UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

HAMMOND DIVISION

DONNA BEAVER, )

Plaintiff, )

)

 v. ) CAUSE NO.: 2:13-cv-269-JEM

)

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security, )

Defendant. )

OPINION AND ORDER

This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Donna Beaver on

August 2, 2013, and an Opening Brief of Plaintiff in Social Security Appeal Pursuant to L.R. 7.3

[DE 15], filed by Plaintiff on January 2, 2014. Plaintiff requests that the decision of the

Administrative Law Judge denying her benefits on March 23, 2012, be remanded. For the reasons

set forth below, the Court grants Plaintiff’s request for reversal and remands this case for further

proceedings.

PROCEDURAL BACKGROUND

On July 2, 2010, Plaintiff filed an application for disability insurance benefits (DIB) and

Supplemental Security Income (SSI) with the U.S. Social Security Administration (SSA) alleging

that she became disabled on July 28, 2008, due to chronic obstructive pulmonary disease (COPD),

lupus, Sjögrens syndrome, asthma, chronic muscle/joint pain, fatigue, pleural effusion in her left

lung, depression, and anxiety. Plaintiff’s application was denied initially and upon reconsideration. 

On February 21, 2012, Administrative Law Judge (ALJ) Henry Kramzyk held a hearing at which

Plaintiff, with an attorney representative, and a vocational expert (VE) testified. Following the

hearing, the ALJ concluded that Plaintiff was not disabled. The ALJ made the following findings

under the required five-step analysis: 
1. The claimant meets the insured status requirements of the Social Security Act

though December 31, 2013. 

2. The claimant has not engaged in substantial gainful activity since July 28,

2008, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.)

3. The claimant has the following severe impairments: chronic obstructive

pulmonary disease (COPD), lupus, and obesity (20 CFR 404.1520(c) and

416.920(c)).

4. The claimant does not have an impairment or combination of impairments

that meets or medically equals the severity of one of the listed impairments

in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1526,

416.920(d), 416.925 and 416.926). 

5. After careful consideration of the entire record, the undersigned finds that the

claimant has the residual functioning capacity to perform light work as

defined in 20 CFR 404.1567(b) and 416.967(b) in that she can lift, carry,

push, and pull up 20 pounds occasionally and 10 pounds frequently. She can

sit for a total of up to 6 hours per workday. The claimant would have to

avoid concentrated exposure to extreme cold and extreme heat, and also

avoid concentrated exposure to fumes, odors, gasses, and poor ventilation. 

6. The claimant is capable of performing past relevant work as a manager. This

work does not require the performance of work-related activities precluded

by the claimant’s residual functioning capacity. (20 CFR 404.1565 and

416.965). 

7. The claimant has not been under a disability, as defined in the Social Security

Act, from July 28, 2008, through the date of this decision (20 CFR

404.1520(f) and 416.920(f)).

On June 19, 2013, the Appeals Council denied Plaintiff’s request for review, making the

ALJ’s decision the final decision of the Commissioner. On August 2, 2013, Plaintiff filed a civil

complaint with this Court. 

The parties filed forms of consent to have this case assigned to a United States Magistrate

Judge to conduct all further proceedings and to order the entry of a final judgment in this case. 

Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42

U.S.C. § 405(g).

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FACTS

A. Background

Plaintiff was 48 years old at the time of her alleged onset date and 50 on the date of the

hearing. She has completed her high school education. She worked in the past as a manager. 

B. Medical Evidence

Plaintiff’s medical records begin in January 2007 with a check-up performed by her primary

care physician, Dr. Kameswari Kalluri. Dr. Kalluri noted that Plaintiff complained of muscle

weakness and fatigue. Dr. Kalluri’s notes from various check-ups through June 2009 contain

continued complaints of muscle weakness and aches, fatigue, and tiredness. After a July 25, 2007,

check-up, Dr. Kalluri also noted that Plaintiff had a rash on her scalp related to lupus.

On May 21, 2007, Dr. Kalluri referred Plaintiff to rheumatologist Dr. Vinay Reddy to assess

her generalized weakness and muscle aches. On June 12, 2007, Dr. Reddy wrote to Dr. Kalluri,

indicating that he did not believe Plaintiff had lupus based on a preliminary examination but that he

would have tests run. Those tests revealed positive ANA, positive SSA and SSB antibodies, but

negative ENA and rheumatoid factors. Dr. Reddy concluded that Plaintiff had Sjögrens syndrome

and prescribed her hydroxychloroquine. Lab results from July 21, 2007, include a statement that

“antibodies to SSA and SSB are observed with the highest frequency in Sjögrens syndrome,

although these antibodies are also found in significant percentage of patients with [systemic lupus

erythematosus].” AR 410. Plaintiff testified at the hearing that she stopped seeing Dr. Reddy after

she lost her insurance. Records indicate that her last visit was on September 21, 2009.

In March 2008, Dr. Kalluri first noted that Plaintiff had a left pleural effusion. When it did

not clear up on its own, Plaintiff was referred to Dr. Asaad Jandali at Chest Physician Consultants. 

On June 30, 2008, Dr. Jandali noted Plaintiff’s history of lupus and Sjögrens but wrote that the

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pleural effusion was not likely related to Plaintiff’s lupus because her lupus was stable. On July 28,

2008, Dr. Jandali noted that Plaintiff’s lupus was in remission.

Plaintiff’s lupus is mentioned frequently throughout later records. On February 2, 2010, Dr.

Deanna Porte-Keene noted that Plaintiff had had lupus with Sjögrens for two and a half years. She

also noted that Plaintiff had problems with becoming easily fatigued and questioned whether it was

related to her lupus. On March 16, 2010, a cardiologist to whom Dr. Porte-Keene referred Plaintiff

noted Plaintiff’s fatigue and stated that Plaintiff “is known to have lupus for which she is under

treatment by Dr. Reddy.” AR 558. On August 10, 2010, Dr. Porte-Keene noted that Plaintiff had

filed for disability because her lupus was affecting her left lung. On September 10, 2010, a

consultative examiner noted that Plaintiff had a history of lupus erythematosus “five or six years

ago” and that she had erythema on her face on that date. AR 612. 

In February 2011, Plaintiff began going to the East Chicago Community Health Center

(“ECCHC”). She saw Dr. Gerri Browning in February, April, May, July, and September of 2011

for general check-ups, evaluation for COPD, evaluation of various muscle and joint pains, coughing,

and for evaluation of a mass suspected to be cancer. She testified that she went to the ECCHC

because it accepted payment on a sliding scale. On February 2, 2011, Dr. Browning noted joint and

muscle pain related to Plaintiff’s lupus diagnosis.

Plaintiff’s records also contain diagnoses and/or treatment for anxiety, depression, minor

degenerative changes of the lumbar spine, mild degenerative changes of the right hip, arthritis,

vertigo, and high blood pressure. Weight gain was reported after Plaintiff quit smoking.

C. Opinion Evidence

On September 8, 2010, state agency physician Fernando Montoya prepared a Physical

Residual Functional Capacity Assessment based on his examination of Plaintiff’s medical records. 

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He concluded that Plaintiff was capable of light work with no postural, manipulative, or visual

limits, but that she should avoid concentrated exposure to extreme heat, extreme cold, fumes, odors,

gases, dusts, and poor ventilation. He also noted that Plaintiff had a “[history of] pleural effusion

from lupus,” but wrote that it was “resolved.” AR 616. On October 4, 2010, state agency

psychologist William Shipley completed a Psychiatric Review Technique form based on his

examination of Plaintiff’s medical records. He concluded that Plaintiff’s mental impairments were

non-severe, diagnosed her with adjustment disorder, and found mild restrictions in activities of daily

living, maintaining social functioning, and maintaining concentration, persistence, or pace.

On February 12, 2012, Gerri Browning, M.D., a treating physician, filled out a medical

source statement. Dr. Browning first addressed Plaintiff’s lupus and noted that she had

constitutional symptoms of severe fatigue and malaise. Dr. Browning indicated that Plaintiff’s lupus

at least moderately involved three major organ or body systems: her respiratory system, her mental

health, and her immune system. He elaborated that her mental health involvement included anxiety

and fluctuating cognition, or “lupus fog,” and her immune system involvement included

inflammatory arthritis and Sjögren’s syndrome. AR 821.

 Dr. Browning also offered an opinion on the effects of Plaintiff’s impairments on her

functional ability. He opined that Plaintiff’s symptoms were likely to be severe enough to interfere

with her attention and concentration, resulting in her likely being off task twenty-five percent of the

time or more. However, Dr. Browning opined that Plaintiff had few limitations with social

functioning, concentration, persistence, and pace. Dr. Browning indicated that Plaintiff could walk

half a block without rest, sit 20 minutes at one time, stand 45 minutes at one time, sit and stand less

than two hours in an eight hour day, needed to be able to shift position at will, and would sometimes

need to take unscheduled breaks every two hours for 15 minutes, during which she would need to

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lie down or sit quietly. Dr. Browning further opined that Plaintiff could rarely lift and carry less

than 10 pounds and could never carry more; could occasionally twist, never stoop, crouch, or climb

ladders; could rarely climb stairs; should avoid all exposure to extreme heat, cold, humidity,

wetness, and cigarette smoke; and should avoid even moderate exposure to perfumes, soldering

fluxes, solvents and cleaners, fumes, odors, gases, dust, and chemicals. He also indicated that

Plaintiff would likely have good days and bad days, and would likely be absent more than four days

per month.

D. Plaintiff’s Testimony

Plaintiff first testified about her work history. In the relevant time period, she performed

work as a supervisor of janitorial workers. At her most recent job, she supervised janitorial

subcontractors at various retail stores, which required her to hire subcontractors, inspect their work

at various properties, and report back to her employer. She estimated that out of an eight hour

workday at that job, she would sit for four hours and stand/walk for four hours. She testified that

she was also expected to lift 25 pounds or more and stated that she could not keep up with the job

because she could not lift that much. She stated that she was terminated in July or August of 2008

while she was on sick-leave due to her pleural effusion.

Plaintiff then testified about her impairments and the effects they have on her functioning. 

She testified that she suffered from joint pain caused by her lupus and arthritis. She also testified

that she suffers from dry eyes and mouth, anxiety, “stabby” and burning pains in her leg, and an

achy shoulder. AR 23-24. She also testified that even minimal activity will cause her to become

fatigued. She also stated that she could walk maybe half a block and could only sit 15 to 20 minutes

before having to change position.

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STANDARD OF REVIEW

The Social Security Act authorizes judicial review of the final decision of the agency and

indicates that the Commissioner’s factual findings must be accepted as conclusive if supported by

substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will

reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an

erroneous legal standard. See Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial

evidence consists of “such relevant evidence as a reasonable mind might accept as adequate to

support a conclusion.” Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2005) (quoting Gudgel v.

Barnhart, 345 F.3d 467, 470 (7th Cir. 2003)).

A court reviews the entire administrative record but does not reconsider facts, re-weigh the

evidence, resolve conflicts in evidence, decide questions of credibility, or substitute its judgment

for that of the ALJ. See Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005); Clifford v. Apfel, 227

F.3d 863, 869 (7th Cir. 2000); Butera v. Apfel, 173 F.3d 1049, 1055 (7th Cir. 1999). Thus, the

question upon judicial review of an ALJ’s finding that a claimant is not disabled within the meaning

of the Social Security Act is not whether the claimant is, in fact, disabled, but whether the ALJ 

“uses the correct legal standards and the decision is supported by substantial evidence.” Roddy v.

Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (citing O’Connor-Spinner v. Astrue, 627 F.3d 614, 618

(7th Cir. 2010); Prochaska v. Barnhart, 454 F.3d 731, 734-35 (7th Cir. 2006); Barnett v. Barnhart,

381 F.3d 664, 668 (7th Cir. 2004)). “[I]f the Commissioner commits an error of law,” the Court

may reverse the decision “without regard to the volume of evidence in support of the factual

findings.” White v. Apfel, 167 F.3d 369, 373 (7th Cir. 1999) (citing Binion v. Chater, 108 F.3d 780,

782 (7th Cir. 1997)).

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At a minimum, an ALJ must articulate his analysis of the evidence in order to allow the

reviewing court to trace the path of his reasoning and to be assured that the ALJ considered the

important evidence. Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002); see Diaz v. Chater, 55

F.3d 300, 307 (7th Cir. 1995); Green v. Shalala, 51 F.3d 96, 101 (7th Cir. 1995). An ALJ must

“‘build an accurate and logical bridge from the evidence to [the] conclusion’ so that, as a reviewing

court, we may assess the validity of the agency’s final decision and afford [a claimant] meaningful

review.” Giles v. Astrue, 483 F.3d 483, 487 (7th Cir. 2007) (quoting Scott, 297 F.3d at 595)); see

also O’Connor-Spinner, 627 F.3d at 618 (“An ALJ need not specifically address every piece of

evidence, but must provide a ‘logical bridge’ between the evidence and his conclusions.”); Zurawski

v. Halter, 245 F.3d 881, 889 (7th Cir. 2001) (“[T]he ALJ’s analysis must provide some glimpse into

the reasoning behind [the] decision to deny benefits.”).

DISABILITY STANDARD

To be eligible for disability benefits, a claimant must establish that she suffers from a

“disability” as defined by the Social Security Act and regulations. The Act defines “disability” as

an inability to engage in any substantial gainful activity by reason of any medically determinable

physical or mental impairment that can be expected to result in death or that 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),

1382c(a)(3)(A). To be found disabled, the claimant’s impairment must not only prevent her from

doing her previous work, but considering her age, education, and work experience, it must also

prevent her from engaging in any other type of substantial gainful activity that exists in significant

numbers in the economy. 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B); 20 C.F.R. §§ 404.1520(e)-(f),

416.920(e)-(f).

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When a claimant alleges a disability, Social Security regulations provide a five-step inquiry

to evaluate whether the claimant is entitled to benefits. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). 

The steps are: (1) Is the claimant engaged in substantial gainful activity? If yes, the claimant is not

disabled, and the claim is denied; if no, the inquiry proceeds to step two; (2) Does the claimant have

an impairment or combination of impairments that are severe? If not, the claimant is not disabled,

and the claim is denied; if yes, the inquiry proceeds to step three; (3) Do(es) the impairment(s) meet

or equal a listed impairment in the appendix to the regulations? If yes, the claimant is automatically

considered disabled; if not, then the inquiry proceeds to step four; (4) Can the claimant do the

claimant’s past relevant work? If yes, the claimant is not disabled, and the claim is denied; if no,

then the inquiry proceeds to step five; (5) Can the claimant perform other work given the claimant’s

RFC, age, education, and experience? If yes, then the claimant is not disabled, and the claim is

denied; if no, the claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v); see

also Scheck v. Barnhart, 357 F.3d 697, 699-700 (7th Cir. 2004).

At steps four and five, the ALJ must consider an assessment of the claimant’s RFC. The

RFC “is an administrative assessment of what work-related activities an individual can perform

despite her limitations.” Dixon v. Massanari, 270 F.3d 1171, 1178 (7th Cir. 2001) (citing SSR 96-

8p, 1996 WL 374184 (July 2, 1996); 20 C.F.R. § 404.1545(a)) (other citations omitted). The RFC

should be based on evidence in the record. Craft v. Astrue, 539 F.3d 668, 676 (7th Cir. 2008) (citing

20 C.F.R. § 404.1545(a)(3)). The claimant bears the burden of proving steps one through four,

whereas the burden at step five is on the ALJ. Zurawski, 245 F.3d at 886; see also Knight v. Chater,

55 F.3d 309, 313 (7th Cir. 1995).

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ANALYSIS

Plaintiff seeks reversal and remand of the ALJ’s decision based on the following arguments:

(1) the ALJ erred in finding that Plaintiff’s lupus did not meet or equal a Listing; (2) the ALJ did

not properly weigh a treating source opinion; (3) the RFC analysis was based on improper

independent medical determinations and mischaracterization of the evidence; and (4) the ALJ

improperly found Plaintiff capable of her past relevant work because he failed to include mental

limitations in her RFC. The Court addresses each argument in turn. 

A. The ALJ’s Listing Determination

Plaintiff first argues that the ALJ disregarded evidence favorable to her without adequate

explanation when he found that she did not meet Listing 14.02 for lupus. The Commissioner argues

that the Listing determination was supported by substantial evidence.

 Appendix 1 of the disability regulations contains a “Listing of Impairments” that the SSA

has pre-determined are disabling regardless of a claimant’s age, education, or work experience. 20

C.F.R. § 404.1525(a). The Listings first enumerate criteria necessary to establish that a claimant’s

diagnosis is based on acceptable medical evidence. 20 C.F.R. § 404.1525(c)(2). The remaining

criteria establish the severity the impairment much reach to be considered disabling. 20 C.F.R. §

404.1525(c)(2). For example, a claimant meets Listing 14.02 for lupus when she has a diagnosis

of systemic lupus erythematosus according to diagnostic requirements established by the American

College of Rheumatology and also establishes the requisite severity by showing “[i]nvolvement of

two or more organs/body symptoms, with . . . [o]ne of the organs/body systems involved to at least

a moderate level of severity; and [a]t least two of the constitutional symptoms or signs (severe

fatigue, fever, malaise, or involuntary weight loss).” 20 C.F.R. Part 404, Subpart P, Appendix 1,

10
§§ 14.00(D)(1), 14.02(A). Organ or body system involvement can include respiratory,

cardiovascular, renal, hematologic, skin, neurologic, or immune system disorders. 20 C.F.R. Part

404, Subpart P, Appendix 1, §§ 14.00(D)(1).

In general, the claimant bears the burden of proving her condition meets all the criteria of

a Listing. Ribaudo v. Barnhart, 458 F.3d 580, 583 (7th Cir. 2006). However, an ALJ’s Listing

determination “must discuss the listing by name and offer more than a perfunctory analysis of the

listing.” Barnett, 381 F.3d at 668 (citing Brindisi ex rel. Brindisi v. Barnhart, 315 F.3d 783, 786

(7th Cir. 2003); Scott, 297 F.3d at 595-96; Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002)). 

If evidence exists in the record that might establish that a Listing’s criteria have been met, an ALJ

cannot simply ignore it without explanation. Ribaudo, 458 F.3d at 583. 

The ALJ begins the section of his decision dedicated to the Listings by writing that “there

is no evidence that the claimant has a physical impairment or combination or impairments that meet

or medically equal one of the listed impairments.” AR 77. He then lists the requirements of Listing

3.02 for COPD and for Listing 14.02 for lupus. The Listings section ends there.

Plaintiff argues that there is evidence in the record showing that she met the criteria for

Listing 14.02, and she further argues that the ALJ disregarded it without adequate explanation. The

ALJ acknowledges that Plaintiff had a diagnosis for lupus. As summarized in the fact section above,

the record suggests that Plaintiff’s lupus might involve her respiratory system and immune system

disorders; namely, that her lupus involves her recurrent pleural effusions and her Sjögrens

syndrome. There is also ample evidence in the record that Plaintiff complained of fatigue. Although

there is no evidence that Plaintiff experienced fever or weight loss, there is evidence she may have

suffered from malaise. Whether this evidence is adequate to find the criteria of the Listing were

satisfied is a call for the ALJ, not the Court, to make. See Clifford, 227 F.3d at 869 (“We review the

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entire administrative record but do not reweigh the evidence, resolve conflicts, decide questions of

credibility, or substitute our own judgment for that of the Commissioner.”). However, this evidence

shows that the ALJ’s statement that “there is no evidence that the claimant has a physical

impairment or combination or impairments that meet or medically equal one of the listed

impairments” is incorrect. AR 77 (emphasis added). Additionally, the lack of discussion of the

evidence that might show Plaintiff meets the lupus Listing makes it impossible for the Court to tell

whether the ALJ acknowledged and rejected the evidence or just ignored it entirely. Accordingly,

standing by itself, the Listings section provides the type of “perfunctory” analysis for which remand

is appropriate. See Scott, 297 F.3d at 596 (stating that when the analysis of the evidentiary record

is so “perfunctory” that the court cannot meaningfully review an ALJ’s Listing determination,

remand is required.); see also Clifford, 227 F.3d at 874 (“For meaningful appellate review,

however, we must be able to trace the ALJ’s path of reasoning.”).

The Commissioner argues that the ALJ’s discussion of evidence related to Plaintiff’s lupus

in the rest of his decision makes up for the perfunctory discussion in the Listings section. The

Commissioner points out that the ALJ addressed Plaintiff’s alleged lupus-related muscle spasms and

dismissed them because no doctor documented them; that the ALJ noted that Dr. Reddy determined

Plaintiff did not have lupus and that Dr. Jandali noted her lupus was in remission; that the ALJ

reasonably gave great weight to the opinions of state agency experts who found Plaintiff did not

meet a Listing; and that the ALJ addressed and properly dismissed Dr. Browning’s opinion that

found the necessary criteria of the lupus Listing present. The ALJ also noted two occasions on

which Plaintiff treated pain with non-prescription medications and wrote that “[t]hese instances also

support the undersigned’s finding that the claimant does not meet or medically equal the

requirements set forth in the lupus listing, especially since her minor complaints of pain or

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discomfort were treated with simple over-the-counter medicine.” AR 81.

The Court agrees that the substance of the ALJ’s analysis matters more than its form. See

Rice v. Barnhart, 384 F.3d 363, 370 (7th Cir. 2004) (stating that it is “proper to read the ALJ's

decision as a whole” and “would be a needless formality to have the ALJ repeat substantially similar

factual analyses” at different steps of the analysis). If the discussion the Commissioner points to

actually provided insight into how the ALJ considered the specific criteria of the Listing, it might

suffice. However, it does not. Muscle spasms and pain are not among the criteria of the Listing,

so those parts of the RFC discussion are irrelevant to the Listing decision. Also, the ALJ never said

he relied on the opinions of state agency experts regarding the Listings. Even if he had, an ALJ may

only rely on those opinions without any discussion “so long as there is no contradictory evidence

in the record,” which is not the case here. Ribaudo, 458 F.3d at 584. Additionally, Dr. Browning’s

opinion would not be necessary to finding Plaintiff met the lupus Listing, so discounting it—even

if for good reason—cannot by itself explain the ALJ’s Listing decision. Finally, the ALJ’s noting

that Plaintiff’s lupus was reportedly in remission on her alleged onset date of July 28, 2008, might

explain why he found that the criteria for the lupus Listing were not present on that date, but it does

not explain why he found the criteria not present at any later point during her insured period, which

did not expire until December 31, 2013. 

The only other discussion in the RFC analysis that might give insight into the ALJ’s Listing

decision relates to Plaintiff’s fatigue. Because the lupus Listing requires that two of the four

constitutional symptoms—severe fatigue, fever, malaise, or involuntary weight loss—be present

and because Plaintiff has not argued she had involuntary weight loss or fever, the existence of severe

fatigue is essential to her argument that she met the lupus Listing. Accordingly, if the ALJ’s

discounting of Plaintiff’s reported fatigue in his statement that “there are no indications that

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[Plaintiff’s] medications of Lopid, Plaquenil, Neurontin, Micardis, Celexa, Moduretic, Zrytec,

ProAir, and Advair were not effective in controlling her symptoms” were well-reasoned, it might

suffice to explain why he found Plaintiff’s lupus did not meet a Listing. AR 81. However, most of

the medications listed were prescribed to treat ailments other than lupus or fatigue. Additionally,

even if no doctor explicitly stated that Plaintiff’s lupus medications were not effective, the record

contains numerous instances when Plaintiff complained of fatigue while on her various medications. 

Because the ALJ’s reasoning for discounting Plaintiff’s reported fatigue is flawed, it cannot explain

why the ALJ found the Listing was not met.

Because none of the ALJ’s discussion of Plaintiff’s lupus in the RFC assessment provides

the Court the missing insight into whether the ALJ acknowledged and rejected the evidence relevant

to those specific criteria or just ignored it entirely, it cannot make up for the deficiencies in the

Listings section of the ALJ’s decision noted above. Accordingly, the Court must remand for the

ALJ to make a complete and supported finding as to whether Plaintiff meets the Listing.

B. The Weight of Dr. Browning’s Opinion

Plaintiff next argues that the ALJ did not properly weigh the opinion of treating physician

Dr. Gerri Browning. The Commissioner responds that the ALJ gave well-supported reasons for

giving the opinion little weight.

“A treating physician’s opinion regarding the nature and severity of a medical condition is

entitled to controlling weight if it is well-supported by medical findings and not inconsistent with

other substantial evidence in the record.” Gudgel, 345 F.3d at 470 (citing 20 C.F.R. §

404.1527(d)(2)); see also Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007). If an ALJ declines

to give a treating source’s opinion controlling weight, he must still determine what weight to give

it according to the following factors: the length, nature, and extent of the physician’s treatment

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relationship with the claimant; whether the physician’s opinions were sufficiently supported; how

consistent the opinion is with the record as a whole; whether the physician specializes in the medical

conditions at issue; and other factors, such as the amount of understanding of the disability programs

and their evidentiary requirements or the extent to which an acceptable medical source is familiar

with other information in the claimant’s case. 20 C.F.R. §§ 404.1527(c)(2)(i)-(ii), (c)(3)-(6). “If

the ALJ discounts the [treating] physician’s opinion after considering these factors, [the Court] must

allow that decision to stand so long as the ALJ ‘minimally articulated’ his reasons.” Elder v. Astrue,

529 F.3d 408, 415 (7th Cir. 2008) (quoting Berger v. Astrue, 516 F.3d 539, 545 (7th Cir. 2008)).

The ALJ wrote:

[L]ittle weight is given to Dr. Browning’s opinions as they are not

supported by the objective record. . . . [T]here is no supporting

evidence of record that would indicate her inability to maintain

employment within the parameters set forth in the residual functional

capacity above. In fact, there is no supporting evidence that

[Plaintiff] could not even sit, stand, or walk more than 2 hours in an

8-hour workday, that she would need to lie down throughout the day,

or that she would be off-task more than 25% of the time, or need

more than 4 days off per month.

AR 84.

Plaintiff points to evidence in the record that she argues supports the limitations in Dr.

Browning’s opinion. She argues that by rejecting that evidence without discussion, the Court cannot

assess whether his conclusory statement is grounded in sound reasoning and must, therefore,

remand.

If this conclusory statement were the ALJ’s only grounds for rejecting Dr. Browning’s

opinion, the Court might be persuaded that the ALJ failed to adequately explain his decision. 

However, the ALJ also noted that Dr. Browning completed the opinion form after having only seen

Plaintiff “a handful of times,” a valid reason to give less weight to a treating source’s opinion. AR

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82; see 20 C.F.R. § 404.1527(c)(2)(i) (“[T]he more times you have been seen by a treating source,

the more weight we will give to the source’s medical opinion.”). The ALJ also noted an apparent

internal inconsistency in Dr. Browning’s opinion, writing that “Dr. Browning opined that [Plaintiff]

would be ‘off task’ 25% or more of her day due to concentration difficulties, even though in the

same report she felt the claimant only had mild to no limitations with regard to her concentration.” 

AR 84. Such internal inconsistency is also a valid reason to give less weight to a medical source’s

opinion. Knight, 55 F.3d at 314 (“Medical evidence may be discounted if it is internally inconsistent

or inconsistent with other evidence.”). Additionally, although the ALJ did not explicitly state that

Dr. Brown’s opinion was inconsistent with the record as a whole, his summary throughout his

decision of numerous unremarkable tests and examinations in the record provides further

explanation for his decision to discount Dr. Browning’s opinion. For the foregoing reasons, the

Court finds that the ALJ met the minimal articulation standard for the weight he gave to Dr.

Browning’s opinion.

C. RFC Analysis 

Plaintiff claims that in forming the RFC, the ALJ made improper independent medical

determinations and mischaracterized the medical evidence. The Commissioner argues that the ALJ

properly supported his RFC finding.

The Seventh Circuit has repeatedly held that ALJs are not permitted to make their own

independent medical findings. See Myles, 582 F.3d at 677-78; Blakes, 331 F.3d at 570; Rohan, 98

F.3d at 970. If ALJs mischaracterize the evidence in the record, they fail to trace their reasoning to

their conclusion. Scott, 297 F.3d at 595. If the ALJ fails to trace his reasoning to his conclusion,

the ALJ fails to “‘build an accurate and logical bridge from the evidence to [the] conclusion,’”

thereby preventing the reviewing court from “assess[ing] the validity of the agency’s final decision

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and afford[ing] [a claimant] meaningful review.” Giles, 483 F.3d at 487 (quoting Scott, 297 F.3d

at 595)); see also O’Connor-Spinner, 627 F.3d at 618 (“An ALJ need not specifically address every

piece of evidence, but must provide a ‘logical bridge’ between the evidence and his conclusions.”);

Zurawski, 245 F.3d at 889. (“[T]he ALJ’s analysis must provide some glimpse into the reasoning

behind [the] decision to deny benefits.”).

The ALJ stated that Plaintiff was “assigned a relatively normal Global Assessment Function

(GAF) score of 60, which is given great weight and is consistent with an individual who has

generally mild symptoms of a mental impairment.” AR 77. Plaintiff argues that a GAF score of 60

actually denotes moderate, not mild, symptoms of mental impairment and that the ALJ thus

mischaracterized the severity of Plaintiff’s mental impairments. The Commissioner concedes that

a 60 GAF score denotes moderate symptoms but argues that because a score of 61 indicates mild

symptoms, 60 is still “generally” mild. Def. Br. 16. If the ALJ had relied on the GAF score as just

one minor piece of evidence, his mischaracterization of it would not have affected his decision

much. However, because he put “great weight” on the GAF score, his mischaracterization concerns 

the Court. 

Plaintiff also claims that ALJ mischaracterized the evidence concerning Plaintiff’s muscle

spasms and her pain. The ALJ claimed that “even though [Plaintiff] has been examined a number

of times, no muscle spasms were noted.” AR 80. Plaintiff points out that muscle spasms were noted

by Dr. Browning during her examination of Plaintiff. The Commissioner concedes that Dr.

Browning did note muscle spasms, but argues that because there were no other references to muscle

spasms in the record, it “proves no meaningful error.” Def. Br. 19. Plaintiff also points to another

of the ALJ’s misreadings of the record. When summarizing an exam, the ALJ stated that Plaintiff

“refused to perform some of the exercises . . . “ AR 82. However, Plaintiff points out that she did

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not refuse to perform the exercises, but, as the physician noted, Plaintiff was unable to perform the

exercises due to pain. The Commissioner argues that the ALJ made no negative inferences based

on his misstatement of the record, so it does not constitute reversible error. The Court agrees. 

While the ALJ did misunderstand or misstate the record on the two points above, his mistakes were

minor and his conclusions did not rely on them. Accordingly, they do not prevent the Court from

being able to trace the path of the ALJ’s reasoning. Scott, 297 F.3d at 595.

 Plaintiff also argues that the ALJ improperly made an independent medical determination

about Plaintiff’s medications and their effectiveness. The ALJ noted that Plaintiff was “consistently

taking several medications, and these have remained unchanged for some time, indicating their

effectiveness.” AR 83. Plaintiff first argues that the ALJ made a mistake of fact because Plaintiff’s

medication did change. However, the Court is less concerned with the ALJ’s small factual error as

it is about the ALJ’s inference that a lack of change in medications “ indicat[es] their effectiveness.”

AR 83. The Seventh Circuit has repeatedly held that ALJs are not to make their own independent

medical findings. See Myles v. Astrue, 582 F.3d 672, 677-78 (7th Cir. 2009); Blakes v. Barnhart,

331 F.3d 565, 570 (7th Cir. 2003); Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996). Plaintiff

argues that the ALJ made an improper medical determination by implying an unchanged medication

regimen means that the medications are effective at alleviating pain. The Commissioner argues that

the ALJ’s inference was supported by substantial evidence elsewhere in the opinion. However, the

Commissioner only cites examples showing that particular medications had beneficial effects. The

Commissioner does not cite any doctor opining that taking multiple medications consistently over

time is indicative of their effectiveness. Plaintiff points out that there are several reasons why a

medication regimen might remain unchanged despite its ineffectiveness; for example, adding more

medications into Plaintiff’s regimen might produce negative side effects. In any case, that

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determination is for a doctor to make, not an ALJ. Rohan, 98 F.3d at 970. (“And, as this Court has

counseled on many occasions, ALJs must not succumb to the temptation to play doctor and make

their own independent medical findings.”); Clifford, 227 F.3d at 870. Therefore, the ALJ erred by

making an independent medical finding.

Because of these errors, this Court cannot trace the ALJ’s reasoning to his conclusions. 

Scott, 297 F.3d at 595. Therefore, the ALJ failed to build a logical bridge to his conclusion, and the

decision requires remand. Giles, 483 F.3d at 487 (quoting Scott, 297 F.3d at 595)); see also

O’Connor-Spinner, 627 F.3d at 618. (“An ALJ need not specifically address every piece of

evidence, but must provide a ‘logical bridge’ between the evidence and his conclusions.”).

D. The ALJ’s past relevant work determination

Finally, Plaintiff argues that the ALJ failed to include an analysis of Plaintiff’s mental

limitations in his RFC analysis, resulting in an improper finding that Plaintiff could perform her past

relevant work as a manager. The RFC is an assessment of what work-related activities a claimant

can perform despite her limitations. Young v. Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004); see also

20 C.F.R. §§ 404.1545(a)(1). In determining an RFC, an ALJ must take into account all of a

claimant’s impairments, even non-severe ones. Golembiewski v. Barnhart, 322 F.3d 912, 918 (7th

Cir. 2003) (citing 20 C.F.R. § 404.1523); Kasarsky v. Barnhart, 335 F.3d 539, 544 (7th Cir. 2003).

At step two of the disability inquiry, the ALJ determined—based on state agency

psychologist William Shipley’s Psychiatric Review Technique form—that Plaintiff had mild

limitations in activities of daily living, maintaining social functioning, and maintaining

concentration, persistence, or pace. He concluded, however, that Plaintiff’s mental impairments

were not severe. In his RFC analysis, the ALJ stated that he gave Dr. Shipley’s opinion “great

weight” and repeated the limitations he found at step two. AR 83. Ultimately, however, the ALJ

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did not include any mental limitations in Plaintiff’s RFC. He also did not explain, as he is required

to do, why he declined to incorporate any of the mild limitations he found. See Golembiewski, 322

F.3d at 918. (“Having found that one or more of [Plaintiff’s] impairments was ‘severe,’ the ALJ

needed to consider the aggregate effect of this entire constellation of ailments—including those

impairments that in isolation are not severe.” (citing 20 C.F.R. § 404.1523; Sims v. Barnhart, 309

F.3d 424, 432 (7th Cir.2002); Green v. Apfel, 204 F.3d 780, 782 (7th Cir.2000)). The Commissioner

argues that nothing in the record warranted including limitations due to mental impairments in

Plaintiff’s RFC. However, the ALJ did not explicitly draw this conclusion in his analysis, and the

Commissioner may not now make new arguments that the ALJ did not include in his analysis. See

SEC v. Chenery Corp., 318 U.S. 80, 87 (1943) (“The grounds upon which an administrative order

must be judged are those upon which the record discloses that its action was based.”); see also

Kastner v. Astrue, 697 F.3d 642, 648 (7th Cir. 2012) (“Under the Chenery doctrine, the

Commissioner's lawyers cannot defend the agency's decision on grounds that the agency itself did

not embrace. On appeal, the Commissioner may not generate a novel basis for the ALJ's

determination.”) (citing Chenery, 318 U.S. at 87-88; Parker v. Astrue, 597 F.3d 920, 922 (7th Cir.

2010)). Accordingly, on remand, the ALJ is instructed to account for Plaintiff’s mental limitations

in her RFC or explain why they do not warrant additional accommodations.

Plaintiff also argues that the ALJ failed to discuss Plaintiff’s testimony that she could not

perform her past relevant work because she could not meet the lifting or standing requirements. 

However, as the Commissioner notes, in determining the past relevant work of a claimant, the ALJ

need only focus on how a job is performed generally, not how the claimant specifically performed

it. Getch v. Astrue, 539 F.3d 473, 482 (7th Cir. 2008); see Smith v. Barnhart, 388 F.3d 251, 253 (7th

Cir. 2004); see also SSR 82–61, 1982 WL 31387, at *2 (1982) (explaining that a claimant who

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“cannot perform the excessive functional demands and/or job duties actually required in the former

job but can perform the functional demands and job duties as generally required by employers

throughout the economy” should not be found to be disabled). The VE testified that the lifting and

standing requirements Plaintiff addressed in her testimony are not generally the requirements of a

manager. Therefore, omitting Plaintiff’s testimony concerning the lifting and standing requirements

of her previous employment was not an error because those were not requirements to perform her

past relevant work in general.

Accordingly, on remand the ALJ is not required to consider the actual lifting and standing

requirements of Plaintiff’s previous employment in determining whether she can do her past relevant

work.

CONCLUSION

Based on the foregoing, the Court hereby GRANTS the relief requested in Plaintiff’s Brief

in Support of Her Motion to Reverse the Decision of the Commissioner of Social Security [DE 15]

and REMANDS this matter for further proceedings consistent with this opinion.

SO ORDERED this 26th day of September, 2014.

s/ John E. Martin 

MAGISTRATE JUDGE JOHN E. MARTIN

UNITED STATES DISTRICT COURT

cc: All counsel of record

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