UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF INDIANA 

KIRK W. STEPHENS, ) 

 ) 

 Plaintiff, ) 

 ) CAUSE NO. 1:15-CV-43 JVB 

 v. ) 

 ) 

CAROLYN W. COLVIN, ) 

Acting Commissioner of the ) 

Social Security Administration ) 

 ) 

 Defendant. ) 

OPINION AND ORDER 

 Plaintiff Kirk W. Stephens seeks judicial review of the Acting Social Security 

Commissioner’s decision denying him Supplemental Security Income (SSI) for the period from 

March 31, 2010, through March 17, 2013, and asks this Court to remand the case. For the 

reasons below, the Court affirms the decision of the Acting Commissioner. 

A. Overview of the Case 

 Plaintiff argues the Administrative Law Judge (ALJ) who denied him an SSI award (1) 

improperly evaluated Plaintiff’s obesity and failed to adequately develop the record, (2) 

improperly weighed relevant medical opinions, and (3) improperly evaluated Plaintiff’s 

combined limitations and resultant Residual Functional Capacity. 

 On May 22, 2008, Plaintiff first submitted an application for SSI under 42 U.S.C. § 1381, 

which was denied. Almost two years later, Plaintiff filed a new SSI application. This second 

application was denied, reconsidered, and denied again. After these repeated denials, Plaintiff 

requested a hearing, which took place before ALJ Yvonne K. Stam. Stam ultimately found the 
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Plaintiff not disabled. Plaintiff requested review of the ALJ’s decision from the Appeals Council, 

but the Council declined to do so. As a result, the denial of SSI became the Commissioner’s final 

decision. Plaintiff then appealed the decision to the District Court. The Court reversed the 

decision and remanded the case for further determinations regarding the ALJ’s findings of 

credibility; assessment of Plaintiff’s obesity; and consideration of Plaintiff’s heart disease, fecal 

incontinence, arthritis of the right ankle, and loss of fine-motor control in his right hand. 

 ALJ Maryann S. Bright received the case on remand and conducted a hearing where both 

Plaintiff and Robert S. Barkhaus, Ph.D., a vocational expert, testified. Because Plaintiff was 

found disabled beginning on March 18, 2013, by a favorable determination from a subsequent 

application for SSI, Bright’s disability determination only considered the period from March 31, 

2010, through March 17, 2013. Ultimately, Bright issued a decision denying Plaintiff’s 

application for SSI, which the Appeals Council declined to review. It is this decision which 

Plaintiff asks this Court to reverse. 

B. Standard of Review 

 This Court has authority to review the Commissioner’s decision under 42 U.S.C. 

§ 405(g). The Court must ensure that the ALJ has built an “accurate and logical bridge” from 

evidence to conclusion. Thomas v. Colvin, 745 F.3d 802, 806 (7th Cir. 2014). The Court will 

uphold decisions that apply the correct legal standard and are supported by substantial evidence. 

Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial evidence is 

“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 

Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). 
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C. Disability Standard 

The Commissioner follows a five-step inquiry in evaluating claims for disability benefits 

under the Social Security Act: 

(1) whether the claimant is currently employed; (2) whether the claimant has a 

severe impairment; (3) whether the claimant’s impairment is one that the 

Commissioner considers conclusively disabling; (4) if the claimant does not have 

a conclusively disabling impairment, whether he can perform his past relevant 

work; and (5) whether the claimant is capable of performing any work in the 

national economy. 

Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012). 

 The claimant bears the burden of proof at every step except step five. Clifford v. Apfel,

227 F.3d 863, 868 (7th Cir. 2000). 

D. Analysis 

 Plaintiff asks this Court to find error in the ALJ’s decision in three respects. First, 

Plaintiff argues the ALJ improperly evaluated Plaintiff’s obesity when determining the aggregate 

impact of Plaintiffs impairments. He also argues the ALJ failed to fulfill her duty to adequately 

develop the record. Secondly, Plaintiff argues the ALJ erred in failing to give a treating 

physician’s opinion controlling weight. Alternatively, Plaintiff argues that, regardless of whether 

the particular opinion is entitled to controlling weight, the ALJ erred in not weighing it in 

general. Third, Plaintiff argues the ALJ erred in not incorporating limitations from all medicallydeterminable impairments into Plaintiff’s Residual Functional Capacity and in not considering 

the combined impact thereof. 

(1) The ALJ’s evaluation of Plaintiff’s obesity 
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 The prior court’s remand order specifically stated that the prior ALJ did not give 

sufficient consideration to the aggravating effects of Plaintiff’s obesity. (R. at 818–19.) The ALJ 

here noted this and, in addition to discussing obesity periodically throughout her decision, 

dedicated a paragraph to addressing the District Court’s instruction. (See R. at 673.) There, the 

ALJ recognized that obesity can cause exacerbation of other limitations, but noted that Plaintiff’s 

doctors did not report any limitations specifically due to obesity. Id. From this, the ALJ 

concluded that the medical records include the effects of obesity “in the background” on 

Plaintiff’s other impairments. Id. The ALJ also noted that Plaintiff’s obesity enhanced the 

credibility of his statements of pain and resulted in deference to his report of limitations, 

resulting in a sedentary limitation and a sit/stand option specifically included in the ALJ’s 

findings of limitations. Id.

 The ALJ is required to consider an applicant’s disabilities in the aggregate. Martinez v. 

Astrue, 630 F.3d 693, 698–99 (7th Cir. 2001). As such, the ALJ must consider Plaintiff’s obesity 

and its bearing on other disabilities. See id. (“It is one thing to have a bad knee; it is another thing 

to have a bad knee supporting a body mass index in excess of 40.”). 

 The ALJ adequately considered Plaintiff’s obesity here, though. In addition to discussing 

Plaintiff’s obesity sporadically throughout her opinion, the ALJ dedicated the following 

paragraph specifically to the issue: 

The District Court found that the prior Administrative Law Judge did not give 

sufficient consideration to the aggravating effects of the claimant's obesity. The 

undersigned finds that obesity is in the background of all the treatment notes 

regarding musculoskeletal, cardiovascular, endocrine and respiratory 

impairments. The undersigned acknowledges that obesity can cause greater 

symptoms and limitations than the other diseases alone. However, the claimant’s 

doctors have not separately reported any limitations due to obesity. Thus, the 

undersigned must conclude that the medical records include the effects of obesity 

when the doctors report symptoms and findings on the other impairments. It is not 

appropriate for the Administrative Law Judge to speculate on any possible 
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additional functional effects of the claimant's obesity, except to concede that 

obesity does enhance the credibility of the claimant’s statements of pain. This is 

reflected in the deference to the claimant's report of limitations, as noted above, 

resulting in the sedentary limitation as well as the sit/stand option. 

(R. at 673.) With a body mass index of 39.1, it was reasonable for the ALJ to conclude 

consulting doctors would have noticed Plaintiff’s obesity. (See R. at 666.) (identifying Plaintiff’s 

BMI at 39.1, classified as Level II obesity under the clinical guidelines of the National Institutes 

of Health). Because the medical records did not specifically attribute limitations to Plaintiff’s 

obesity, the ALJ concluded that the doctors incorporated the aggravating effects of obesity in 

their reports. This conclusion draws a logical bridge between evidence and conclusion and is 

supported by substantial evidence. See Thomas v. Colvin, 745 F.3d 802, 806 (7th Cir. 2014) 

(“[W]e will uphold the ALJ’s decision so long as it is supported by ‘substantial evidence’ and the 

ALJ built an ‘accurate and logical bridge’ between the evidence and her conclusion.”). 

 Furthermore, contrary to Plaintiff’s argument, the ALJ was not required to independently 

retrieve medical examinations and records from Plaintiff’s doctors dealing specifically with the 

effects of obesity. See Skarbek v. Barnhart, 390 F.3d 500, 504 (7th Cir. 2004) (“An ALJ need 

recontact medical sources only when the evidence received is inadequate to determine whether 

the claimant is disabled.”). See also 20 C.F.R. § 404.1512(e). The ALJ had adequate evidence to 

determine Plaintiff was not disabled and thus was not required to develop the record further. 

(2) The ALJ’s weighing of Dr. Sanjay Jain’s opinion 

 The ALJ stated in her decision “there is no opinion from any treating source or 

examining source.” (R. at 672.) Accordingly, she gave no opinion controlling weight when 

making her determination. Plaintiff argues the ALJ failed to analyze Doctor Sanjay Jain’s 

opinion regarding Plaintiff’s sleep apnea and improperly failed to give the opinion the 
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controlling weight it deserved. The opinion Plaintiff claims the ALJ should have accorded 

controlling weight is the following statement from Doctor Jain: “He [the Plaintiff] should not 

drive if he has hypersomnolence.” Plaintiff Opening Br. 9–10 (quoting R. at 477.) Doctor Jain’s 

full statement is as follows: “It is recommended that the patient undergo repeat 

polysomnography with CPAP titration. He should not use over the counter sleeping medications, 

sedative-hypnotic agents or alcohol. He should not drive if he has hypersomnolence. Clinical 

correlation is required.” (R. at 477.) 

 The Administration must evaluate every medical opinion it receives regarding a 

claimant’s disability. 20 C.F.R. § 404.1527(c). It must also give an opinion from a treating 

medical provider “controlling weight” over opinions from non-treating sources if the opinion and 

treating relationship meet certain criteria. 20 C.F.R. § 404.1527(c)(2). Determining whether a 

medical opinion is entitled to controlling weight is often a complicated and difficult affair. See 

78 Fed. Reg. 41352, 41353–54 (July 10, 2013) (identifying erroneous application of the treating 

source rule as the basis for remand by the Appeals Council and federal courts at frequency rates 

of 10% and 35%, respectively). 

 Ultimately, however, it is not necessary to embark on the multi-stage analysis 

determining whether Dr. Jain’s “opinion” is entitled to controlling weight because it does not 

constitute an opinion. Controlling weight can only be given to medical opinions which meet the 

necessary criteria. See 20 C.F.R. § 404.1527(c)(2). Medical opinions are “statements from 

physicians and psychologists or other acceptable medical sources that reflect judgments about 

the nature and severity of [the claimant’s] impairment(s), including [the claimant’s] symptoms, 

diagnosis and prognosis, what [the claimant] can still do despite impairment(s), and [the 

claimant’s] physical or mental restrictions.” 20 C.F.R. § 404.1527(a)(2). 
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 The statement Plaintiff presents reflects no judgment about his impairments at all; it 

merely presents a conditional which could be applied to any person who might suffer from 

hypersomnolence. The statement does not even diagnose the Plaintiff with hypersomnolence. In 

effect, it merely asserts that those with hypersomnolence should not drive. This does not 

constitute a medical opinion about Plaintiff’s specific impairments and is therefore ineligible to 

be afforded controlling weight. 

(3) The ALJ’s incorporation and consideration of all combined limitations 

 Plaintiff argues the ALJ erred in failing to incorporate limitations from all medicallydeterminable impairments and from their combined impact into the Residual Functional Capacity 

(RFC) determination. Specifically, Plaintiff contends the ALJ failed to incorporate into the RFC 

Plaintiff’s (1) frequent urination, (2) coronary artery disease, (3) balance, and (4) upper 

extremities. 

 An ALJ is tasked with determining a claimant’s RFC—the most the claimant can still do 

despite his limitations. 20 C.F.R. 404.1545(a). In determining a claimant’s RFC, the ALJ must 

consider all medically-determinable impairments, including those which are not severe. Id. The 

claimant’s RFC must be assessed based on all relevant evidence in the record. Id. 

(a) Frequent urination 

 At a hearing on September 16, 2011, Plaintiff testified that he requires bathroom breaks 

every hour or two, and has accidents two to three times per week. (R. at 44–45.) At the same 

hearing, a vocational expert also testified that most employees in Plaintiff’s prior work are 

allowed two fifteen-minute breaks with one half-hour lunch break per day, with two to three 
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additional breaks per week of a five- to fifteen-minute duration. (R. at 56–57.) It is on the basis 

of this testimony which Plaintiff asks this Court to find the ALJ neglected to incorporate 

Plaintiff’s frequent urination into the RFC determination. This testimony was not, however, the 

only evidence in the record relevant to Plaintiff’s urinary problems. For example, a July 14, 

2011, record from Plaintiff’s urologist stated his “urgency and incontinence has resolved.” (R. at 

507.) Urologist records from 2012 and 2013 also fail to even mention frequent urination as a 

problem. (R. at 1115–24.) With respect to Plaintiff’s urination, the ALJ’s RFC determination is 

supported by substantial evidence. 

(b) Coronary artery disease 

 Plaintiff argues the ALJ did not consider his aspirin regimen into her RFC determination, 

thereby failing to incorporate an increased risk of bleeding. Plaintiff Br. at 12, (No. 20-17). Yet 

Plaintiff does not point to any medical records which indicate this apparent risk of bleeding. Id.

Nor do any appear in the record. The ALJ is only required to consider impairments which are 

asserted or about which the ALJ has evidence. 20 C.F.R. 404.1512(a). Furthermore, a social 

security claimant bears the burden of supplying evidence to prove his claim of disability. 

Bibaudo v. Barnhart, 458 F.3d 580, 583 (7th Cir. 2006). Moreover, in an appeal before a 

reviewing court, the plaintiff bears the burden of showing the Commissioner’s decision was not 

based on substantial evidence. McLaurin v. Colvin, 121 F. Supp. 3d 134, 139 (D.D.C. 2015); 

Charles v. Astrue, 854 F. Supp. 2d 22, 27–28 (D.D.C. 2012); Lane-Rauth v. Barnhart, 437 F. 

Supp. 2d 63, 64 (D.D.C. 2006). Plaintiff cites to no medical evidence in the record indicating a 

bleeding risk. Plaintiff Br. at 12, (No. 20-17). Instead, he requests remand for failure of the ALJ 

to independently diagnose him with a bleeding risk due to the possible effects of aspirin and for 
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failure to incorporate that diagnosis into the RFC determination. Extrapolating the potential risks 

of a medication taken by a claimant into a diagnosis of specific risks faced by a particular 

claimant is not within the ALJ’s authority, nor within the authority of this Court. Without at least 

a claim of a bleeding risk before the ALJ, and no medical evidence in support of said risk 

contained within the record, the ALJ could not have erred in failing to consider it. See 20 C.F.R. 

404.1512(a) (“We will consider only impairment(s) you say you have or about which we receive 

evidence”). See also Nelms v. Astrue, 553 F.3d 1093, 1097 (7th Cir. 2009) (reiterating that 

judicial review of an ALJ’s decision is limited to determining whether she applied the correct 

legal standards and whether there is substantial evidence to support the findings). 

(c) Balance 

 Plaintiff claims “[t]he ALJ included a frequent balancing limitation in the RFC.” Plaintiff 

Br. at 12, (No. 20-17). He takes issue with this, asserting that “[t]he facts lean overwhelmingly 

toward an occasional or less balancing limitation.” Id. at 13, (No. 20-17). It is unclear, however, 

where Plaintiff finds this frequent balancing limitation. The RFC determination contained within 

the decision on review provides that Plaintiff “can occasionally . . . balance.” (R. at 667.) Even 

the decision by the prior ALJ contained an occasional—not frequent—balancing limitation. (R. 

at 19.) Plaintiff’s own brief asserts the facts “lean overwhelmingly” in favor of an occasional 

balancing limitation. Plaintiff Br. at 13, (No 20-18). Without some additional explanation or 

citation, which Plaintiff does not provide in his Reply brief, the Court must conclude he has 

conceded the ALJ’s occasional balancing limitation is supported by substantial evidence. 

(d) Upper extremities 
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 Finally, Plaintiff asserts the ALJ’s failure to include manipulative limitations in her RFC 

determination for problems associated with his hands and shoulders is unsupported by substantial 

evidence. When determining the RFC, the ALJ must consider all medically determinable 

impairments, even those not considered “severe.” 20 C.F.R. 404.1545(a). 

 The ALJ determined the Plaintiff’s impairments to his left hand did not necessitate more 

restrictive limitations than “lift, carry, push and pull up to 10 pounds occasionally” and “never 

climb ladders, ropes or scaffolds.” (R. at 667.) Furthermore, she did not include limitations for 

Plaintiff’s right hand and shoulders because she found no medically determinable impairments in 

those joints. (R. at 664–66.) Despite Plaintiff’s citations to medical records which may support 

mild limitations, there is substantial evidence in the record to support the ALJ’s determination. 

See id. She drew a logical bridge between the evidence and her conclusions. Plaintiff may 

disagree with the ALJ’s decision not to include a specific limitation on “reaching, handling and 

fingering.” That does not mean, however, that the ALJ failed to account for Plaintiff’s 

limitations, nor does it mean her RFC determination is unsupported by substantial evidence. 

E. Conclusion 

 For the reasons stated above, the Court affirms the decision of the Acting Commissioner. 

 SO ORDERED on September 27, 2016. 

 s/ Joseph S. Van Bokkelen 

 JOSEPH S. VAN BOKKELEN 

 UNITED STATES DISTRICT JUDGE