In the

United States Court of Appeals

For the Seventh Circuit ____________________ 

No. 22-2381 

ANGEL COMBS, 

Plaintiff-Appellant, 

v.

KILOLO KIJAKAZI, 

Acting Commissioner of Social Security, 

Defendant-Appellee. 

____________________ 

Appeal from the United States District Court for the

Northern District of Indiana, Fort Wayne Division.

No. 1:21-cv-00328 — William C. Lee, Judge. 

____________________ 

ARGUED MARCH 31, 2023 — DECIDED MAY 30, 2023 

____________________ 

Before EASTERBROOK, RIPPLE, and WOOD, Circuit Judges. 

RIPPLE, Circuit Judge. Angel Combs filed for disability benefits on August 2, 2019. An Administrative Law Judge (“ALJ”) 

considered her claim and determined that Ms. Combs was not 

disabled at any time since the alleged onset of disability. On 

review, the district court concluded the ALJ’s determination 

was supported by substantial evidence.
2 No. 22-2381 

In this court, Ms. Combs maintains that the ALJ should 

have concluded that she suffered a closed period of disability 

from June 2019 to July 2020. Nevertheless, the record amply 

supports the ALJ’s conclusion that Ms. Combs was not disabled at any time, including during this period. We therefore 

affirm the judgment of the district court. 

I.

BACKGROUND

A.

The evidence in the administrative record reveals that 

Ms. Combs suffers from several physical and mental impairments including lumbar spondylosis, diabetes, and migraines. She sought treatment for lower back pain in March 

2018 at PPG Pain Management Clinic (“PPG”), where she received an epidural steroid injection. Due to a loss of insurance, she did not return to PPG until May 2019, when she 

sought treatment for radiating lower back pain. She reported 

that her pain was aggravated by standing in one spot and mitigated by lying down. The pain did not disturb her sleep. 

Dr. Kenneth Austin’s notes of that visit indicate that 

Ms. Combs’s straight-leg test was positive for radicular pain 

on the right side; she also had pain with flexion at her hips, 

tenderness in her lower back, and an antalgic gait. He also 

noted that Ms. Combs had normal ranges of motion, normal 

sensation, normal reflexes, and full strength. He replaced her 

Tizanidine (a muscle relaxant) with Gabapentin (for nerve 

pain) and refilled her Diclofenac (an anti-inflammatory). He 

scheduled her for a right medial branch block, encouraged 

daily low-impact exercise, and referred her to physical therapy and nutrition services. 
No. 22-2381 3

Ms. Combs returned to PPG on June 19, 2019. She reported 

improvement with Gabapentin and Diclofenac without side 

effects. She was no longer going to physical therapy. Dr. Austin observed that Ms. Combs had an antalgic gait and tenderness to the touch in the lower back, but her straight-leg test 

was negative for radicular pain. Although Dr. Austin’s treatment notes from that visit state the “professional judgement 

that this patient’s diagnosis requires narcotic therapy for their 

management of pain for greater than 7 days,” Ms. Combs was 

not prescribed narcotic pain medication.1 She was scheduled 

for a medial branch block later that month. 

On June 28, 2019, Ms. Combs received a right medial 

branch block at the L3 level of her lumbar spine. The administration of the branch block took ten minutes with no complications. Two weeks later, Ms. Combs returned to PPG and reported that the branch block provided one hundred percent 

relief for three days.2She stated that she was not experiencing 

any side effects from her medications, Gabapentin and Diclofenac. Her physical exam revealed a normal range of motion 

without pain. Her treatment plan included a second medial 

branch block and a follow-up appointment in three months. 

Her medications were not changed.

Ms. Combs received a second right medial branch block 

on July 26, 2019. The administration of the branch block took 

ten minutes with no complications. At her follow-up appointment, Ms. Combs indicated that the branch block gave her 

ninety-five percent pain relief for four days. Nurse 

1 A.R. 367.

2 Id. at 347.
4 No. 22-2381 

Practitioner Sheila Barlow observed that Ms. Combs was 

again tender to the touch on her lower back, but had a normal 

range of motion without pain reproduction, as well as normal 

strength, sensation, and gait. Ms. Combs was continued on 

the same dosage of Gabapentin and Diclofenac; she also was 

counseled about the importance of activity modification, dietary changes, and tobacco cessation.3

 

On November 5, 2019, Ms. Combs saw Dr. Gianna Casini 

at PPG. Dr. Casini observed that Ms. Combs was again tender 

to the touch on her lower back, but otherwise had a normal 

examination. She performed a right L3-sacral radiofrequency 

ablation, a procedure in which radio waves are sent through 

a needle to heat an area of the nerve and prevent it from sending pain signals to the brain. The procedure took twenty 

minutes. 

On December 4, 2019, Ms. Combs returned to PPG for a 

follow-up appointment. Ms. Combs indicated that the radiofrequency ablation performed one month earlier had given 

her eighty percent pain relief to date. Ms. Combs’s examination was the same as it had been at the last appointment, and 

her medications remained the same.4

 

On December 31, 2019, Dr. Casini administered a left L3-

sacral medial branch block. The procedure took nine minutes. 

At her follow-up appointment, Ms. Combs reported that the 

3 The notes from an October 2019 appointment addressing Ms. Combs’s 

diabetes state that Ms. Combs was negative for “arthralgias, back pain and 

joint swelling.” Id. at 646.

4 In December 2019, Ms. Combs’s counseling notes stated that Ms. Combs 

had a normal gait and normal strength.
No. 22-2381 5

branch block gave her eighty percent relief lasting two days. 

Ms. Combs’s medications remained the same, and she again 

was counseled on the importance of activity modification and 

dietary changes.5 

On March 10, 2020, Ms. Combs saw Dr. Casini, who administered a left medial branch block. The procedure lasted 

ten minutes. At a follow-up appointment a week later, 

Ms. Combs reported that the branch block had given her 

ninety percent relief for four days. Ms. Combs’s examination 

revealed a “[n]ormal range of motion without pain reproduction,” and she was continued on the same medications and 

dosages.6

In June 2020, Ms. Combs saw Nurse Practitioner Barlow. 

Ms. Combs’s physical exam was unchanged, and she was 

continued on the same medications and dosages. The treatment notes indicate that Ms. Combs would be scheduled for 

a left radiofrequency ablation as soon as COVID protocols 

were eased.

On July 14, 2020, Dr. Casini performed a left sacral radiofrequency neurotomy (another name for radiofrequency ablation) on Ms. Combs; the procedure took twenty minutes.7

Two months later, Ms. Combs reported to Nurse Practitioner 

5 On January 20, 2020, Ms. Combs attended a counseling session in which 

she reported that she “cleans and keeps the inside of the house maintained.” Id. at 914.

6 Id. at 729–30.

7 At a counseling session on August 17, 2020, Ms. Combs related that she 

was still having “quite a bit of pain” in her back that was making it difficult to do chores like vacuuming and sweeping. Id. at 894.
6 No. 22-2381 

Barlow that the procedure had provided ten percent relief to 

date. Her physical exam revealed a normal gait and “[n]ormal 

range of motion with minimal pain reproduction,” but she 

was experiencing some “[p]ain radiation down right hip to 

feet.”8 Nurse Practitioner Barlow recommended that she get 

an x-ray of her lower back before her next appointment. Regarding her medications, Ms. Combs stayed on the same dosages of Diclofenac and Gabapentin; she had not been taking 

her Gabapentin for a month because she thought she was out 

of refills. Ms. Combs was not prescribed any narcotic pain 

medication.9

 

On December 10, 2020, Ms. Combs had an appointment 

with Nurse Practitioner Barlow in which she reported that her 

pain was approximately a four out of ten. Her straight leg test 

was “negative to radicular pain,” and she had a normal range 

of motion and gait.10 Her medications were unchanged, and a 

follow-up appointment was scheduled in eight weeks.

B.

Ms. Combs applied for Disability Insurance Benefits on 

August 2, 2019, alleging an onset of disability of December 24, 

2015. The claim was denied initially and upon reconsideration. 

8 Id. at 707.

9 On October 12, 2020, Ms. Combs had a telephonic counseling session in 

which she reported that she was watching her granddaughter while her 

daughter attended college. 

10 Id. at 700.
No. 22-2381 7

Ms. Combs filed a request for a hearing, and a telephonic 

hearing was held before an ALJ on March 26, 2021. At the 

hearing, Ms. Combs testified that her back pain prevented her 

from standing in one spot for more than ten minutes at a time 

before she had to sit down. The various interventions—injections and nerve blocks—had not brought her any relief. She 

further testified that there were days that her back was 

“worse,” to the point that she could “barely move” and had 

to have someone “help [her] physically out of [her] bed” because she felt “paralyzed.”11 

The ALJ issued an unfavorable decision. The ALJ found 

that Ms. Combs had the following severe impairments: 

lumbar spondylosis, asthma, migraines/headaches, chronic pain syndrome, diabetes with diabetic polyneuropathy, obesity, attention deficit 

hyperactivity disorder, schizoaffective disorder, bipolar type, posttraumatic stress disorder, 

social anxiety disorder, generalized anxiety disorder, and borderline personality disorder.12 

However, the ALJ continued, Ms. Combs’s statements related 

to “the intensity, persistence and limiting effects of the[] 

symptoms” of these impairments were “not entirely consistent with the medical evidence and other evidence in the 

record.”13 Thus, the ALJ concluded that Ms. Combs had the 

residual function to

11 Id. at 44.

12 Id. at 17.

13 Id. at 21.
8 No. 22-2381 

perform light work ... except that the claimant 

can occasionally climb ramps and stairs, she can 

never climb ladders, ropes, scaffolds, she can 

occasionally balance, stoop, kneel, crouch, and 

crawl, and she should avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, wet, slippery or uneven surfaces, and unguarded moving machinery. In addition, the 

claimant can understand, remember, and carry 

out simple instructions and tasks, ... make judgments related to simple decisions, ... respond 

appropriately to brief interactions with coworkers and supervisors[.] [S]he should avoid work 

activity performed in tandem with others, she 

should avoid work activity requiring interactions with the general public, she can respond 

appropriately to usual work situations, and she 

can deal with routine changes in a routine work 

setting.14 

The ALJ also determined that, even with these limitations, 

there were jobs in the national economy, in significant numbers, that Ms. Combs could perform. The ALJ thus found that 

Ms. Combs “was not under a disability, ... at any time from 

14 Id. at 20 (emphasis removed).
No. 22-2381 9

December 24, 2015,[

15] the alleged onset date, through December 31, 2020, the date last insured.”16

C.

Ms. Combs brought this action in district court. She maintained that the ALJ “erred in not finding a closed period of 

disability from at least February 21, 2018 to a reasonable time 

of healing after July 14, 2020 due to her back impairment, her 

pain, and her multiple invasive procedures that would have 

rendered her off task or absent beyond employer tolerances.”17 The district court disagreed. It noted that the ALJ’s 

determination included a detailed discussion of Ms. Combs’s 

treatment history and physical examination findings 

throughout the relevant period. These revealed that, during 

the relevant period, Ms. Combs underwent several injections 

and procedures for back pain, which provided her with some 

relief. Moreover, her physical exams during this time revealed normal strength and range of motion. In short, the ALJ 

had considered all of the evidence and had reasonably 

15 Although the ALJ references Ms. Combs’s onset date, the ALJ only considered evidence from October 2018 forward. This is because Ms. Combs 

had pursued other disability claims through the administrative process, 

and those claims had ended in adverse administrative findings that were 

not appealed. Thus, at the outset of Ms. Combs’s hearing in this action, the 

ALJ clarified that the earliest date that Ms. Combs could be found to be 

disabled was “the date following the prior hearing decision,” which was 

sometime in October 2018. Id. at 36. 

16 Id. at 26 (emphasis removed).

17 R.25 at 4–5.
10 No. 22-2381 

concluded that Ms. Combs was capable of light work that accommodated her documented limitations. 

Ms. Combs timely appealed.

II.

DISCUSSION

“We review de novo the district court’s affirmance of the 

ALJ’s decision and review directly the decision of the ALJ.” 

Butler v. Kijakazi, 4 F.4th 498, 501 (7th Cir. 2021). We will affirm 

the ALJ’s decision if it is supported by substantial evidence. 

See 42 U.S.C. § 405(g); Biestek v. Berryhill, 139 S. Ct. 1148, 1152 

(2019). “[S]ubstantial evidence” is “such relevant evidence as 

a reasonable mind might accept as adequate to support a conclusion.” Simila v. Astrue, 573 F.3d 503, 513 (7th Cir. 2009) 

(quoting Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008)). If 

reasonable minds could disagree on whether a claimant is disabled based on the evidence, a reviewing court must affirm 

the agency’s decision to deny benefits. Elder v. Astrue, 529 F.3d 

408, 413 (7th Cir. 2008). 

An individual is entitled to disability benefits if the person 

is unable “to do any substantial gainful activity by reason of 

any medically determinable physical or mental impairment 

which ... has lasted or can be expected to last for a continuous 

period of not less than 12 months.” 20 C.F.R. § 404.1505(a). 

Thus, a disability for a continuous period of twelve or more 

months entitles a person to benefits for that period of time. 

The burden is on the claimant to establish disability. See 

Bowen v. Yuckert, 482 U.S. 137, 146 (1987). 
No. 22-2381 11

A.

Ms. Combs now maintains that the ALJ’s determination is 

not supported by substantial evidence because it failed to recognize a closed period of disability between June 2019 and 

July 2020. Specifically, Ms. Combs faults the ALJ for failing to 

acknowledge that her back pain was at its worst during this 

period as evidenced by the numerous procedures that she underwent. Second, the ALJ’s decision was deficient because it 

failed to discuss the medial branch blocks in December 2019 

and March 2020. Finally, Ms. Combs submits, the ALJ did not 

consider the excessive number of absences Ms. Combs would 

have incurred during the relevant period. We consider each 

of these.

Turning to Ms. Combs’s first contention, she maintains 

that the record establishes a closed period of disability from 

June 2019 to July 2020 because, “[d]uring this fourteen-month 

period, [she] had six spinal procedures done, of increasing severity.”18 Ms. Combs’s characterization of her spinal procedures is not supported by the record. Ms. Combs received the 

same procedure—a medial branch block—on four occasions: 

June 2019 (right side), July 2019 (right side), December 2019 

(left side), and March 2020 (left side). None of these procedures took longer than ten minutes. She also had two ablation 

procedures: November 2019 (right side) and July 2020 (left 

side). Neither of these procedures took more than twenty 

minutes. This treatment regimen, without further clinical 

elaboration, does not establish that the treatments were of increasing severity or indicate a disabling condition.

18 Appellant’s Br. 15.
12 No. 22-2381 

Additionally, although Ms. Combs maintains that the frequency of her treatments is evidence that her back condition 

“was at its worse [sic] from June 2019 through July 2020,”19

her hearing testimony did not distinguish the pain she endured before, during, or after the relevant period. Ms. Combs 

stated that she had been suffering debilitating back pain at 

least since 2018, and that the “injections” and procedures that 

“burnt the nerves” did not bring her relief.20 According to 

Ms. Combs, at the time of the hearing, she still was experiencing days where her back was “awful,” she could “barely 

move,” and it felt as if she were “paralyzed almost.”21 Thus, 

Ms. Combs’s testimony undermines her argument that her 

back condition clearly was worse during the proposed closed 

period.

Ms. Combs’s second contention—that the ALJ failed to 

mention, and therefore must have ignored, relevant evidence—is also unpersuasive. Although the ALJ may not ignore “an entire line of evidence that supports a finding of disability,” Jones v. Astrue, 623 F.3d 1155, 1162 (7th Cir. 2010), the 

19 Id.

20 See A.R. 38–40. This testimony is in tension with the contemporaneous 

statements that Ms. Combs made to her medical providers. At the time 

she underwent these procedures, she reported experiencing between ten

and one hundred percent pain relief that lasted between a few days and a 

few months. See, e.g., id. at 347, 702, 724, 748, 775. The ALJ’s decision took 

note of these discrepancies, stating that “the claimant’s statements concerning the intensity, persistence and limiting effects of these symptoms 

are not entirely consistent with the medical evidence and other evidence 

in the record for the reasons explained in this decision.” Id. at 21.

21 Id. at 44. 
No. 22-2381 13

ALJ is not required to mention every piece of evidence, Gedatus v. Saul, 994 F.3d 893, 901 (7th Cir. 2021). Here, the ALJ did 

not mention the medial branch blocks that took place in December 2019 and March 2020. However, the ALJ mentioned 

the two other medial blocks as well as the ablation procedures. The evidence recited by the ALJ shows an understanding that Ms. Combs was undergoing multiple and different 

procedures for pain relief on both the left and right side of her 

back. Thus, the ALJ did not ignore an entire line of evidence 

that would have supported a finding of disability.

Ms. Combs lastly submits that the ALJ should have considered the amount of time that she would have missed work 

between June 2019 and July 2020. Ms. Combs estimates that 

she would have missed fourteen and one-half days of work 

during this period due to her multiple procedures and appointments. Ms. Combs submits that this number of absences 

would have been unacceptable to any employer and therefore 

rendered her unemployable during this period.22 

There is no evidence in the record to support the time estimates that Ms. Combs employs. By way of example, 

Ms. Combs assigns one day off work for each of the medial 

branch blocks. However, the record shows that each of these 

lasted only ten minutes. Given that one of these procedures 

took place at 3:30 p.m., it is difficult to see how this would 

have necessitated a full day off work. See Barnett v. Apfel, 231 

22 The Commissioner maintains that this argument was forfeited because 

it was not made before the district court. See Appellee’s Br. 24. Although 

the argument before the district court was paltry, the district court nevertheless recognized the argument and addressed it. See R.25 at 5. Therefore, 

it has not been forfeited.
14 No. 22-2381 

F.3d 687, 691 (10th Cir. 2000) (rejecting argument that the ALJ 

should have “consider[ed] plaintiff’s absenteeism” when 

“plaintiff’s ... extrapolation of how many days she [would] 

have missed from work ... assume[d] she was required to 

miss entire days of work for each appointment”). Therefore, 

Ms. Combs has not met her burden of showing that the additional appointments would have resulted in a level of absenteeism that employers would have found unacceptable.

B.

Ms. Combs submits that, even if the record does not compel a finding that she was disabled between June 2019 and 

July 2020, her case should be remanded because it was incumbent upon the ALJ to address explicitly whether she endured 

a closed period of disability. Ms. Combs relies upon two cases 

in support of this contention: Reed v. Colvin, 656 F. App’x 781 

(7th Cir. 2016), and Jackson v. Astrue, No. 09 C 50028, 2010 WL 

4793309 (N.D. Ill. Nov. 18, 2010). Neither case is helpful to 

Ms. Combs.

In Reed, the claimant was injured in a car accident and underwent surgery. Her application for disability benefits was 

denied, and she maintained that the ALJ had not “adequately 

explain[ed] why she did not satisfy the standard for disability 

for at least the 12 months following the accident.” Id. at 788. 

We upheld the ALJ’s determination even though the ALJ had 

“not separately explain[ed] the basis for concluding that Reed 

was not disabled for at least the 12 months after the accident.” 

Id. We noted that “[t]he ALJ’s discussion of the medical evidence from that period makes evident her conclusion that 

Reed’s injuries had healed and ceased to prevent a return to 

work long before the one-year anniversary of the accident.” 

Id. 
No. 22-2381 15

Here, as in Reed, the ALJ discussed the medical records 

from the proposed period of disability. Those records reveal 

largely normal physical evaluations, no prescriptions for narcotics,23 and minor procedures to relieve back pain. The ALJ’s 

recitation makes it evident that the ALJ did not believe that 

Ms. Combs was disabled during this time.

Jackson presents a scenario different from that in Reed and 

the present case. Jackson involved a claimant who slipped and 

fell in July 2004, necessitating ankle surgery. In February 2005, 

while still healing from the ankle surgery, she developed “a 

large disc herniation,” and a microdiskectomy was performed 

in May 2005. Jackson, 2010 WL 4793309, at *14. The following 

month, while recovering from her back surgery, the claimant 

was hospitalized for deep vein thrombosis. Despite these repeated, serious incidents over a twelve-month period, the ALJ 

had “not ma[d]e clear during Claimant’s hearing or in his decision that he considered the possibility of a closed period of 

disability around the times Claimant underwent her surgeries.” Id. Consequently, the district court remanded the case to 

the ALJ. 

Here, unlike in Jackson, there was no clear evidence of serious, repeated medical interventions over a defined period 

of time that should have alerted the ALJ to consider a closed 

period of disability. There were no falls, trips to the emergency room, surgeries, or hospitalizations that would have 

23 The notes from several of Ms. Combs’s appointments contain the following statement: “It is our professional judgment that this patient’s diagnosis requires narcotic therapy for their management of pain for greater 

than 7 days.” See, e.g., A.R. 367. Nevertheless, Ms. Combs was not prescribed narcotics for pain.
16 No. 22-2381 

apprised the ALJ that Ms. Combs’s back pain was becoming 

more serious. 

Moreover, Ms. Combs has struggled to identify consistent 

dates to bookend the proposed closed period. In the district 

court, Ms. Combs argued that the ALJ “erred in not finding a 

closed period of disability from at least February 21, 2018 to a 

reasonable time of healing after July 14, 2020.”24 In this court, 

however, the proposed closed period is June 2019 to July 

2020.25 We cannot fault the ALJ for failing to consider a closed 

period that Ms. Combs herself has had difficulty identifying. 

Conclusion

The record supports the ALJ’s determination that 

Ms. Combs was not disabled during a closed period between 

June 2019 and July 2020. We therefore affirm the judgment of 

the district court.

AFFIRMED

24 R.21 at 10.

25 See Appellant’s Br. 15.