UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF INDIANA 

FORT WAYNE DIVISION 

CHRISTINA M. TUCKER, ) 

 ) 

 Plaintiff, ) 

 ) 

 v. ) Case No. 1:16-cv-4 

 ) 

NANCY A. BERRYHILL, ) 

Acting Commissioner of Social Security,1

 ) 

 ) 

 Defendant. ) 

OPINION AND ORDER 

 This matter is before the court on the petition for judicial review of the decision of the 

Commissioner filed by the plaintiff, Christina M. Tucker, on January 4, 2016.2

 For the following 

reasons, the decision of the Commissioner is AFFIRMED. 

Background 

The plaintiff, Christina M. Tucker, filed an application for Supplemental Security Income 

on December 18, 2012, alleging a disability onset date of October 1, 2012. (Tr. 10). The 

Disability Determination Bureau denied Tucker’s application on April 9, 2012, and again upon 

reconsideration on June 12, 2013. (Tr. 10). Tucker subsequently filed a timely request for a 

hearing on July 10, 2013. (Tr. 10). A hearing was held on October 2, 2014, before 

Administrative Law Judge (ALJ) Terry Miller, and the ALJ issued an unfavorable decision on 

 1

 Nancy A. Berryhill is now the Acting Commissioner of Social Security. Pursuant to Rule 25(d) of the 

Federal Rules of Civil Procedure, Nancy A. Berryhill should be substituted for Acting Commissioner Carolyn W. 

Colvin as the defendant in this suit. No further action needs to be taken to continue this suit by reason of the last 

sentence of section 205(g) of the Social Security Act, 42 U.S.C. § 405(g). 

2

 On April 1, 2016, this case was reassigned to Magistrate Judge Susan L. Collins upon the parties’ consent 

under 28 U.S.C. § 636(c), and then was reassigned to Magistrate Judge Andrew P. Rodovich. On October 12, 2016, 

the court ordered the parties to file any objection to Magistrate Judge Rodovich conducting all further proceedings in 

this case. Because neither party filed an objection, this court finds that the parties voluntarily consent to Magistrate 

Judge Rodovich under 28 U.S.C. § 636(c). 
2 

December 17, 2014. (Tr. 10-26). Vocational expert (VE) Sharon D. Ringenberg, Tucker, and 

Tucker’s mother, Anne Johnson, testified at the hearing. (Tr. 10). The Appeals Council denied 

review, making the ALJ’s decision the final decision of the Commissioner. (Tr. 1-6). 

 At step one of the five step sequential analysis for determining whether an individual is 

disabled, the ALJ found that Tucker had not engaged in substantial gainful activity since 

December 18, 2012, the application date. (Tr. 12). At step two, the ALJ determined that Tucker 

had the following severe impairments: history of low back pain, likely myofascial, obesity, 

history of headaches including migraines, major depressive disorder/depressive disorder, and 

anxiety. (Tr. 12). The ALJ reported that Tucker’s impairments, or combination of impairments, 

were severe and more than minimally affected her ability to perform work related activities that 

required heavy lifting, extreme climbing, and more than occasional performance of other 

postural maneuvers. (Tr. 12). Also, the ALJ indicated that she must avoid exposure to loud 

noises and bright flashing lights, and that she could not tolerate sudden or unpredictable work 

place changes. (Tr. 12). Finally, he found that Tucker could not maintain tasks requiring intense 

or focused attention for prolonged periods and that her ability to interact with others was 

diminished. (Tr. 12). 

 The ALJ found that Tucker’s right shoulder complaints were resolved in less than seven 

months and that her allegations of ongoing pain were not supported by the evidence. (Tr. 12). 

Tucker claimed that her fingers locked up, but she was unsure of how long it had been 

happening. (Tr. 12). The ALJ determined that the evidence was insufficient to establish a severe 

hand, finger, or wrist impairment. (Tr. 12-13). Tucker reported that she had left arm numbness 

that tingled and extended down to her fingertips at her October 9, 2013 and November 28, 2013 

primary care visits. (Tr. 13). However, the ALJ indicated that both examinations were normal. 
3 

(Tr. 13). Tucker saw R. Yu Mendador, M.D., who reported no abnormal upper extremity 

findings and no diagnosis of hand or wrist problems. (Tr. 13.) 

 The ALJ also found that Tucker’s left arm complaints were resolved in less than 12 

months and that her examination results were normal. (Tr.13). On November 8, 2012, Tucker 

complained about her right wrist and reported that she was unable to lift more than two pounds. 

(Tr. 13). She was prescribed Naprosyn, which the ALJ indicated appeared to be effective 

because no further reports of wrist pain were made during treatment. (Tr. 13). Moreover, 

Tucker had full range of motion and her fine manipulation, gross manipulation, gripping, and 

grasping were intact at the 2013 consultative physical examination. (Tr. 13). 

 Tucker testified that she experienced pain in the back of her legs if her legs got cold and 

that at times she felt like her foot was curving in. (Tr. 13). She reported that Dr. Yu-Mendador 

believed that neuropathy was present in her legs due to a previous head injury. (Tr. 13). 

However, the ALJ indicated that Tucker was prescribed Neurontin for treatment of restless leg 

syndrome (RLS). (Tr. 13). The ALJ noted that the records did not indicate that Tucker failed to 

respond to treatment for RLS or that it occurred for the 12-month durational requirement. (Tr. 

13-14). Tucker also complained of chest pain, but the ALJ found that Dr. Yu-Mendador’s 

records showed intermittent complaints of chest pain and that no cardiac testing had been 

recommended or performed. (Tr. 14). The ALJ noted that at Tucker’s most recent visit in May 

2014 she did not complain of chest pain. (Tr. 14). 

 At step three, the ALJ concluded that Tucker did not have an impairment or combination 

of impairments that met or medically equaled the severity of one of the listed impairments. (Tr. 

14). Specifically, the ALJ found that Tucker did not meet Listing 1.04, Disorders of the Spine, 

because there was no evidence of root compression, limitation in motion, motor loss, and she 
4 

performed a positive straight leg test. (Tr. 14). Also, the ALJ found that Tucker’s mental 

impairments did not meet the criteria of Listings 12.04 or 12.06. In finding that Tucker did not 

meet the above listings, the ALJ considered the paragraph B criteria for mental impairments, 

which required at least two of the following: 

marked restriction of activities of daily living; marked difficulties in 

maintaining social functioning; marked difficulties in maintaining 

concentration, persistence, or pace; or repeated episodes of decompensation, 

each of extended duration. 

(Tr. 14). The ALJ defined a marked limitation as more than moderate but less than extreme and 

repeated episodes of decompensation, each of extended duration, as three episodes within one 

year or once every four months with each episode lasting at least two weeks. (Tr. 14-15). 

 The ALJ found that Tucker had mild restrictions in daily living activities. (Tr. 15). The 

ALJ indicated that the treatment record was inconsistent with the testimony of Tucker and her 

mother that Tucker had more bad days than good and stayed in bed on bad days. (Tr. 15). 

Throughout her treatment at the Bowen Center, which began in late 2012, psychiatrist S. 

Maharjan, M.D., reported that Tucker was able to do her daily routine and daily chores with no 

reports of her spending days in bed. (Tr. 15). The function reports completed by Tucker and her 

mother in January of 2013 indicated that Tucker prepared simple meals, washed dishes, and 

helped care for the family’s pets. (Tr. 15). Also, Tucker reported that she enjoyed television, 

movies, and listening to music, but that she had a diminished interest in writing and drawing. 

(Tr. 15). She testified that she spent her time playing games and on the computer. (Tr. 15). 

Also, she occasionally needed to be reminded about her self-care. (Tr. 15). She stated that she 

was able to cook microwavable meals and on the stovetop occasionally. (Tr. 15). The ALJ 

concluded that the record as a whole failed to establish more than mild limitations in activities of 

daily living. (Tr. 15). 
5 

 The ALJ found that Tucker had moderate difficulties in social functioning. (Tr. 15). 

Tucker reported that she did not have an interest in having friends. (Tr. 15). However, the ALJ 

noted that during her treatment at Bowen she indicated that she was interested in establishing 

friendships. (Tr. 15). In the January 2013 function report, Tucker and her mother confirmed that 

she did not have difficulty getting along with authority figures. (Tr. 15). The ALJ indicated that 

Tucker had appropriate interaction with treating and examining sources. (Tr. 15). Therefore, the 

ALJ concluded that the evidence in the record failed to establish that Tucker was unable to 

maintain appropriate interactions and that she had marked limitations in social functioning. (Tr. 

15). 

 The ALJ determined that Tucker had moderate difficulties in concentration, persistence, 

or pace. (Tr. 15). The ALJ noted that the treatment records indicated that Tucker wrote scripts 

and had a copyrighted piece of fiction, which the ALJ concluded required a high level of 

concentration and persistence. (Tr. 15). Also, Tucker testified that she was able to play 

computer games for approximately an hour. (Tr. 15). Dr. Maharjan indicated that Tucker’s 

attention and concentration were either “fair” or “good” and noted an average 

knowledge/intellect. (Tr. 15). Therefore, the ALJ concluded that the objective evidence failed to 

establish marked limitations in concentration, persistence, or pace. (Tr. 15). 

 The ALJ concluded that Tucker did not satisfy the paragraph B criteria because her 

mental impairments did not cause at least two marked limitations or one marked limitation and 

repeated episodes of decompensation of extended duration. (Tr. 16). He also found that Tucker 

did not satisfy the paragraph C criteria because Tucker’s mental impairments would not be 

expected to cause decompensation if she were placed in a typical work setting and that she could 

function outside a highly-supportive living arrangement and outside her own home. (Tr. 16). 
6 

 The ALJ then assessed Tucker’s residual functional capacity (RFC) as follows: 

the claimant has the residual functional capacity to perform light work as 

defined in 20 CFR 416.967(b), reduced as follows: only occasional 

climbing of ramps and stairs, balancing, stooping, kneeling, crouching, 

and crawling; never climbing ladders, ropes, or scaffolds; and, needs to 

avoid concentrated exposure to loud noise and bright/flashing lights. 

Mentally the claimant cannot tolerate sudden or unpredictable workplace 

changes; cannot perform tasks requiring intense/focused attention for 

prolonged periods; can have only occasional work in close proximity to 

others to minimize distractions; can tolerate only casual/superficial/brief 

interactions with others, including supervisors, coworkers, and the 

general public; only occasional interactions with the general public; no 

exposure to intense or critical supervision; and, is best suited to working 

alone, in semi-isolations from others, or as part of a small group. 

(Tr. 16). The ALJ explained that in considering Tucker’s symptoms he followed a two-step 

process. (Tr. 16). First, he determined whether there was an underlying medically determinable 

physical or mental impairment that was shown by a medically acceptable clinical and laboratory 

diagnostic technique that reasonably could be expected to produce Tucker’s pain or other 

symptoms. (Tr. 17). Then, he evaluated the intensity, persistence, and limiting effects of the 

symptoms to determine the extent to which they limited Tucker’s functioning. (Tr. 17). 

 Tucker reported that her back pain had developed over time. (Tr. 17). She indicated that 

her daily pain was at the 7-8/10 level. (Tr. 17). However, the ALJ noted that there were no xrays of her back. (Tr. 17). Tucker testified that after walking or standing for 10 to 15 minutes 

she would have to sit. (Tr. 17). Also, she reported that her back pain occurred when lifting more 

than 10 pounds. (Tr. 17). However, she claimed that she had no problems climbing stairs with 

the use of a handrail and that she could pick something up from the floor as long as it was not 

heavy. (Tr. 17). She also testified that she had reoccurring migraines for about two years 

following a concussion. (Tr. 17). Tucker reported that the migraines occurred three to four days 

per week and that they lasted about one hour after taking over-the-counter Excedrin. (Tr. 17). 
7 

 Tucker claimed that she had diagnoses of anxiety, depression, and social anxiety. (Tr. 

17). She testified that she cried often and that she either did not sleep or slept too much. (Tr. 

17). Also, she reported that her appetite fluctuated. (Tr. 17). She stated that she frequently 

woke up angry and that her moods changed from happy to angry, but she denied ever being 

diagnosed with bipolar disorder. (Tr. 17). Tucker reported that when she last worked at 

McDonalds her manager held a knife to her neck. (Tr. 17). After this incident, she testified that 

she began cutting herself. (Tr. 17). Tucker stated that she had not had a job since the incident. 

(Tr. 17). Tucker indicated that she had difficulty being in groups of people, but she agreed that 

she was open to attending group sessions at Bowen. (Tr. 18). She reported nightmares and 

flashbacks, yet she indicated that those had reduced with therapy and that her medications were 

helpful. (Tr. 18). 

 Tucker reported that she got along well with her mother and brother. (Tr. 18). She 

denied having friends over in the last few years and claimed that she preferred being alone most 

of the time. (Tr. 18). She indicated that her reading skills were poor, yet she testified that she 

wrote fiction and that she had a story copyrighted. (Tr. 18). Tucker’s mother testified that 

Tucker had difficulty with change and criticism, and that she was distractible. (Tr. 18). Also, 

Tucker’s mother indicated that Tucker struggled with daily living. (Tr. 18). She reported that 

Tucker had struggled her entire life due to abuse. (Tr. 18). 

 The ALJ found that Tucker’s impairments could cause her alleged symptoms, but that she 

was not entirely credible regarding the intensity, persistence, and limiting effects of her 

symptoms. (Tr. 18). The ALJ noted that Dr. Yu-Mendador’s records showed various physical 

complaints, yet Tucker had received minimal treatment and there were no recommendations for 

diagnostic imaging or referrals. (Tr. 18). The State agency determined that Tucker had the 
8 

capacity to work at a medium exertional level with minimal postural limitations. (Tr. 18). The 

ALJ indicated that the RFC granted great deference to Tucker to account for the effects of her 

back pain, obesity, and migraine headaches. (Tr. 18). 

 On January 9, 2013, Tucker went to the Bowen Center for her initial medication 

management visit with Dr. Maharjan. (Tr. 19). Tucker complained of back pain, however, the 

ALJ indicated that Tucker’s pain level decreased at subsequent visits. (Tr. 19). The ALJ noted 

that at the most recent visit with Dr. Maharjan on June 20, 2014, Tucker reported a pain level of 

2/10. (Tr. 19). Dr. Maharjan reported that no pain problems were present. (Tr. 19). 

 On April 21, 2013, B.T. Onamusi, M.D., performed a comprehensive consultative 

examination. (Tr. 19). Dr. Onamusi’s results were negative other than obesity, therefore, Dr. 

Onamusi concluded that Tucker could perform light to moderate activities. (Tr. 19). In addition 

to back pain, Tucker complained of multiple daily headaches. (Tr. 19). She reported that her 

headaches had been reoccurring for approximately one year and that the pain level was at 11/10 

at least two times per week. (Tr. 19). She indicated that the headaches began after she hit her 

head on a beam and was incapacitated for 45 minutes to one hour. (Tr. 19). 

 On June 17, 2012, Tucker went to the emergency room with a headache. (Tr. 19). She 

reported hitting her head and that she had two to three headaches per week with some nausea, but 

no vomiting. (Tr. 19). The head CT was normal and post concussive syndrome was diagnosed. 

(Tr. 19). The ALJ noted that Tucker reported to Dr. Yu-Mendador’s office on August 28, 2012 

that she had hit her head on a cabinet, rather than the beam as previously mentioned. (Tr. 20). 

The ALJ reported that Tucker’s examination showed intact recent and remote memory. (Tr. 20). 

 The ALJ noted that at Tucker’s January 17, 2013 and April 21, 2013 visits she did not 

complain about headaches. (Tr. 20). Also, the ALJ indicated that at the most recent primary 
9 

care visit on May 19, 2014, a review of systems was positive for headaches, but no specific 

complaints were made and no diagnosis was listed. (Tr. 20). The ALJ concluded that Tucker’s 

allegations regarding the severity and frequency of her headaches were not well-supported and 

contributed to credibility concerns. (Tr. 20). The ALJ determined that there was no evidence 

that supported Tucker’s reports of extreme headaches and that Dr. Yu-Mendador’s records 

contradicted her complaints. (Tr. 20). However, the ALJ stated that he gave deference to 

Tucker’s testimony that her headaches were triggered by loud noises and bright lights. (Tr. 20). 

 The ALJ indicated that the RFC limited Tucker to light work activity, precluding extreme 

climbing, and limiting other postural maneuvers to occasional performance to account for 

Tucker’s back complaints. (Tr. 21). The ALJ noted that Tucker’s obesity likely affected both 

her exertional and postural capacities and supported the restriction of light work. (Tr. 21). 

However, the ALJ found that Tucker’s subjective complaints were not well-supported and that 

Tucker failed to establish physical limitations beyond the RFC. (Tr. 21). Also, the ALJ 

concluded that Tucker’s allegations of mental impairments were not fully supported. (Tr. 21). 

The ALJ indicated that the diagnoses of PTSD and bipolar disorder were not considered severe 

impairments because they were made only during the consultative psychological examination. 

(Tr. 21). Therefore, the ALJ indicated that he assigned greater weight to diagnoses made during 

actual treatment. (Tr. 21). 

 The ALJ noted that Tucker failed to report at her consultative psychological examination 

on October 2, 2009, in connection with a prior application, the incident that occurred with her 

employer at McDonalds. (Tr. 22). The ALJ stated that Tucker first reported the incident during 

her intake at Bowen one month before this application was filed. (Tr. 22). Therefore, the ALJ 
10 

concluded that Tucker’s failure to report the incident earlier and her vague responses regarding 

the handling of the complaint brought her reports into question. (Tr. 22). 

 Dr. Maharjan completed the initial psychiatric evaluation on December 19, 2012. (Tr. 

22). Tucker was able to perform serial 7’s correctly during the evaluation, despite being unable 

to during the October 2009 and March 2013 examination. (Tr. 22). Dr. Maharjan diagnosed 

Tucker with depressive disorder and anxiety disorder. (Tr. 22). Tucker began individual therapy 

in November of 2012. (Tr. 22). In June of 2013, she reported emotional abuse from her 

stepfather. (Tr. 22-23). Tucker and her mother acknowledged that they needed to move out due 

to the stepfather’s abusive behavior, and by May of 2014, Tucker’s mother had filed for divorce. 

(Tr. 23). 

 At the final therapy session, Tucker admitted that she often forgot to take her medications 

as also reflected in Dr. Maharjan’s records. (Tr. 23). Even though Tucker was less than fully 

compliant with her medication, Dr. Maharjan’s records showed improvement by March 2013 

while on Abilify. (Tr. 23). In July, Tucker’s symptoms increased, but she reported that she had 

been out of Abilify for one week. (Tr. 23). Her mood and anxiety improved by August 2013, 

but her insomnia worsened. (Tr. 23). The ALJ noted that by December of 2013 Tucker’s mood, 

anxiety, and insomnia were all stable. (Tr. 23). 

 At Tucker’s next appointment on May 21, 2014, she denied taking any medications and 

reported having mood swings, crying, and problems sleeping. (Tr. 23). Her mental status exam 

showed an irritable mood and restricted affect. (Tr. 23). The ALJ noted that at Dr. Maharjan’s 

final recorded visit on June 20, 2014, he found Tucker’s mood to be euthymic, but not 

controlled. (Tr. 23). He noted that her anxiety was stable and that she had good response to 
11 

medication. (Tr. 23-24). However, he indicated that her symptoms would increase when she 

was noncompliant. (Tr. 24). 

 Tucker offered a medical source statement from Dr. Maharjan into evidence. (Tr. 24). 

The ALJ found that the opinion did not accurately represent Tucker’s functioning throughout the 

period in issue. (Tr. 24). The ALJ stated that the definitions in the questionnaire indicated that a 

moderate limitation was a disabling distraction. (Tr. 24). The ALJ concluded that the definition 

represented more than moderate limitations and that there was no way to know that Dr. Maharjan 

had read and applied the definitions. (Tr. 24). The ALJ noted that the questionnaire was 

completed on August 4, 2013, after Dr. Maharjan had seen Tucker on July 24, 2013. (Tr. 24). A 

review of the record established that the medical source statement was completed on August 14, 

2013. (Tr. 489-490). The record indicated that at the July 24, 2013, visit Tucker was 

noncompliant with her medication and that her symptoms were increased. (Tr. 24). 

 The ALJ found that the Bowen records reflected improvement with therapy and 

medication. (Tr. 24). Also, Tucker indicated that treatment was helpful at the hearing. (Tr. 24). 

The ALJ determined that Dr. Maharjan’s GAF score of 65 was inconsistent with the disabling 

symptoms and limitations that he imposed in the questionnaire. (Tr. 24). Also, the ALJ 

concluded that Dr. Maharjan’s findings that Tucker had moderate and moderately severe 

limitations were inconsistent with the overall treatment records. (Tr. 24). Therefore, the ALJ 

determined that the medical source statement was entitled to little weight. (Tr. 24). 

 At step four, the ALJ found that Tucker had no past relevant work. (Tr. 25). Considering 

Tucker’s age, education, work experience, and RFC, the ALJ concluded that there were jobs in 

the national economy that she could perform, including housekeeper/cleaner (2,000 jobs 
12 

statewide and 130,000 nationwide), routing clerk (1,100 jobs statewide and 50,000 nationwide), 

and package sorter (1,000 jobs statewide and 43,000 nationwide). (Tr. 26). 

Discussion 

 The standard for judicial review of an ALJ’s finding that a claimant is not disabled within 

the meaning of the Social Security Act is limited to a determination of whether those findings are 

supported by substantial evidence. 42 U.S.C. § 405(g) (“The findings of the Commissioner of 

Social Security, as to any fact, if supported by substantial evidence, shall be conclusive.”); 

Moore v. Colvin, 743 F.3d 1118, 1120–21 (7th Cir. 2014); Bates v. Colvin, 736 F.3d 1093, 1097 

(7th Cir. 2013) (“We will uphold the Commissioner’s final decision if the ALJ applied the 

correct legal standards and supported his decision with substantial evidence.”). Courts have 

defined substantial evidence as “such relevant evidence as a reasonable mind might accept to 

support such a conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S. Ct. 1420, 1427, 28 

L. Ed. 2d 852 (1972) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S. Ct. 206, 

217, 83 L. Ed. 2d 140 (1938)); see Bates, 736 F.3d at 1098. A court must affirm an ALJ’s 

decision if the ALJ supported his findings with substantial evidence and if there have been no 

errors of law. Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (citations omitted). However, 

“the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues.” 

Lopez ex rel Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). 

 Supplemental insurance benefits are available only to those individuals who can establish 

“disability” under the terms of the Social Security Act. The claimant must show that she is 

unable “to engage in any substantial gainful activity by reason of any medically determinable 

physical or mental impairment which can be expected to result in death or which has lasted or 

can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. 
13 

§ 423(d)(1)(A). The Social Security regulations enumerate the five-step sequential evaluation to 

be followed when determining whether a claimant has met the burden of establishing disability. 

20 C.F.R. § 416.920. The ALJ first considers whether the claimant is presently employed or 

“engaged in substantial gainful activity.” 20 C.F.R. § 416.920(b). If she is, the claimant is not 

disabled and the evaluation process is over. If she is not, the ALJ next addresses whether the 

claimant has a severe impairment or combination of impairments that “significantly 

limits . . . physical or mental ability to do basic work activities.” 20 C.F.R. § 416.920(c); see 

Williams v. Colvin, 757 F.3d 610, 613 (7th Cir. 2014) (discussing that the ALJ must consider the 

combined effects of the claimant’s impairments). Third, the ALJ determines whether that severe 

impairment meets any of the impairments listed in the regulations. 20 C.F.R. § 401, pt. 404, 

subpt. P, app. 1. If it does, then the impairment is acknowledged by the Commissioner to be 

conclusively disabling. However, if the impairment does not so limit the claimant’s remaining 

capabilities, the ALJ reviews the claimant’s “residual functional capacity” and the physical and 

mental demands of her past work. If, at this fourth step, the claimant can perform her past 

relevant work, she will be found not disabled. 20 C.F.R. § 416.920(e). However, if the claimant 

shows that her impairment is so severe that she is unable to engage in her past relevant work, 

then the burden of proof shifts to the Commissioner to establish that the claimant, in light of her 

age, education, job experience, and functional capacity to work, is capable of performing other 

work and that such work exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. § 

416.920(f). 

 Tucker has argued that the ALJ improperly evaluated the opinion of Dr. Santosh 

Maharjan. A treating source’s opinion is entitled to controlling weight if the “opinion on the 

issue(s) of the nature and severity of [the claimant’s] impairment(s) is well-supported by 
14 

medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with 

the other substantial evidence” in the record. 20 C.F.R. ' 404.1527(d)(2); see Bates v. Colvin, 

736 F.3d 1093, 1099 (7th Cir. 2013); Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011); 

Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007). The ALJ must “minimally articulate his 

reasons for crediting or rejecting evidence of disability.” Clifford v. Apfel, 227 F.3d 863, 870 

(7th Cir. 2000) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1076 (7th Cir. 1992)); see 20 

C.F.R. ' 404.1527(d)(2) (“We will always give good reasons in our notice of determination or 

decision for the weight we give your treating source’s opinion.”). 

 “‘[O]nce well-supported contradicting evidence is introduced, the treating physician’s 

evidence is no longer entitled to controlling weight’ and becomes just one more piece of 

evidence for the ALJ to consider.” Bates, 736 F.3d at 1100. Controlling weight need not be 

given when a physician’s opinions are inconsistent with his treatment notes or are contradicted 

by substantial evidence in the record, including the claimant’s own testimony. Schmidt, 496 

F.3d at 842 (“An ALJ thus may discount a treating physician’s medical opinion if the opinion is 

inconsistent with the opinion of a consulting physician or when the treating physician’s opinion 

is internally inconsistent, as long as he minimally articulates his reasons for crediting or rejecting 

evidence of disability.”); see, e.g., Latkowski v. Barnhart, 93 Fed. App’x 963, 970-71 (7th Cir. 

2004); Jacoby v. Barnhart, 93 Fed. App’x 939, 942 (7th Cir. 2004). If the ALJ was unable to 

discern the basis for the treating physician’s determination, the ALJ must solicit additional 

information. Moore v. Colvin, 743 F.3d 1118, 1127 (7th Cir. 2014) (citing Similia v. Astrue, 

573 F.3d 503, 514 (7th Cir. 2009)). Ultimately, the weight accorded a treating physician’s 

opinion must balance all the circumstances, with recognition that, while a treating physician “has 

spent more time with the claimant,” the treating physician may also “bend over backwards to 
15 

assist a patient in obtaining benefits . . . [and] is often not a specialist in the patient’s ailments, as 

the other physicians who give evidence in a disability case usually are.” Hofslien v. Barnhart, 

439 F.3d 375, 377 (7th Cir. 2006) (internal citations omitted); see Punzio, 630 F.3d at 713. 

 Tucker has argued that the ALJ made an incorrect statement regarding the medical source 

statement that was completed by Dr. Maharjan. Tucker contends that the ALJ confused the 

definition of moderate on the questionnaire. The ALJ stated that the definitions provided in the 

questionnaire indicated that even “moderate” limitations in any area of functioning would result 

in disabling distraction. (Tr. 24). The definition of moderate on the questionnaire was that an 

individual would be distracted from the job 11% to 20% of a workday or work week. (Tr. 489). 

The VE testified that an individual must be on task 80% to 85% of a workday to perform 

competitive work. (Tr. 90). Thus, if Tucker was distracted from the job for 15% to 20% of the 

workday it may preclude some competitive work. 

 The Commissioner indicated that Dr. Maharjan found that Tucker had moderate-severe 

limitations in making simple work-related decisions, performing at a consistent pace without an 

unreasonable number and length of rest periods, and completing a normal workday or workweek 

without interruptions from psychologically-based symptoms. The Commissioner contends that 

that the State agency psychologist assessed Tucker with only moderate limitations in any area of 

functioning. However, the circuit court has made clear that what matters are the reasons 

articulated by the ALJ. Spiva v. Astrue, 628 F.3d 346, 353 (7th Cir. 2010); Larson v. Astrue,

615 F.3d 744, 749 (7th Cir. 2010). Although the ALJ cited the opinions the agency 

psychologists, he did not use their opinions to support his decision to give little weight to Dr. 

Maharjan's opinion. See 20 C.F.R. § 404.1527(d)(2); Larson, 615 F.3d at 751; Moss v. Astrue,

555 F.3d 556, 561 (7th Cir. 2009). 
16 

 Tucker has argued that it was improper for the ALJ to fault her for her noncompliance 

with medications. She indicated that she had problems affording medications. Tucker contends 

that under SSR 96-7 the ALJ needed to question her further when there was evidence in the file 

of noncompliance. The Commissioner indicated that the ALJ did not find that her 

noncompliance cut against her credibility. Rather the ALJ concluded that Dr. Maharjan’s 

opinion was completed shortly after a visit with Tucker while she was noncompliant with her 

medications, therefore, her symptoms were increased. 

 The ALJ’s decision indicated that the medical source statement was entitled to little 

weight because it was answered by Dr. Maharjan shortly after he had seen Tucker while she was 

noncompliant with her medications on July 24, 2013. The ALJ noted that the record stated that 

on July 24, 2013, Tucker had increased symptoms due to noncompliance with her medication. 

(Tr. 24). Dr. Maharjan’s records reflected that Tucker had periods of noncompliance. (Tr. 23). 

Tucker reported that she had been out of Abilfy for one week because she forgot to get the 

medication from patient assistance. (Tr. 23). The ALJ indicated that by August 23, 2013, 

Tucker’s mood and anxiety already had improved while on Abilfy. Her symptoms increased 

again in May 2014, however, she reported that she was noncompliant. Dr. Maharjan indicated 

that Tucker showed good response to medication with increased symptoms usually occurring 

during periods of noncompliance. (Tr. 23-24). Also, he indicated that throughout his visits 

Tucker had no memory problems and her attention and concentration were fair or good. (Tr. 24). 

 The ALJ concluded that the questionnaire had been completed 16 months prior to the 

decision and while Tucker was noncompliant. Therefore, it did not accurately reflect her 

functioning throughout the period in issue. The ALJ did not rely on Tucker’s noncompliance as 

a ground for denying disability, rather as a factor in discrediting Dr. Maharjan’s opinion. In 
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addition, the ALJ indicated that Tucker’s records at Bowen reflected improvement with therapy 

and medication and that Tucker had reported that treatment had been helpful. 

 The ALJ also found that Dr. Maharjan’s initial GAF score of 65 was inconsistent with his 

finding that Tucker had moderate and moderately severe limitations. Tucker has argued that it 

was improper for the ALJ to find that Dr. Maharjan’s GAF score was inconsistent with his 

opinion. She contends that her mental illness is an episodic one, therefore, she can be 

functioning on one day and significantly different on another. However, the Seventh Circuit has 

upheld the ALJ’s decision to consider GAF scores to some degree. Walters v. Astrue ̧ 444 F. 

App’x 913, 919 (7th Cir. 2011). A GAF score of 61–70 indicated “some mild symptoms” or 

“some difficulty in social, occupational, or school functioning, but generally functioning pretty 

well.” Am. Psychiatric Ass'n, Diagnosis and Statistical Manual of Mental Disorders, Fourth 

Edition, Text Revision, 32, 34 (2000) (DSM IV–TR). The court finds that Tucker’s December 

2012 GAF score of 65 was wholly inconsistent with Dr. Marharjan’s finding that she had 

moderate and moderately severe limitations. 

 The ALJ minimally articulated his reasoning to give little weight to Dr. Maharjan, and his 

decision was supported by substantial evidence. The medical source statement shed little light 

on Tucker’s overall abilities because it was completed shortly after she reported that she was 

noncompliant with her medications. Also, the ALJ found that Dr. Maharjan’s opinion was 

inconsistent with his GAF score and the overall record. The record indicated that Tucker’s 

condition improved with medications, as reflected in appointments with Dr. Maharjan in late 

2013 and the Bowen treatment records. Thus, the ALJ determined that the medical source 

statement was reflective of only a brief window of time. Therefore, the ALJ has presented good 

reasons to assign little weight to Dr. Maharjan. 
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 Based on the foregoing reasons, the decision of the Commissioner is AFFIRMED. 

 ENTERED this 29th day of March, 2017. 

 /s/ Andrew P. Rodovich 

 United States Magistrate Judge