UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

SOUTH BEND DIVISION

KASANDRA JO JORDAN, ) 

)

Plaintiff, )

) 

v. ) CAUSE NO. 3:13-CV-236-CAN 

) 

CAROLYN W. COLVIN, ) 

Acting Commissioner of Social Security, ) 

 ) 

Defendant. )

OPINION AND ORDER

On March 28, 2013 Plaintiff Kasandra Jo Jordan, (“Jordan”) filed her Complaint against

Defendant, Carolyn W. Colvin, Acting Commissioner of the Social Security Administration

(“the Commissioner”), seeking judicial review of the Commissioner’s final decision denying

Jordan Social Security Disability Insurance Benefits (“DIB”) and Supplemental Security Income

(“SSI”). On July 16, 2013, Jordan filed her opening brief requesting reversal or remand of the

Commissioner’s decision. On December 2, 2013, the Commissioner responded asking the Court

to affirm her final decision on Jordan’s disability benefits application. Jordan filed a reply brief

on December 12, 2013. This Court may enter a ruling on this matter based on the parties’

consent, 28 U.S.C. § 636(c) and 42 U.S.C. §§ 405(g).

I. PROCEDURE

On April 29, 2010, Jordan applied for DIB and SSI alleging disability due to Crohn’s

disease, depression, and cervical spin degeneration and stenosis with an alleged onset date of

May 16, 2007. Her claims were initially denied on August 12, 2010, and were denied again on

reconsideration on January 3, 2011. Jordan appeared before an administrative law judge

(“ALJ”) on November 21, 2011, for a hearing. 
On December 2, 2011, the ALJ issued a decision holding that Jordan was not disabled

and therefore not entitled to SSI or DIB. On February 2, 2012, the Appeals Council denied

Jordan’s request for review of the ALJ’s decision rendering the ALJ’s decision the final decision

of the Commissioner. See 20 C.F.R. §404.981, 416.1481.1

 Jordan now seeks review of the

Commissioner’s decision in this Court pursuant to 42 U.S.C. § 405(g). 

II. ANALYSIS

A. Facts

Jordan was 37 years old at the time of her hearing before the ALJ. She completed high

school and attended college until she was a sophomore. Jordan is divorced and lives with her

mother and her 17-year old daughter. Jordan testified that she had not worked since her alleged

onset date of May 16, 2007. She had discontinued her work due to an auto accident. Jordan

performed past relevant work as an Inventory Clerk, Retail Department Manager, Teller, and

Customer Service Representative. Jordan began her last job in January 2007 working at Kroger

in the meat department where she was responsible for inventory, management and ordering, and

stocking. When she started the job, Jordan was able to lift and carry approximately 50 pounds or

more of meat for at least eight hours a day while standing/walking the entire period. However,

after the auto accident in May 2007, Jordan had to quit her job at Kroger after only working

there for approximately five months.

B. Medical Background

1. Back, Neck, and Abdominal Pain

1 The regulations governing DIB are found at 20 C.F.R. Part 404. The SSI regulations are substantially

identical to the DIB regulations and are set forth at 20 C.F.R. Part 416. For convenience, only the DIB regulations

will be cited henceforth in this opinion.

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In December 2007, Jordan began seeing Steven Posar, M.D., a pain management

specialist, for the treatment of her neck, shoulder, and low back pain. Dr. Posar’s initial tests in

early 2008 showed changes in her cervical spine as well as disc bulging. By the end of 2008,

Jordan’s pain had gotten better even though her mobility was “not very good”. Doc. No. 8 at

429. To alleviate the pain and other effects, Jordan received a series of epidural steroid

injections from Dr. Ralph Carbone over about fifteen months. While receiving the injections,

Jordan continued to see Dr. Posar. Dr. Posar noted no major changes even after Jordan was

involved in a second car accident in April 2009. 

In June 2009, Jordan was hospitalized for five days due to abdominal pain, vomiting, and

diarrhea. A History and Physical form, completed by Dr. John Taylor during Jordan’s

hospitalization, indicated that Jordan’s neck pain was controlled with medication and that her

physical exam showed no spinal tenderness. The cause of the abdominal pain was not confirmed

at that time. In September 2009, Jordan was hospitalized again for a diagnostic laparoscopy for

pelvic endometriosis with no complications.

In October 2009, Jordan returned to Dr. Posar for further treatment of neck and back

pain. Physical examination revealed that there was no distress and that Jordan had a normal gait

and station. Dr. Posar noted that Jordan had moderated neck stiffness, but did have full range of

motion without pain. Additionally, he noted full motor strength and made no mention of any

radicular symptoms.

In March 2010, an MRI revealed that Jordan had a broad posterior disk osteophyte

complex in her cervical spine. Based on this diagnosis, Jordan began physical therapy in May

2010. Jordan complained that the physical therapy caused her headaches, but an MRI revealed

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no problems with her brain. In June 2010, however, Jordan was discharged from physical

therapy after failing to meet long-term goals after she cancelled or “no-showed” three straight

sessions.

In July 2010, consultative examiner Dr. Peter Sices examined and evaluated Jordan as

part of her disability benefits application. Dr. Sices noted that Jordan had a normal gait and walk

with some limitations in her range of motion. Furthermore, Dr. Sices noted no joint swelling or

synovitis and that Jordan was able to get on and off the exam table without difficulty. Dr. Sices

concluded after the exam that Jordan had no impairment as to gait, coordination, vision, hearing,

speech, memory, concentration, attention span, or fine and gross manual dexterity.

During the late part of July 2010, Jordan was evaluated by physical therapist Kristy

Showley to determine if more physical therapy was appropriate. Jordan told Showley that she

was not driving at that time, had headaches/migraines, was unable to do light housework,

experienced pain when watching her daughter play sports, and was unable to lay in supine

position. Showley noted that Jordan had a positive Waddell’s sign,2

 and noted contradictions,

such as Jordan’s ability to fix her hair without demonstrating any deficits despite her claims of

excessive pain. Showley provided for a “precautionary” two-pound weight restriction, which

does not appear to have been reinforced by a doctor’s diagnosis. In August 2010, Dr. Posar

noted that Jordan’s second round of physical therapy had been discontinued because she made

no functional improvement. After the therapy ended, Jordan continued to see Dr. Posar for her

primary care mainly dealing with abdominal pain and neck pain, which was manageable with

pain relievers.

2 Positive Waddell’s signs may indicate a non-organic or psychological component to complaints of pain. See

https://www.mls-ime.com/articles/GeneralTopics/Waddell%20Signs.html

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2. Crohn’s Disease

During Jordan’s June 2010 emergency treatment for abdominal pain, a CT scan revealed

signs that Jordan may have Crohn’s disease. In August 2010, Dr. Eugene Lyubashevky, a

gastroenterologist, diagnosed her with irritable bowel syndrome with spastic colon. In February

2011, Jordan returned to the emergency department with pelvic/abdominal pain. During this

visit, Jordan was formally diagnosed with Crohn’s disease. On March 16, 2011, Jordan visited

her local emergency department again with abdominal pain, bloating, nausea, and vomiting. She

was then transferred to St. Vincent’s Hospital, where a CT scan revealed progression of the

Crohn’s disease with 15-20 cm of terminal ileal involvement.

After March 2011, Jordan received most of her primary care from Beth Taylor, a nurse

practitioner. In June 2011, Jordan underwent a colonoscopy, which showed a tortuous colon. In

August 2011, Ms. Taylor noted that Jordan was eating better. Ms. Taylor’s progress notes

indicate that Jordan had an exacerbation of her Crohn’s disease in October and November of

2011, as evidenced by diagnostic imaging. However, Jordan gained weight during this same

time period despite having issues with nausea, diarrhea, and progression of the Crohn’s disease. 

In June 2011, Jordan also saw Dr. Charles Heinsen as her treating physician for various

conditions and for a Medical Source Statement related to disability benefits application.

According to Dr. Heinsen, Jordan’s Crohn’s disease could cause her to have twenty to thirty

loose stools per day. He also noted that Jordan’s anxiety and depression affected her pain and

could interfere with her attention and concentration. Dr. Heinsen, along with Ms. Taylor,

restricted Jordan to sitting no more than two hours and standing and walking about one hour

during an eight-hour workday. Dr. Heinsen opined that both of Jordan’s legs required elevation

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to waist level for two hours during an eight-hour work day. Dr. Heinsen reported that Jordan

would need to lie down or recline in a supine position for thirty-minute period after standing or

walking. Dr. Heinsen opined that Jordan needed five hours of rest during each eight-hour

workday. As for a weight restriction, Dr. Heinsen stated that Jordan could occasionally lift up to

twenty pounds but never lift anything above twenty-one pounds. He said she could occasionally

balance, stoop, look down, and look sideways and was limited to occasional use of her hands.

Both Dr. Heinsen and Ms. Taylor thought that Jordan’s impairments would prevent her from

maintaining any type of employment.

3. Mental Conditions

In July 2010, Jordan saw Alan Wax, Ph.D, a psychological consultative examiner,

complaining of anxiety and depression. Jordan reported a wide range of symptoms and feelings

for which she had been prescribed various medications over the years. Jordan told Dr. Wax that

some of these medications had caused her adverse side effects. After examining Jordan, Dr.

Wax diagnosed major depressive disorder and panic disorder and assigned a Global Assessment

of Functioning (“GAF”) score of 52.3

 Dr. Wax also noted that Jordan’s cognitive functioning

appeared to be in the average range and that Jordan is independent in self-care, but does lack

motivation at times. 

State agency psychological consultants, Benetta Johnson, Ph.D, and Kenneth Neville,

Ph.D., also reviewed Jordan’s record, including the medical evidence submitted in her file

through the reconsideration level of her disability benefits application process. The consultants

3 Physicians assign GAF scores that reflect an individual’s overall level of social, occupational, and

psychological functioning. See American Psychological Association, Diagnostic and Statistical Manual of Mental

Disorders 32 (4th ed. 2000). A GAF score of 51-60 indicates that a person suffers from moderate symptoms or

moderate difficulty in social, occupational, or school functioning. Id. at 34. 

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found that Jordan had mild restrictions in activities of daily living, mild difficulties in

maintaining social functioning, mild difficulties in maintaining concentration, persistence, or

pace, and no episodes of decompensation.

C. Claimant’s Testimony

At the hearing, Jordan testified as to her conditions, treatment history, and work history.

Jordan stated that she has been unable to work since May 16, 2007, when she flipped the vehicle

that she was driving and sustained injury to her neck, foot, and back. Jordan also discussed her

Crohn’s disease explaining that it contributed to her inability to work. Jordan stated that she has

neck and back pain daily, but “on a good day it is managed by medication, at times.” Doc. No. 8

at 59. Jordan had hoped to undergo surgery to alleviate this pain, but the surgery was precluded

by the discovery of her Crohn’s disease. Jordan testified that the Crohn’s disease causes her

abdominal pain of varying intensity for which she has had inconsistent results in trying to

control. Jordan described her Crohn’s as “insufferable” especially on days when it flares up. 

When the ALJ asked Jordan about activities that aggravate her conditions, she noted long

periods of time on her feet, lifting and moving objects over a certain weight, extreme

movements, and pushing and pulling. Jordan also said that sitting in certain positions caused her

more pain. For instance, she explained that sitting at a desk looking at a computer screen could

increase her neck pain. As to her Crohn’s disease, Jordan stated that she has daily pain and that

she is on a special diet to help control the condition. Jordan also explained that she suffers from

diarrhea every day requiring her to use the bathroom from seven to fifteen times a day. On flareup days, Jordan said that she can be in the bathroom twenty to twenty-five times. Despite her

diet and medications, Jordan finds her condition to be uncontrollable on some days.

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As for Jordan’s mental conditions, Jordan stated that she takes medication for her anxiety

and depression. Jordan explained that she does not currently see a therapist or psychiatrist and

relies on her family doctor to prescribe her medications. 

Jordan testified that she believes she might be able to lift five pounds, but would be

unable to repeat this too often as it would cause neck pain. Furthermore, Jordan testified that on

a good day that she may be able to walk for half an hour at a time and stand in one position for

roughly five to ten minutes. Depending on her position, her ability to sit would vary. For

example, she said she could sit in a chair upright for twenty minutes. However, if she was in

more of a reclined position, she could sit longer. 

Jordan mentioned that she could stoop, squat, and generally manipulate things in her

hands. However, Jordan admitted that her conditions cause some things to slip through her

fingers at times. As for her daily activities, Jordan indicated that she lays down every day for at

least two hours. Jordan admitted that she is independent in personal care tasks, walks outside in

her yard, prepares meals for herself and her daughter, and washes dishes and laundry, as well as

completing other small chores around the house. Jordan testified that she is also able to go out

on her own and drive. Jordan said that she tries to attend her daughter’s athletic events, but has

difficulty sitting in the bleachers for different reasons. Jordan also reported that she maintains

her personal relationships by telephone and social networking websites.

When questioned by her attorney at the hearing, Jordan indicated that her weight

fluctuates as much as ten pounds in a week, due to her conditions. Jordan also mentioned that on

her “bad” days, she spends a lot of time in bed. During “flare-ups,” she noted that she has been

hospitalized. 

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D. Standard of review

The Social Security Act authorizes judicial review of decisions of the agency. The court

will uphold the decision of the agency as long as the ALJ’s decision is supported by substantial

evidence and free of legal error. 42 U.S.C § 405(g); Briscoe v. Barnhart, 425 F.3d 345, 351 (7th

Cir. 2005). Substantial evidence is more than a scintilla and includes evidence that a reasonable

mind might accept to support such a conclusion. Richardson v. Perales, 402 U.S. 389, 401

(1972). A reviewing court is not to substitute its own opinion for that of the ALJ’s or to reweigh the evidence. Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005). An ALJ decision

cannot stand if it lacks evidentiary support or an adequate discussion of the issues. Lopez v.

Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). If an error of law is committed by the

Commissioner, then the “court must reverse the decision regardless of the volume of the

evidence supporting the factual findings.” Binion v. Chater, 108 F.3d 780,782 (7th Cir. 1997).

The Social Security regulations prescribe a sequential five-part test for determining

whether a claimant is disabled. The ALJ must consider whether: (1) the claimant is presently

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 RFC leaves him unable to

perform his past relevant work; and (5) whether the claimant can perform other work in the

national economy given the claimant’s RFC, age, education, and experience. Briscoe, 425 F.3d

at 352; 20 C.F.R. § 404.1520(a)(4)(i)–(v). If the ALJ can find that the claimant is not disabled at

any step, he does not go on to the next step. 20 C.F.R. § 404.1520(a)(4).

In his decision, an ALJ must, at a minimum, provide the rationale for his decision or

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otherwise provide analysis of the evidence in order to allow the reviewing court to trace the path

of his reasoning and to be assured that he considered the important evidence. Scott v. Barnhart,

297 F.3d 589, 595 (7th Cir. 2002). The ALJ is not however required to address “every piece of

evidence or testimony in the record,” but rather provide some insight into the reasoning behind

the decision to deny benefits. Zurawski v. Halter, 245 F.3d 881, 888 (7th Cir. 2001). The ALJ

must build an “accurate and logical bridge from the agency’s ultimate findings and afford a

claimant meaningful judicial review.” Young, 362 F.3d at 1002.

E. Issues for Review

In this case, Jordan raises four issues for review. First, Jordan alleges that the ALJ

improperly determined that Jordan’s anxiety and depression were not severe at Step Two of the

disability analysis. Second, Jordan challenges the ALJ’s RFC determination arguing that (1) the

ALJ improperly failed to give controlling weight to the opinion of her treating physician, Dr.

Charles Heinsen; and (2) the ALJ failed to evaluate her credibility properly. And lastly, Jordan

asserts that the ALJ’s Step Five finding was not supported by substantial evidence. 

1. The ALJ’s Severity Determination

At Step Two of the Social Security disability determination, an impairment is “severe” if

it is one that significantly limits a person’s physical or mental ability to do basic work activities.

20 C.F.R. § 404.1521(a)–(b). An impairment is not severe when medical and other evidence

show only a slight abnormality with no more than a minimal effect on the claimant’s ability to

work. SSR 96-4p; 96-3p; 85-28. In evaluating the severity of mental health impairments, the

ALJ must use a technique whereby he first evaluates “pertinent symptoms, signs, and laboratory

findings” to determine whether the claimant has a medically determinable mental impairment. 

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20 C.F.R. § 404.1520a(b)(1). If the claimant has a medically determinable mental impairment,

then the ALJ must document that finding and rate the degree of the claimant’s functional

limitations in activities of daily living; social functioning; concentration, persistence, or pace;

and episodes of decompensation, 20 C.F.R. § 404.1520a(c)(3). Activities of daily living, social

functioning, and concentration, persistence, or pace are rated on a five-point scale of none, mild,

moderate, marked, and extreme. 20 C.F.R. § 404.1520a(c)(4). Episodes of decompensation are

rated on a four-point scale of none, one or two, three, and four or more. Id. If the ALJ rates the

first three functional areas as none or mild and the fourth area as none, then generally the

impairment is not considered severe. 20 C.F.R. § 404.1520a(d)(1). Otherwise, the impairment

is considered severe, and the ALJ must conduct the Step Three analysis and determine whether

the severe impairment meets or equals a listed mental disorder. 20 C.F.R. § 404.1520a(d)(2). If

the severe mental impairment does not meet or equal any listing, then the ALJ will assess the

claimant’s RFC. 20 C.F.R. § 404.1520a(d)(3).

In his opinion, the ALJ must incorporate the pertinent findings and conclusions used to

support his severity decision. 20 C.F.R. § 404.1520a(e)(2). The ALJ must identify any

significant medical history, including examination and laboratory findings, and the functional

limitations that were considered in reaching a conclusion about the severity of the claimant’s

mental impairment. The decision must also incorporate “a specific finding as to the degree of

limitation in each of the functional areas.” Id.

In this case, Jordan contends that the ALJ should have determined that her anxiety and

depression were severe impairments. Furthermore, Jordan contends that remand is necessary

because the ALJ failed to consider all of the relevant evidence that may have affected the Step

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Three analysis and the RFC determination at Step Four. Specifically, Jordan challenges the

ALJ’s alleged rejection of Dr. Wax’s diagnosis of Major Depressive Disorder, Panic Disorder

NOS, and a GAF of 52. Jordan also claims that the ALJ improperly discounted Dr. Sices’

notation that Jordan was emotionally fragile and that she was taking prescription medications for

her mental impairments. 

Despite Jordan’s allegations to the contrary, however, the ALJ did consider Dr. Wax’s

diagnoses and assessment as evidenced by his discussion of inconsistencies in the evidence,

which caused the ALJ to give less weight to Dr. Wax’s opinion. For example, the ALJ

highlighted Dr. Wax’s comment that Jordan was “independent in all aspects of self-care” with no

significant cognitive deficits, which conflicted with the GAF score of 52 that Dr. Wax assigned

to Jordan indicating moderate impairment in social, occupational, or school functioning. 

Notably, Dr. Wax’s comments also conflicted with the findings of the State agency

psychologists, Drs. Johnson and Neville, who noted that Jordan only had mild restrictions in

daily living; social functioning; and concentration, persistence, or pace with no episodes of

decompensation. Such results do not support a finding of a severe mental impairment. See 20

C.F.R. § 404.1520a(d)(1).

Moreover, the ALJ also considered Jordan’s concession that she had no ongoing treating

relationship with any therapist or counselor. The ALJ also specifically noted that Jordan’s only

mental health treatment included the medication that she received from her primary care doctor.

As a result, the Court is not persuaded that the ALJ disregarded Dr. Wax’s opinion and Jordan’s 

medication regimen as Jordan alleges. In fact, the ALJ analyzed and thoroughly explained his

decision that Jordan’s anxiety and depression did not constitute severe impairments. Therefore,

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the ALJ supported his severity determination with substantial evidence such that his severity

determination must be affirmed. 

2. The ALJ’s RFC Determination 

Having determined that Jordan’s degenerative changes of the cervical spine and Crohn’s

disease constituted severe impairments that did not meet or equal a Listing, the ALJ proceeded to

assess Jordan’s RFC. An RFC is “an administrative assessment of what work-related activities

an individual can perform despite her limitation.” Dixon v. Massanari, 270 F.3d 1171, 1178 (7th

Cir. 2001). In making an RFC determination, the ALJ must determine and articulate the weight

applied to each medical opinion. SSR 96-8p. A treating physician’s medical opinion is entitled

to controlling weight if it is well supported by objective medical evidence and is consistent with

other substantial evidence in the record. Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013);

Skarbek v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004); 20 C.F.R. § 404.1527(c)(2). However,

the ALJ is not required to give the treating opinion controlling weight. If the ALJ rejects a

treating physician’s opinion or accepts an alternate opinion, he must provide a sound 

explanation for his decision. Jelinek v. Astrue, 662 F.3d 805, 811 (7th Cir. 2011); 20 C.F.R. §

404.1527(c)(2). Even so, the ALJ is not required to detail every reason for discounting a treating

physician’s report. Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008).

In addition, the ALJ must consider the following factors, identified in the Social Security

regulations, when assigning a weight to any medical opinion: (1) the length, nature, and extent

of the physician’s treatment relationship with the claimant; (2) whether the physician’s opinions

were sufficiently supported; (3) how consistent the opinion is with the record as a whole; (4)

whether the physician specializes in the medical conditions at issue; and (5) other relevant

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factors that tend to support or contradict the opinion. 20 C.F.R. §§ 404.1527(c)(2)(I)-(ii),

(c)(3)–(6); see also Elder, 529 F.3d at 415; Clifford, 227 F.3d at 871. “If the ALJ discounts the

[treating] physician’s opinion after considering these factors, [the court] must allow that decision

to stand . . . .” Elder, 529 F.3d at 415 (quoting Berger v. Astrue, 516 F.3d 539, 545 (7th Cir.

2008)). Alternatively, remand may be appropriate if the ALJ discounts a treating physician’s

opinion without considering these regulatory factors. See Larson v. Astrue, 615 F.3d 744, 751

(7th Cir. 2010).

In this case, the ALJ found that Jordan retained the RFC to perform a limited range of

light work as defined in 20 C.F.R. § 404.1567(b), including lifting and/or carrying up to twenty

pounds occasionally and up to ten pounds frequently and standing and/or walking for about six

hours and sitting for about six hours in an eight-hour workday, except that Jordan can frequently

balance, stoop, kneel, crouch, crawl, and climb ramps or stairs but must never climb ladders,

ropes, or scaffolds. In reaching that conclusion, the ALJ considered objective medical evidence,

including but not limited to, doctors’ testimony, Jordan’s own testimony, and other medical

evidence that was provided. The ALJ’s opinion shows that he did not rely upon any one medical

report or doctor. Rather, this ALJ’s opinion reflects his consideration of multiple medical

opinions and evidence. Jordan contends that even though the ALJ considered the opinion of

Jordan’s treating physician, Dr. Heinsen, he erred by not assigning controlling weight to Dr.

Heinsen’s opinion.

In his medical source statement prepared on June 20, 2011, and discussed in the Facts

section above, Dr. Heinsen described in detail the effects of Jordan’s impairments and opined

that her symptoms affected her quality of life such that she could not maintain any type of

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employment. Dr. Heinsen’s statement noted extreme limitations to the tasks Jordan would be

able to perform. Despite Dr. Heinsen’s familiarity with Jordan’s medical issues over time,

including reports from other doctors and hospitals about her ongoing medical treatment, the ALJ

acknowledged Dr. Heinsen’s opinion but noted that he could “find no support for these

limitations in the record.” Doc. No. 8 at 33. In discounting Dr. Heinsen’s opinion, the ALJ also

referenced conflicts between Dr. Heinsen’s opinion and Jordan’s own testimony that she could

still perform a wide range of activities of daily living and that her neck pain was largely

manageable. Id. The ALJ also noted that none of Jordan’s other treating or examining

physicians assigned functional limitations based on her impairments that would be consistent

with the extreme limitations set forth by Dr. Heinsen. Id. 

In particular, the ALJ relied upon the opinions of consultative examiner Dr. Peter Sices

and non-examining state agency physicians Dr. D. Neal and Dr. J. Sands. Jordan challenges the

ALJ’s reliance on these opinions alleging first that the ALJ failed to cite to key parts of Dr.

Sices’ opinion that could be consistent with Dr. Heinsen’s opinion. For instance, Dr. Sices

acknowledged that his examination of Jordan was brief such that he could not evaluate the

effects of prolonged activity on her ability to work. In addition, Jordan highlights Dr. Sices’

notations that Jordan was emotionally fragile, that her prognosis for improvement was good, and

that he had no opinion about the severity or effects of her Crohn’s disease. 

Second, Jordan contends that all three doctors’ opinions were based only on partial

medical information. Dr. Sices examined Jordan on July 22, 2010; Dr. Neal’s and Dr. Sands’

opinions were dated August 11, 2010, and December 27, 2010. Jordan notably underwent

additional treatment, including physical therapy, office visits, medical testing, and

15
hospitalizations after the state agency doctors rendered their opinions. 

Of greatest concern to the Court is the ALJ’s statement that Jordan “has not sought

emergency treatment for abdominal pain since receiving a diagnosis of Crohn’s disease” in

February 2011. Id. Based on this statement and the rest of the ALJ’s opinion, the Court finds no

evidence to suggest that the ALJ considered Jordan’s eight or nine-day hospitalization for

symptoms related to her Crohn’s disease that began with a trip to Starke County Emergency

Department on March 16, 2011.4 See Doc. No. 8 at 625–36. As a result, the Court is not

convinced that the ALJ considered all the objective medical evidence when assessing Jordan’s

RFC. In light of this gap in the ALJ’s logical bridge, remand is appropriate for further

consideration of Jordan’s RFC. 

The Court refuses to reach any conclusion about the effect full consideration of all the

evidence should have on the Commissioner’s ultimate determination on remand. However, the

Court recognizes that consideration of all the objective medical evidence could cause the ALJ to

reach a different conclusion about the consistency of Dr. Heinsen’s opinion with other evidence

in Jordan’s record, the need to re-contact Dr. Heinsen or any other medical source to gather

additional evidence, and ultimately Jordan’s disabled status and her eligibility for disability

benefits. Therefore, any decision related to Jordan’s remaining arguments would be premature.

Similarly, because the Court is remanding the Commissioner’s decision for further consideration

of Jordan’s RFC, the Court need not address Jordan’s arguments about the ALJ’s credibility

determination and his Step Four and Five analysis because those determinations will all be

4 Jordan also directs the Court to Jordan’s hospitalization records dated December 12, 2011, through

December 16, 2011 at Pulaski Memorial Hospital for treatment of Crohn’s disease. Because the ALJ’s opinion was

issued on December 2, 2011, he could not have had access to the December 2011 records Jordan cites. Therefore,

they cannot be considered here.

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dependent upon the new RFC determination.

III. CONCLUSION

For the reasons stated above, the Court concludes that the ALJ’s decision is not

supported by substantial evidence. Therefore, this case is REMANDED to the Commissioner

pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this

opinion. 

SO ORDERED.

Dated this 6th Day of June, 2014.

S/Christopher A. Nuechterlein

Christopher A. Nuechterlein

United States Magistrate Judge

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