five.
Id. The Commissioner must then establish that the claimant – in light of her age,
education, job experience, and residual 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. § 416.920(f).
Judicial review of the Commissioner's denial of benefits is to determine
whether it was supported by substantial evidence or is the result of an error of law.
Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). This review is limited to
determining whether the ALJ's decision adequately discusses the issues and is based
on substantial evidence. Substantial evidence "means – and means only – such
relevant evidence as a reasonable mind might accept as adequate to support a
conclusion." Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019); Rice v. Barnhart, 384
F.3d 363, 369 (7th Cir. 2004). The standard demands more than a scintilla of
evidentiary support but does not demand a preponderance of the evidence. Wood v.
Thompson, 246 F.3d 1026, 1029 (7th Cir. 2001). Thus, the issue before the Court is
not whether Jani is disabled, but, rather, whether the ALJ's findings were supported
by substantial evidence. Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995).
Under this administrative law substantial evidence standard, the Court
reviews the ALJ's decision to determine if there is a logical and accurate bridge
between the evidence and the conclusion. Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir.
2013) (citing Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008)). In this substantial
evidence determination, the Court must consider the entire administrative record but
not "reweigh evidence, resolve conflicts, decide questions of credibility, or substitute
its own judgment for that of the Commissioner." Clifford v. Apfel, 227 F.3d 863, 869
(7th Cir. 2000), as amended (Dec. 13, 2000). Nevertheless, the Court must conduct a
critical review of the evidence before affirming the Commissioner's decision, and 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); see also
Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).
When an ALJ denies benefits, she must build an "accurate and logical bridge
from the evidence to [her] conclusion," Clifford, 227 F.3d at 872, articulating a
minimal, but legitimate, justification for the decision to accept or reject specific
evidence of a disability. Scheck v. Barnhart, 357 F.3d 697, 700 (7th Cir. 2004). The
ALJ need not address every piece of evidence in her decision, but she cannot ignore a
line of evidence that undermines the conclusions she made, and she must trace the
path of her reasoning and connect the evidence to her findings and conclusions.
Arnett v. Astrue, 676 F.3d 586, 592 (7th Cir. 2012); Clifford, 227 F.3d at 872.
A. Factual Background
Jani was twenty-six years old on the date her application was filed. (Dkt. 16-6
at 2, R. 233). She has a high school education. (Dkt. 16-2 at 58, R. 57). She has no
past relevant work history. (Id.).
B. ALJ Decision
In determining whether Jani qualified for benefits under the Act, the ALJ
employed the five-step sequential evaluation process set forth in 20 C.F.R.
§ 404.1520(a) and concluded that Jani was not disabled. (Dkt. 16-2 at 52-60, R. 5159). At Step One, the ALJ found that Jani had not engaged in substantial gainful
activity since her application date of May 30, 2017. (Id. at 54, R. 53).
At Step Two, the ALJ found that Jani has severe impairments of interstitial
cystitis, kidney stones, endometriosis, gastroesophageal reflux disorder, lower
extremity paresthesias, hypertension, autism spectrum disorder, anxiety with panic
attacks, and binge eating disorder. (Dkt. 16-2 at 54, R. 53).
At Step Three, the ALJ found that Jani's impairments did not meet or
medically equal the severity of one of the listed impairments in 20 C.F.R. §
416.920(d), 416.925, and 416.926, considering Listings 11.14, 12.06, 12.10, and 12.13.
(Dkt. 16-2 at 54-56, R. 53-55). As to the "paragraph B" criteria, the ALJ concluded
that Jani had moderate limitations in all four categories: understanding,
remembering or applying information; interacting with others; adapting or managing
oneself and concentrating, persisting, or maintaining pace. (Id.).
After Step Three but before Step Four, the ALJ found that Jani had the
residual functional capacity ("RFC") to perform "light work," as defined in 20 C.F.R. §
416.967(b), with the following limitations: occasionally climb ramps and stairs; never
crawl or climb ladders, ropes, or scaffolds; avoid all exposure to unprotected heights
and moving mechanical parts; occasionally operate a motor vehicle; limited to simple,
routine tasks not at a production rate pace and simple work-related decisions; and
occasionally interact with general public. (Dkt. 16-2 at 56, R. 55).
At Step Four, the ALJ concluded that Jani has no past relevant work. (Dkt. 162 at 58, R. 57). The ALJ then concluded that, considering Jani's age, education, work
experience, and residual functional capacity, that Jani could perform jobs that exist
in significant numbers in the national economy, such as hand packager, small
products assembler, and visual inspector checker. (Id. at 58-59, R. 57-58). The ALJ
thus concluded that Jani was not disabled. (Id. at 59-60, R. 58-59).
The Plaintiff challenges the ALJ's decision on several grounds. First, the
Plaintiff argues that the ALJ erred when considering the "paragraph B" criteria by
only considering a limited view of Jani's activities of daily living, failing to consider
the entirety of her behavioral therapist's medical opinion, and omitting all
consideration of her therapist's records and opinions. (Dkt. 21 at 13 at 24; Dkt. 23 at
1-16). Second, the Plaintiff contends that the ALJ did not properly consider Social
Security Ruling 15-1p when evaluating whether Jani's impairments met or equaled
any of the Listings or conducting the RFC analysis. (Id.). Third, Jani maintains that
the ALJ failed to provide sufficient support for finding the medical opinion of her
behavioral therapist to be unpersuasive and explain why she did not consider the
medical opinion of her therapist. (Id.). Fourth, Jani argues that the ALJ conducted a
faulty 16-3p analysis of her subjective symptoms. (Id.).
A. "Paragraph B" Analysis
The ALJ concluded that the severity of Jani's "mental impairments, considered
singly and in combination, do not meet or medically equal the criteria of [L]istings
12.06, 12.10, and 12.13." (Dkt. 16-2 at 55, R. 54). In making that conclusion, the ALJ
considered whether the "paragraph B" criteria were satisfied. (Id.). Jani argues that
the ALJ relied on a limited and skewed version of her activities of daily living when
evaluating her limitations in the four "paragraph B" areas. (Dkt. 21 at 17-23) 2.
To determine whether a mental impairment meets or equals listing level
severity at Step Three of the sequential analysis, a claimant must prove she meets
the severity criteria of either paragraph B or C. 20 C.F.R. Pt. 404, Subpt. P, App. 1,
§§ 12.04, 12.06. To satisfy the paragraph B criteria, a plaintiff must demonstrate an
“[e]xtreme limitation of one, or marked limitation of two” of four areas:
understanding, remembering, or applying information; interacting with others;
concentrating, persisting, or maintaining pace; and adapting and managing oneself.
Id. To evaluate these four areas, ALJs will investigate how an impairment interferes
with a claimant's ability to function independently, appropriately, effectively, and on
The paginated numbers provided at the bottom of Plaintiff's Opening Brief do not correspond with
the paginated numbers of the brief on the Docket. The Undersigned has chosen to cite to the paginated
numbers from the Docket.
a sustained basis, as well as the quality and level of overall functional performance,
any episodic limitations, the amount of supervision or assistance required, and the
settings in which a claimant is able to function. 20 C.F.R. § 404. 1520a(c)(2). Plaintiff
bears the burden of proving that her "impairments satisfy all of the various criteria
specified in the listing." Ribaudo v. Barnhart, 458 F.3d 580, 583 (7th Cir. 2005); see
also 20 C.F.R. § 404.1525(d). "To support reversal, 'a claimant is required to identify
the medical evidence showing that he or she would have satisfied the Step 3 criteria
if the ALJ had considered the relevant issues.'" Esther V. v. Saul, No. 19-CV-8093,
2021 WL 1121123, at *5 (N.D. Ill. Mar. 24, 2021) (citing Heuschmidt v. Colvin, 2015
WL 7710368, at *3 (N.D. Ill. Nov. 30, 2015)).
The ALJ explained her findings regarding the "paragraph B" areas as follows:
In understanding, remembering, or applying information, the
claimant has a moderate limitation. The claimant reported she is
able to prepare food, visit with a friend, help to care for her pets, do
laundry, vacuum the floor, handle a savings account, use a
checkbook, and play videogames. (Claimant Testimony, Ex. 6E).
In interacting with others, the claimant has a moderate limitation.
The claimant reported she is able to visit with her friend (Claimant
Testimony, Ex. 6E).
With regard to concentrating, persisting or maintaining pace, the
claimant has a moderate limitation. The claimant reported she is
able to prepare food, visit with her friend, help care for her pets, do
laundry, vacuum the floor, handle a savings account, use a
checkbook, and play videogames. (Claimant Testimony, Ex. 6E).
As for adapting or managing oneself, the claimant has experienced a
moderate limitation. The claimant reported she is able to prepare
food, visit with her friend, help care for her pets, do laundry, vacuum
the floor, handle a savings account, use a checkbook, and play
videogames. (Claimant Testimony, Ex. 6E).
(Dkt. 16-2 at 55, R. 54).
From this explanation, the only reason the ALJ found to support assigning
moderate limitations to each of the four "paragraph B" areas came from Plaintiff's
activities of daily living endorsed at the hearing and in her function report. The Court
notes, however, that the ALJ's decision is read as a whole and that the ALJ's RFC
discussion may be considered in conjunction with the Step Three discussion. Curvin
v. Colvin, 778 F.3d 645, 650 (7th Cir. 2015).
Plaintiff argues that the ALJ placed too much emphasis on Jani's activities of
daily living without considering their context, and failed to explain how these cited
activities translate into her ratings under the "paragraph B" criteria. First, the Court
acknowledges that the ALJ simply listed the same activities of daily living for three
of the four areas, regardless of the functional area in question. Second, the ALJ's
presentation of the Plaintiff's claimed activities of daily living is limited and, at
times, skewed, often leaving out the Plaintiff's qualifications. On her November 30,
2017 function report, Plaintiff listed her activities as follows: Plaintiff's mother helps
her care for her ferrets, which her therapist encouraged her to interact with since it
helps her mental health symptoms; she often forgets to brush her teeth unless she
sets an alarm, but oftentimes sleeps through the alarm; she must set alarms to
remind herself to take medications and then write a note to herself so that she does
not accidentally take the medication; she can make packaged foods and sandwiches,
but her mom cooks for her when she is in too much pain; when her pain levels are
very high, she will sometimes forget to eat; she will do laundry sporadically or
vacuum every few weeks, but her parents assist with laundry; she goes out of the
house alone, but only on particularly good pain days; her pain often wakes up her up
multiple times in the middle of the night; she rarely drives for long distances in case
her pain levels spike; she shops for pet supplies, clothes, and household items by
computer; her father helps her pay any bills that she does have; and she talks with
friends online instead of in person since she does not drive due to her pain and
fatigue levels. (Dkt. 16-6 at 37-42, R. 268-273). Additionally, Plaintiff noted that she
needs instructions repeated to her multiple times; she does not handle stress well
because she breaks down and cries daily, along with having panic attacks; she does
not handle changes in routine well due to her anxiety; and in the few times she has
left her house on her own, she has gotten scared and had to talk herself down from
having a panic attack. (Dkt. 16-6 at 42-43, R. 273-74). Finally, Plaintiff included this
narrative at the end of the function report:
Memory, completing tasks, concentration, understanding/following
instructions are all things affected by my autism, depression, ADD,
and anxiety disorder. Also, since being on pain meds and Lupron, it
is more difficult to focus and remember things. My usual pain level
is at a 6 on good days, but bad days are common. I conserve pain
meds and only take them when the pain is completely intolerable and
when it's too terrible to get to sleep. I've been getting kidney stones
since I was twelve, and the stones have completely redefined my pain
scale. What was once a 9 is now a 5, but that doesn't make it any less
painful or horrible to live with. I have had three surgeries over the
last year, and November of last year was the first time I was ever put
under general anesthesia. I was in so much pain from various
illnesses that I thought it would be fine if I simply didn't wake up.
Now, I at least have answers, but the pain is still there.
(Dkt. 16-6 at 44, R. 275).
At the disability hearing in November 2019, the Plaintiff noted that she shuts
down when she gets overwhelmed. (Dkt. 16-2 at 78, R. 77). She also stated that her
anxiety is triggered by crowded places, loud noises, and being touched, and that her
anxiety makes it difficult for her to leave the house. (Dkt. 16-2 at 86-87, R. 85-86).
Plaintiff testified that her social worker, Ms. Julie Krasnow, would assist her in
getting acclimated to environments that make her anxious, such going to the bank or
grocery store or other places outside of the home. (Dkt. 16-2 at 81, R. 80). Since
Plaintiff had not left her house much in the years preceding the hearing, Jani
testified that Ms. Krasnow would come to Plaintiff's home and assist her with things
around the house. (Id.). When questioned about whether there was anything else the
Plaintiff would like to tell the ALJ about her disability from work, Plaintiff
eventually stated: "my mental health, and my physical health problems are very
closely linked. The worse my pain is, the more likely I am to go into sensory overload
and shut down, and when I shut down, I often can't speak, or communicate with
people really at all; I go non-verbal. And, I think, that's like one of my main obstacles
is that I shut down when I have too much sensory input, and that includes pain."
(Dkt. 16-2 at 82-83, R. 81-82). On a bad day, Plaintiff testified that she stays in bed
and does not eat, sleep, or shower, and that these bad days occur two or three times
per week. (Dkt. 16-2 at 84-85, R. 83-84). On good days, she is able to make food, go to
therapy, and pick up a prescription at the nearby pharmacy. (Id.). As part of her
Asperger's syndrome, she has sensory issues and auditory processing issues, which
often result in her squinting at someone trying to speak to her because she needs to
concentrate in order to process what that person is saying. (Id. at 85, R. 84). Plaintiff
also noted again that all of her conditions, physical and mental, interact with and
feed off of each other. (Id. at 84-86, R. 83-85). She interacts with her friends online for
the most part, and sees one friend in person every few months. (Id. at 86-87, R. 8586). She has panic attacks a few times per week, and has the most severe panic
attacks once per month. (Id. at 88, R. 87).
Jani's social worker, Ms. Krasnow, compiled quarterly reports regarding Jani's
progress. On December 27, 2018, Ms. Krasnow filled out a Functional Behavior
Assessment. (Dkt. 16-8 at 118-122, R. 729-733). Ms. Krasnow noted that Jani suffers
immensely from her medical conditions and continues to be in pain on a daily basis,
and that as a result of her diagnoses, it is difficult for Jani to function as an
independent adult, hold down a job, and access the community on a regular basis. (Id.
at 120, R. 731). Ms. Krasnow further stated that Jani's mental disorders have a great
impact on her behavior as they interfere with her executive functions, which include
poor planning, difficulty switching focus, difficulty staying on task, time
management, organization, and remembering details. (Id.). Ms. Krasnow indicated
that "Jani's behavior is a function of how she is feeling physically. Jani is more likely
to engage in her target behaviors when she is ill or in pain. She is also more likely to
engage in these behaviors when she is feeling overwhelmed or stressed." (Id. at 121,
R. 732). For the quarterly report ending February 2019, Plaintiff reported an increase
in stress related to recovering from the family holidays, pain, computer failure, and
her ferret's poor health. (Dkt. 16-8 at 116, R. 727). During that quarter, Jani had not
been getting out as much in the community, had been driving less, and had been
spending less time with her friend. (Id.). For each of the three months in that quarter,
Jani reported having four meltdowns per months, with meltdowns involving crying,
rocking, hyperventilating, starching herself, an inability to speak, and shrieking. (Id.
at 115-116, R. 726-27). Finally, Plaintiff points out that the SSA employee who took
Plaintiff's benefit application over the phone on June 2, 2017, M. Bryja, specifically
noted that Jani "seemed to have a lot of trouble remembering and some trouble
understanding the questions and the process." (Dkt. 16-6 at 73, R. 234).
Little to none of this information was included or referenced in the ALJ's
opinion. Moreover, as Plaintiff points out, the ALJ cites to a limited view of Plaintiff's
activities, but never explains how those activities support a finding of moderate
limitations in the four functional areas or indicate that Plaintiff is exaggerating her
symptoms. Sam K. v. Saul, 391 F. Supp. 3d 874, 881 (N.D. Ill. 2019) (ALJ erred by
listing activities of daily living but failing to explain how those activities were
inconsistent with Plaintiff's claimed symptoms). Additionally, despite multiple
mentions from Plaintiff, it does not appear the ALJ considered how Plaintiff's pain
and fatigue combined with her mental impairments interfered with her daily
activities. Clark v. Saul, 421 F. Supp. 3d 628, 633 (N.D. Ind. 2019) (ALJ erred when
not considering how fatigue affected daily activities, especially where claimant had
more flexibility to complete activities as compared with full-time work). Similarly,
ALJs must take into consideration that, when performing activities of daily living,
Plaintiff can obtain as much help from others as needed, work at her own pace
depending on symptoms, and take as many breaks between activities for as long as
needed, and that employers generally do not permit such flexibility. RuthAnn G. v.
Saul, No. 2:20-cv-252, 2021 WL 2349671, at *9 (N.D. Ind. June 9, 2021) (citing
Bjornson v. Astrue, 671 F.3d 640, 647 (7th Cir. 2012)).
Despite the ALJ's failure to consider the above-referenced information in the
"paragraph B" section, when reading the ALJ's decision as a whole, the Court finds
that the ALJ considered the relevant medical and non-medical evidence in other
sections of the opinion. Although the ALJ considered a limited version of the
Plaintiff's activities of daily living in the "paragraph B" section, the ALJ also weighed
this evidence alongside the relevant record evidence when determining Jani's degree
of limitation in each "paragraph B" area. For example, the ALJ considered Plaintiff's
report to her doctor in March 2019 that medication and therapy were helping her
mental health symptoms; and her report in July 2019 that her mental health
symptoms were stable, she had fewer mood swings and panic attacks, and she was
able to get outside more. (Dkt. 16-2 at 57, R. 56). The ALJ noted that Jani presented
to her consultative psychological evaluation with intact memory and normal thought
content/process. (Id.). The ALJ also weighed the medical opinion of Jani's social
worker, Ms. Krasnow, along with the opinions of the state agency psychological
consultants, and discounted both due to Jani's reports of improving symptoms and
her normal mental status during examinations. (Id. at 58, R. 57). "While there may
be other evidence that could support/disprove any of the ALJ's conclusions in h[er]
Paragraph B analysis, this is a question of weighing the evidence." Esther V. v. Saul,
No. 19-CV-8093, 2021 WL 1121123, at *7 (N.D. Ill. Mar. 24, 2021). The ALJ engaged
with both sides of the record here, and her analysis and explanation when read as a
whole is sufficient to justify her conclusion regarding the "paragraph B" limitations.
B. Social Security Ruling 15-1p
Next, Jani argues that the ALJ erred by providing little to no analysis as to
how her interstitial cystitis interacted with her mental disorders, which resulted in
an insufficient consideration of whether her impairments met or medically equaled
any listing and how the interplay of her medical conditions would impact the RFC
analysis. (Dkt. 21 at 13-23). Additionally, Plaintiff maintains that Social Security
Ruling 15-1p outlines how ALJs should evaluate cases involving interstitial cystitis,
and that the ALJ failed to meet those requirements. (Id.).
SSR 15-1p states that interstitial cystitis ("IC") is a complex genitourinary
disorder involving recurring pain or discomfort in the bladder and pelvic region. 2015
WL 1292257, *2. IC may co-occur with fibromyalgia, chronic fatigue syndrome,
irritable bowel syndrome, inflammatory bowel disease, vulvodynia, chronic
headaches, Sjögren's syndrome, endometriosis, or systemic lupus erythematosus. Id.
Treatments for IC are mostly directed at symptom control. . . . but [t]reatment is not
effective for everyone because response varies among patients. 3 Id. at *3. IC
"Like fibromyalgia, interstitial cystitis is a chronic pain disorder, one that seems to have a similar
difficulty in diagnosis and treatment. See Mayo Clinic website, http://www.mayoclinic.org/diseasesconditions/interstitial-cystitis/home/ovc-20251830 ('Interstitial cystitis most often affects women and
can have a long-lasting impact on quality of life. Although there's no cure, medications and other
therapies may offer relief. [ ] Frequent urination and pain may interfere with social activities, work
and other activities of daily life.'); Harvard Health Publications, 'Diagnosing and treating interstitial
cystitis,' http://www.health.harvard.edu/diseases-and-conditions/diagnosing-and-treating-interstitialcystitis ('There's no cure for IC, but many treatments offer some relief, either singly or in combination.
Figuring out what works can be hit-or-miss; there's no way to predict who will respond best to which
symptoms may vary in incidence, duration, and severity from person to person, and
even in the same person. For example, a woman's symptoms may worsen around the
time of menstruation. Id. at *4. Symptoms of IC include, but are not limited to:
1. Pain. People who have IC report chronic bladder and pelvic pain,
pressure, and discomfort. This pain may range from mild discomfort to
extreme distress. The intensity of the pain may increase as the bladder
fills and decrease as it empties. In addition to bladder and pelvic pain,
people with IC may experience vaginal, testicular, penile, low back, or
2. Urinary urgency and frequency. People who have IC may report an
urgent need to urinate (urgency) or a frequent need to urinate
(frequency), or both. Some people with severe cases of IC may need to
void as often as 60 times per day, including nighttime urinary frequency
(nocturia) with associated sleep disruption.
3. Other symptoms. In addition to chronic pain and urinary urgency or
frequency or both, the person may report additional IC symptoms, such
• Suprapubic tenderness on physical examination;
Id. at *4.
Sexual dysfunction (including dyspareunia);
Sleep dysfunction; and
Chronic fatigue or tiredness.
"People who have IC may report ongoing mental conditions directly associated
with their IC. For example, a person may report having anxiety or depression
associated with IC symptoms of chronic bladder and pelvic pain, and urinary
urgency, frequency, or both. When these mental conditions are documented by mental
status examination(s) or psychological testing, they may constitute medical signs or
(in the case of psychological testing) laboratory findings that help establish a
treatment. Fortunately, increasing awareness and greater understanding of this complex disorder are
helping to speed diagnosis and encourage research.') (August 2011)." Merriman v. Berryhill, No. 16 CV
50073, 2017 WL 2345551, at *1 (N.D. Ill. May 30, 2017).
[medically determinable impairment] of IC." Id. at *5. The process for evaluating a
claimant's statements regarding symptoms and functional limitations associated with
IC is similar to the two step-process used for evaluation of symptoms generally.
Compare SSR 15-1p, 2015 WL 1292257 with SSR 16-3p, 2017 WL 5180304 (Oct. 25,
2017). "In assessing RFC related to a [medically determinable impairment] of IC, we
must consider all of the person's impairment-related symptoms in deciding how such
symptoms may affect functional capacity. For example, many people with IC have
chronic pelvic pain, which can affect the ability to focus and sustain attention on the
task at hand. Nocturia may disrupt sleeping patterns and lead to drowsiness and lack
of mental clarity during the day. Urinary frequency can necessitate trips to the
bathroom as often as every 10 to 15 minutes, day and night. Consequently, some
individuals with IC essentially may confine themselves to their homes." Id. at *8.
Plaintiff contends that the ALJ never mentions Social Security Ruling 15-1p,
but more importantly that it does not appear the ALJ complied with the directive
contained in that SSR to consider the combination of Plaintiff's impairments when
conducting the Listing and RFC analyses. (Dkt. 21 at 14-23). As noted previously,
Jani endorsed having chronic pelvic and urinary pain, not alleviated by position
changes; difficulty sleeping; chronic fatigue; and difficulty concentrating and
sustaining attention, among other symptoms. Plaintiff maintains that the ALJ failed
to adequately consider the combined impact of these symptoms, in violation of SSR
Several cases across the country have concluded that an ALJ's failure to
discuss SSR 15-1p (or its almost identical predecessor SSR 02-2p), along with a
failure to adequately analyze the full scope of a claimant's interstitial cystitis, its
interplay with other impairments, and any limitations imposed by those
impairments, constitutes reversible error. See Chavis v. Astrue, 2012 WL 2711271, at
*23 (S.D. Ohio July 9, 2012) (finding that the ALJ's decision does not demonstrate
that he followed SSR 02–2p because he failed to examine the intensity, persistence
and limiting effects of claimant's IC and the decision is void of any discussion of the
limitations imposed by claimant's impairment), adopted by 2012 WL 5306130 (S.D.
Ohio Oct. 26, 2012); Powell v. Comm'r of Soc. Sec., No. 2:12-CV-12955, 2013 WL
3762954, at *11 (E.D. Mich. July 17, 2013) (same); Janine H. v. Kijakazi, No. 2:21CV-00183-LRS, 2022 WL 1086616, at *5 (E.D. Wash. Apr. 11, 2022) (ALJ's failure to
discuss IC at Step Three, in addition to over-emphasis on limited view of activities of
daily living, required remand); Schneider v. Colvin, No. 8:16-CV-338-T-30TBM, 2017
WL 345877, at *6-7 (M.D. Fla. Jan. 5, 2017), report and recommendation adopted sub
nom. Schneider v. Comm'r of Soc. Sec., No. 8:16-CV-338-T-30TBM, 2017 WL 320948
(M.D. Fla. Jan. 23, 2017) (ALJ's failure to consider combined effect of claimant's
impairments and symptoms, in violation of SSR 02-2p, was error); Burns v. Berryhill,
No. 1:18-CV-01015-CBK, 2018 WL 4938585, at *5 (D.S.D. Oct. 11, 2018) (ALJ erred
by failing to comply with SSR 15-1p's directive to consider combination of claimant's
impairments at Step Three and in RFC analysis); Denslow v. Comm'r of Soc. Sec.
Admin., No. CV-19-01718-PHX-MTM, 2020 WL 1083788, at *4 (D. Ariz. Mar. 6, 2020)
The Court has already determined that the ALJ's "paragraph B" and Listing
analysis, although perfunctory and somewhat limited in scope in that section, was
sufficient because the entire opinion as a whole addressed the relevant medical and
non-medical evidence and was sufficient to justify the conclusions drawn.
Additionally, the ALJ was entitled to rely on the opinions of the state agency
physicians who determined that Jani did not meet or medically equal any of the
Listings for mental disorders.
Nevertheless, however, the Court does find that the ALJ erred when
conducting her RFC analysis. The ALJ does not mention SSR 15-1p at any point in
the opinion, but more importantly she does not appear to consider the impact of
Jani's IC symptoms with her other impairments; instead, the ALJ appears to
evaluate each symptom and impairment separately – specifically, the ALJ mentions
IC only in a few isolated sentences when reciting Jani's physical medical history.
(Dkt. 16-2 at 57, R. 56).
As a result, the Court is not confident that the ALJ considered the combined
effect of Jani's impairments, especially the interplay between her IC and pain with
her mental disorders of autism, anxiety, and depression. Without this consideration,
the Court is not positive that the ALJ's RFC analysis is adequate. It is not at all clear
what RFC limitations the ALJ assigned to address Jani's interstitial cystitis and its
wide-ranging effects, not least because the ALJ fails to even mention the condition
beyond stating that it was diagnosed or acknowledge the relevant SSR that should
guide her consideration of this issue. See Parker v. Astrue, 597 F.3d 920, 923 (7th Cir.
2010), as amended on reh'g in part (May 12, 2010) (an ALJ's failure to consider the
cumulative effect of impairments not totally disabling in themselves is error).
Without any such discussion or consideration, the Court is left without the
opportunity for meaningful review. See Carter v. Colvin, No. 4:12-CV-00075-RLY,
2013 WL 5303744, at *5 (S.D. Ind. Sept. 19, 2013). As such, this matter must be
remanded for further consideration of how Jani's interstitial cystitis impacts the
C. Opinion Evidence
Next, Jani argues that the ALJ's decision to find Ms. Julie Krasnow's medical
opinion unpersuasive was not supported by substantial evidence, and that the ALJ's
failure to even mention the treatment records of her long-time therapist, Ms. Nancy
Eisenman requires remand. (Dkt. 21 at 19-20). Plaintiff first argues that the ALJ
failed to adequately consider the opinion of her behavioral therapist, Ms. Julie
Krasnow. The ALJ's consideration of Ms. Krasnow's opinion 4 is as follows:
Julie Krasnow, LCSW, issued a medical opinion restricting the
claimant would be off-task for 25% of the workday and be absent
more than 4 days per month (Ex. 24F). The undersigned does not
find the Ms. Krasnow’s assessment is persuasive because the
limitations were not supported by the specific medical evidence
The Commissioner urges the Court to deem Ms. Krasnow's opinion non-medical and, thus, one that
the ALJ was not "required to discuss at all, let alone with any specificity." (Dkt. 22 at 16). However,
the ALJ deemed Ms. Krasnow's opinion a medical one, and the ALJ evaluated it as such – therefore,
the Commissioner's argument constitutes a post-hoc rationalization that the Court cannot consider.
See Pierce v. Colvin, 739 F.3d 1046, 1050 (7th Cir. 2014) (attempts to bolster ALJ's position with posthoc rationale are impermissible); Phillips v. Astrue, 413 F. App'x 878, 883 (7th Cir. 2010) ("We confine
our review to the reasons offered by the ALJ and will not consider post-hoc rationalizations that the
Commissioner provides to supplement the ALJ's assessment of the evidence.")
relied upon. The restrictions are also inconsistent with the
medical record, including the claimant’s presentation with a
normal mood and affect during treatment. (Ex. 19F/4, 7, 25F/3).
(Dkt. 16-2 at 58, R. 57). First, the Court notes that the ALJ failed to
acknowledge over half of the opinions provided in Ms. Krasnow's June 11, 2019
medical statement. For example, Ms. Krasnow indicated that Jani has moderate
limitations in interacting with others, marked limitations in understanding,
remembering, or applying information, and extreme limitations in concentrating,
persisting, or maintaining pace and adapting or managing oneself. (Dkt. 16-8 at 373,
R. 984). Ms. Krasnow also indicated that Jani has repeated episodes of
decompensation in work-like settings; a residual disease process such that even a
minimal increase in mental demands or change in environment would cause a
decompensation; a history of one or more years' inability to function outside a highly
supportive living arrangement. (Id. at 374, R. 985). Finally, Ms. Krasnow stated that
"Jani's diagnoses of depression, anxiety, and ADHD, as well as the pain she has, all
impact her executive functioning skills. These skills include, but are not limited to,
poor planning, difficulty switching focus, difficulty staying on task, time
management, organization, and remembering details." (Id.).
Instead, the ALJ provides two conclusory reasons for finding Ms. Krasnow's
opinion not persuasive: the opinion is not supported by the specific medical evidence
relied upon and is inconsistent with the medical record, including the claimant's
normal mood and affect at two medical visits. (Dkt. 16-2 at 58, R. 57). The ALJ never
actually explains how Ms. Krasnow's opinion is "not supported by the specific medical
evidence relied upon," or points to any inconsistencies between the record and the
opinion, apart from the two exams showing normal mood and affect. As Plaintiff
points out, however, those two medical visits were to Dr. Beam, her urologist, who
only treats Jani for interstitial cystitis and kidney stones. (Dkt. 16-8 at 53, 377, R.
664, 988). A review of the record, as outlined above, shows considerable support for
Ms. Krasnow's opinion, in her own treatment records, Plaintiff's subjective symptom
complaints, and the records of Jani's therapist, Ms. Nancy Eisenman. As discussed
infra, the ALJ never mentions Ms. Eisenman or evaluates her treatment records, and
provides no analysis of Ms. Krasnow's treatment records either. This omission is
particularly important in this case, because it appears neither of the state agency
reviewing physicians were in possession of Ms. Krasnow's records at the time they
rendered their opinions. (Dkt. 16-3 at 3-4, 16-20, R. 95-96, 108-112). Moreover, Ms.
Krasnow's medical records and her evaluations directly relate to Jani's repeated
assertions regarding the impact of her physical impairments on her mental
impairments, and vice versa, as discussed in the previous section. The ALJ may have
considered this evidence from Ms. Krasnow and deemed it unsupported, inconsistent,
and unpersuasive, but without any such discussion provided in ALJ's opinion, this
Court is not capable of undertaking any meaningful review.
As to Ms. Eisenman, the Court's review finds no mention of Ms. Eisenman, her
treatment records, or her medical statement in the ALJ's decision 5. Recognizing the
Since the ALJ remains silent on Ms. Eisenman, the Court does find that her status as a social worker
renders her a non-medical source whose opinion is not required to be considered by the ALJ. 20 C.F. R.
§ 416.920c(d). Nevertheless, given her long-standing treatment relationship with Jani and the fact
that her records and statement lend considerable support for Jani's subjective symptom allegations
ALJ was not required to consider Ms. Eisenmann's opinion, the Court notes that Ms.
Eisenman had weekly or bi-weekly visits with Jani for almost four years prior to the
hearing, and Jani specifically mentioned Ms. Eisenman at the hearing. (Dkt. 16-2 at
81-82, R. 80-81; Dkt. 16-8 at 235-381, R. 846-992). Ms. Eisenman provided the
following medical statement on December 12, 2017:
Jani has reported to me several physical limitations based on clinical
diagnoses from other medical professionals. I'm sure her medical
files from these other professionals are a part of her assessment as
well. While I do not diagnose formally, my diagnostic impression is
that Jani suffers from trauma (PTSD) from childhood, and it is my
understanding that another provider has given a formal diagnosis of
such. This trauma has had far-reaching effects on day to day living,
as has the chronic physical pain associated with other health
problems. Jani also struggles with anxiety, some depressive
symptoms, and other emotional problems (like being on the autistic
spectrum) that make it very difficult to engage in interpersonal
interactions and relationships.
While Jani has days every once in awhile where she can understand,
remember, and concentrate on things, functioning pretty well, she
cannot predict when they will be. She cannot predict when she will
be in too much pain to function normally throughout the day, when
she will be too fatigued to get out of bed; and by her report, those
days when she can are few and far between. There are times when
her self-care suffers because of the fatigue and pain associated with
her health concerns. Her lack of reliability on which days she will be
well enough to work, and the infrequency of those days, would make
it basically impossible to maintain a regular work schedule.
(Dkt. 16-7 at 304, R. 608). From the Court's review, Ms. Eisenman's statement
touches on the same issues that both Jani and Ms. Krasnow mention, namely the
interplay of Jani's mental disorders with the pain she experiences from her
interstitial cystitis and the unpredictability of her symptoms. It is not clear why the
and for Ms. Krasnow's opinion, all of which undermine the ALJ's assigned RFC limitations, the Court
finds that it was error for the ALJ to entirely ignore this highly pertinent evidence.
ALJ never addressed Ms. Eisenman's statement or her four year history of treating
Jani on a weekly or bi-weekly basis, but that statement and those records
undoubtedly constitute evidence that contradict the ALJ's conclusion. Because the
Court is remanding on another matter, the Undersigned encourages the ALJ to
evaluate Ms. Eisenman's records and statement on remand.
D. Subjective Symptom Analysis
Since the Court has already determined that the ALJ's consideration of SSR
15-1p and the RFC warrants remand, the Court will not address the Plaintiff's
argument that the ALJ erred during her 16-3p evaluation of Plaintiff's subjective
symptoms. On remand, the ALJ should give further consideration to the interplay
between Plaintiff's interstitial cystitis and her mental health complaints when
evaluating Plaintiff's subjective symptoms.
For the reasons detailed herein, the Court REVERSES the ALJ's decision
denying the Plaintiff benefits and REMANDS this matter for further proceedings.
Final judgment will issue accordingly.
All ECF-registered counsel of record via email.
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