UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

HAMMOND DIVISION

BARBARA A. HENSLEY, )

Plaintiff, )

)

v. ) CAUSE NO.: 2:16-CV-320-JEM

)

NANCY A. BERRYHILL, )

Acting Commissioner of the )

Social Security Administration, )

Defendant. )

OPINION AND ORDER

This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Barbara A. Henley

on July 8, 2016, and Plaintiff’s Opening Brief in a Social Security Matter [DE 13], filed by Plaintiff

on November 21, 2016. Plaintiff requests that the decision of the Administrative Law Judge be

reversed and remanded for further proceedings. On February 24, 2017, the Commissioner filed a

response, and on March 14, 2017, Plaintiff filed a reply. For the following reasons, the Court grants

Plaintiff’s request for remand.

I. Background

On May 10, 2013, Plaintiff filed an application for benefits alleging that she became disabled

on October 1, 2009. Plaintiff’s application was denied initially and upon reconsideration. On

February 20, 2015, Administrative Law Judge (“ALJ”) Christopher Helms held a hearing at which

Plaintiff, with an attorney, Plaintiff’s husband, and a vocational expert (“VE”) testified. On March

9, 2015, the ALJ issued a decision finding that Plaintiff was not disabled. 

The ALJ made the following findings under the required five-step analysis:

1. The claimant last met the insured status of the Social Security Act on

December 31, 2011.

2. The claimant did not engage in substantial gainful activity during the period
from her alleged onset date of October 1, 2009, through her date last insured

of December 31, 2011.

3. Through the date last insured, the claimant had severe impairments: “low

grade” cervical spondylosis and cervical radiculopathy, degenerative disc

disease of the lumbar spine and obesity.

4. Through the date last insured, the claimant did not have an impairment or

combination of impairments that met or medically equaled the severity of one

the listed impairments in 20 CFR 404, Subpart P, Appendix 1.

5. Through the date last insured, the claimant had the residual functional

capacity to lift and carry up to 10 pounds occasionally and nominal weight

frequently, stand and/or walk about 2 hours in an 8-hour workday, and sit

about 6 hours in an 8-hour workday. The claimant could never climb

ladders, ropes, or scaffolds but may occasionally climb ramps and stairs,

balance, stoop, kneel, crouch, or crawl. She was limited to occasional

overhead reaching bilaterally and was to avoid concentrated exposure to

cold/heat, wetness, humidity, and pulmonary irritants. She could perform

handling frequently.

6. Through the date last insured, the claimant was unable to perform any of her

past relevant work.

7. The claimant was a younger individual age 18-44 on the date last insured.

8. The claimant has at least a high school education and is able to communicate

in English. 

9. Transferability of job skills is not material to the determination of disability

because using the Medical-Vocational Rules as a framework supports a

finding that the claimant is “not disabled,” whether or not she has

transferable job skills.

10. Considering the claimant’s age, education, work experience, and residual

functional capacity, there were jobs that existed in significant numbers in the

national economy that the claimant could perform through the date last

insured.

11. The claimant was not under a disability, as defined in the Social Security

Act, from the alleged onset date through the date last insured.

On May 6, 2016, the Appeals Council denied Plaintiff’s request for review, leaving the

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ALJ’s decision the final decision of the Commissioner. 

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).

II. Standard or 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

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(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)).

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

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

important evidence. See Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002); 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.”).

III. Analysis

Plaintiff argues that the ALJ erred in weighing the evidence and failed to adequately explain

how he reached his conclusions, particularly as to how he incorporated her impairments into the

RFC and how he weighed the testimony of Plaintiff and her husband. The Commissioner argues that

the ALJ’s findings are supported by substantial evidence.

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Plaintiff argues that the ALJ failed to explain how Plaintiff’s limitations are incorporated into

the RFC and failed to address evidence that did not support his conclusions. The ALJ found that

during the time in which she was insured, Plaintiff was limited to essentially sedentary work because

of her impairments. Plaintiff argues that the ALJ did not explain how he arrived at the RFC from

the evidence. 

The ALJ described the statements of two of Plaintiff’s treating physicians. Dr. Leestma had

been treating Plaintiff for several years, completed a medical source statement that gave specific

functional limitations. The ALJ gave it very little weight on the grounds that it was not supported

by objective evidence and was not consistent with the findings of other examining physicians. The

ALJ also did not give weight to the opinion of another treating physician, Dr. Okoro, who opined

that Plaintiff was incapable of performing even sedentary work by October 2009. The ALJ

explained that he did not give this assessment weight because it did not include objective findings,

because the physician did not begin treating Plaintiff until several months after the date he opined

that she became disabled, and because the ALJ concluded that the limitations were inconsistent with

other medical records. 

“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 the 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

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

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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).

Furthermore, “whenever an ALJ does reject a treating source’s opinion, a sound explanation must

be given for that decision.” Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011). 

The ALJ discounted the opinions of two treating physicians who specifically opined on the

extent of Plaintiff’s limitations. He also described the conclusions of the non-examining state

agency medical consultants who reviewed the Plaintiff’s medical record, but found that Plaintiff was

more limited than they concluded. Although medical evidence “may be discounted if it is internally

inconsistent or inconsistent with other evidence,” Knight v. Chater,55 F.3d 309, 314 (7th Cir. 1995)

(citing 20 C.F.R. § 404.1527(c)) (other citations omitted), the ALJ “must provide a ‘logical bridge’

between the evidence and his conclusions.” O’Connor-Spinner, 627 F.3d at 618. In this case, the

ALJ did not identify any treating or examining source to whom he gave more than “very little

weight.” He summarized other medical evidence in the record, but did not identify any other

medical source statements or give any indication that he gave weight to any physician’s opinion, let

alone that of a treating or examining physician. This failure to identify any medical source opinion

entitled to weight leaves the Court unable to trace the path of the ALJ’s reasoning from the medical

evidence to his conclusion regarding Plaintiff’s limitations. It also leaves the Court concerned that

the ALJ substituted his own medical determination for that of the actual medical professionals

whose opinions appear in the record, in violation of the Seventh Circuit Court of Appeals’ repeated

warning that ALJs are not to make their own independent medical findings and should not “succumb

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to the temptation to play doctor” because “lay intuitions about medical phenomena are often wrong.”

 Schmidt v. Sullivan, 914 F.2d 117, 118 (7th Cir. 1990) (citing cases); see also, e.g., Myles v. Astrue,

582 F.3d 672, 677-78 (7th Cir. 2009) (warning that an ALJ may not “play[] doctor and reach[] his

own independent medical conclusion”); Blakes v. Barnhart, 331 F.3d 565, 570 (7th Cir. 2003);

Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996). 

Not only did the ALJ not identify any medical sources which he afforded weight, he also

failed to explain how he accounted for Plaintiff’s impairments in the RFC. The RFC is an

assessment of what work-related activities the 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);

416.1545(a)(1). In evaluating a claimant’s RFC, an ALJ is expected to take into consideration all

of the relevant evidence, including both medical and non-medical evidence. See 20 C.F.R. §§

404.1545(a)(3); 416.945(a)(3). Plaintiff argues that the ALJ did not explain what limitations he

provided to account for Plaintiff’s back pain or why other limitations in the record, such as

Plaintiff’s need to elevate her legs, were ignored. Indeed, the record contains multiple indications

that Plaintiff needed to elevate her legs, including physician notes as well as Plaintiff’s and her

husband’s testimony, but the RFC does not include a provision for elevating her legs. In fact, the

ALJ did not explain how the RFC incorporates any limitations Plaintiff suffers as a result of her back

pain, leaving the Court unable to trace the path of the ALJ’s reasoning. See Scott, 297 F.3d at 595

(reminding that the ALJ must build an “accurate and logical bridge from the evidence to his

conclusion”) (quoting Steele v. Barnhart, 290 F.3d 936, 941 (7th Cir. 2002)). 

The ALJ also did not explain how Plaintiff’s migraines or problems with dizziness were

incorporated into the RFC. The medical records, including those summarized by the ALJ, include

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repeated complaints of migraines and episodes of dizziness with occasional loss of consciousness,

although Plaintiff did not initially complete her request for benefits based on these impairments and

does not argue that they alone are disabling. The ALJ did not find Plaintiff’s migraines or syncope

to be severe impairments. However, “[a]lthough [] impairments may not on their own be disabling,

that would only justify discounting their severity, not ignoring them altogether. Moreover, . . . an

ALJ must consider the combined effects of all of the claimant’s impairments, even those that would

not be considered severe in isolation.” Terry v. Astrue, 580 F.3d 471, 477 (7th Cir. 2009); see also

Martinez v. Astrue, 630 F.3d 693, 698 (7th Cir. 2011) (“Even if each problem assessed separately

were less serious than the evidence indicates, the combination of them might be disabling.”); Getch

v. Astrue, 539 F.3d 473, 483 (7th Cir. 2008) (“[A]n ALJ is required to consider the aggregate effects

of a claimant’s impairments, including impairments that, in isolation, are not severe.”) (citing 20

C.F.R. § 404.1523; Golembiewski v. Barnhart, 322 F.3d 912, 918 (7th Cir. 2003)). 

In this case, the ALJ’s summary of Plaintiff’s medical records included reference to

migraines and syncope. However, the ALJ barely discussed these symptoms and did not explain

either why he discounted them or, if he did not, how he incorporated their limiting effects into the

RFC. Even though they may not themselves be disabling, dizziness, fatigue, and loss of

consciousness could obviously affect Plaintiff’s capacity for work. Despite that, the ALJ’s opinion

does not include any discussion of their limiting effects, either as part of the RFC or to describe why

he completely discounted them, and this omission is an error. See Campbell v. Astrue, 627 F.3d 299,

306 (7th Cir. 2010) (“A decision denying benefits need not discuss every piece of evidence, but if

it lacks an adequate discussion of the issues, it will be remanded.”); Golembiewski, 322 F.3d at 917

(“[T]he ALJ may not ignore an entire line of evidence that is contrary to the ruling.”).

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Although the ALJ need not specifically include every limitation alleged by Plaintiff in the

RFC, she must consider the combination of impairments, and explain how she incorporated all of

symptoms and limitations into the RFC. “In determining an individual’s RFC, the ALJ must

evaluate all limitations that arise from medically determinable impairments, even those that are not

severe, and may not dismiss a line of evidence contrary to the ruling.” Villano v. Astrue, 556 F.3d

558, 563 (7th Cir. 2009) (citing SSR 96-8p, 1996 WL 374184 (Jul. 2, 1996)); Golembiewski, 322

F.3d at 917). This the ALJ failed to do, and this case must be remanded for a new RFC that

incorporates all of Plaintiff’s limitations, including an explanation of how the limitations from each

of her impairments (particularly her severe impairments, but also those that are not severe), alone

and in combination, are taken into account in the RFC. 

Plaintiff also argues that the ALJ improperly analyzed her subjective statements. An ALJ

is not required to give full credit to every statement of pain made by the claimant or to find a

disability each time a claimant states he or she is unable to work, but “must ‘consider the entire case

record and give specific reasons for the weight given to the individual’s statements.’” Shideler v.

Astrue, 688 F.3d 306, 311 (7th Cir. 2012) (quoting Simila v. Astrue, 573 F.3d 503, 517 (7th Cir.

2009)). The ALJ mentioned some statements of Plaintiff’s that he appears to have found less-thancredible. It appears that he used Plaintiff’s misstatements about the timing and extent of her weight

gain and the fact that she tried marijuana for pain relief as justifications to misbelieve the entirety

of her testimony, but the ALJ did not explain how those statements made Plaintiff’s testimony about

her pain and physical limitations less believable.

Similarly, the ALJ did not explain how much weight he gave to the testimony of Plaintiff’s

husband, although it appears that he disregarded it. At the very least, the ALJ appears to have

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ignored his testimony regarding Plaintiff’s fatigue and need to elevate her legs, limitations that, as

discussed above, were not incorporated into the RFC. Although the ALJ was not required to credit

all of the husband’s statements, he was required to address the weight given to these statements and

consider how they supported or were inconsistent with other evidence in the record. SSR 06-03P,

2006 WL 2329939, *4 (Aug. 9, 2006) (requiring the ALJ to address factors such as: “How long the

source has known and how frequently the source has seen the individual; How consistent the opinion

is with other evidence; The degree to which the source presents relevant evidence to support an

opinion; How well the source explains the opinion; [and] Whether the source has a specialty or area

of expertise related to the individual’s impairment(s)”); see also 20 C.F.R. § 404.1545(a)(3). The

failure of the ALJ to do leaves the Court unable to determine whether the ALJ adequately considered

the record as a whole, and removes further planks from the already-failing “logical bridge” from the

evidence to the ALJ’s conclusions.

In short, the ALJ’s summary of the portions of the medical record, without analysis or

description of how that medical evidence supported Plaintiff’s claimed limitations, and discounting

of all medical source statements and testimony describing Plaintiff’s actual work-related physical

limitations, leaves the Court unable to determine what the ALJ based his opinion on. See Scrogham

v. Colvin, 765 F.3d 685, 698 (7th Cir. 2014) (“[T]he ALJ identified pieces of evidence in the record

that supported her conclusion that [the plaintiff] was not disabled, but she ignored related evidence

that undermined her conclusion. This ‘sound-bite’ approach to record evaluation is an impermissible

methodology for evaluating the evidence.”); Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010)

(“An ALJ has the obligation to consider all relevant medical evidence and cannot simply

cherry-pick facts that support a finding of non-disability while ignoring evidence that points to a

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disability finding.”). 

On remand, the ALJ is reminded of the need to thoroughly analyze the medical evidence and

personal testimony in the record, particularly statements relating to Plaintiff’s ability to perform

work-related activity, and to thoroughly explain how claimed limitations are either incorporated into

the RFC or found to be unsupported.

IV. Conclusion

For the foregoing reasons, the Court hereby GRANTS the relief requested in Plaintiff’s

Opening Brief in a Social Security Matter [DE 13] and REMANDS this matter for further

proceedings consistent with this opinion.

SO ORDERED this 20th day of September, 2017.

s/ John E. Martin 

MAGISTRATE JUDGE JOHN E. MARTIN

UNITED STATES DISTRICT COURT

cc: All counsel of record

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