IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

FARZAD K.,

Plaintiff,

v.

KILILO KIJAKAZI, Commissioner of the 

Social Security Administration,

Defendant.

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No. 20-cv-2594

Magistrate Judge Susan E. Cox

MEMORANDUM OPINION AND ORDER

Plaintiff Farzad K.

1 (“Plaintiff”) appeals the decision of the Commissioner of the Social 

Security Administration (“Commissioner”) denying his application for disability insurance benefits 

(“DIB”) under the Social Security Act. The Parties have filed cross motions for summary judgment.

2

For the reasons detailed below, the Commissioner’s Motion for Summary Judgment (dkt. 32) is 

denied and Plaintiff’s motion (dkt. 27) is granted. The case is remanded for further proceedings 

consistent with this opinion. 

I. Background

On May 5, 2017 Plaintiff filed claims for DIB with an onset date of September 3, 2015. 

(R.15.) The claim was denied initially and upon reconsideration, after which Plaintiff timely 

requested a hearing before an Administrative Law Judge (“ALJ”). The hearing was held on December 

20, 2018. (R. 15.) On March 20, 2019, ALJ Kimberly Cromer denied Plaintiff’s claim, finding him

not disabled under the Act and therefore ineligible for benefits. (R. 15-29.) The Appeals Council 

denied Plaintiff’s request for review on March 17, 2020 (R. 1-5), leaving the ALJ’s decision as the 

1 In accordance with Northern District of Illinois Internal Operating Procedure 22, the Court refers to Plaintiff only by 

his first name and the first initial of his last name(s).

2 Plaintiff filed a Memorandum in Support of Summary Remand (Dkt. 27), which this Court construes as a motion for 

summary judgment.

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final decision of the Commissioner, reviewable by the District Court under 42 U.S.C. § 405(g). See 

Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005). 

The ALJ issued a written decision on March 20, 2019, following the five-step analytical 

process required by 20 C.F.R. § 416.920. At step one, the ALJ found that Plaintiff has not engaged 

in substantial gainful activity since September 3, 2015. (R. 17.) At step two, the ALJ concluded that 

Plaintiff has the severe impairments of morbid obesity, arthritis, asthma/chronic obstructive 

pulmonary disease, anxiety and depression. (R. 17.) At step three, the ALJ concluded that Plaintiff 

does not have an impairment or combination of impairments that meet or medically equal the severity 

of a listed impairment. (R. 18.) The ALJ next found that Plaintiff retained the residual functional 

capacity (“RFC”) to perform sedentary work with the following restrictions: no climbing of ladders, 

ropes, or scaffolds; occasional climbing of ramps or stairs; occasional balancing, stooping, crouching, 

kneeling, but no crawling; occasional operation of foot controls and bilateral reaching overhead; no 

working in environments of unprotected heights or around hazardous machinery and environments 

of concentrated exposure to vibration; limited to simple routine tasks with no work with general public 

as part of his routine job duties and only occasional interaction with coworkers and supervisors; no 

fast-paced production such as assembly lines or work where the machine sets the pace, but must be 

allowed to work at a variable rate; no strict hourly production requirements, only end-of-the-day work 

goals and no tandem tasks. (R. 21-22.) At step four, the ALJ concluded that Plaintiff was able to 

perform his past relevant work as an assembler. (R. 28.) Although not necessary after the step four 

finding, the ALJ determined that, in light of Plaintiff’s age, education, work experience and RFC, 

there are jobs that exist in significant numbers in the national economy that he can perform. (R. 28-

29.) These findings led to the conclusion that Plaintiff is not disabled as defined by the Social Security 

Act. (R. 29.) 

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As part of the written opinion, the ALJ discussed Plaintiff’s lengthy medical history, which 

includes longstanding degenerative disc disease in his spine with radiculopathy as well as knee 

cartilage surgery. (R. 378, 401, 489, 500, 2499.) On September 3, 2015, Plaintiff was also involved 

in an armed robbery while at work at a convenience store and was hit in the head with a shotgun; he 

lost consciousness, and medical records around the incident indicate that Plaintiff suffered from postconcussion syndrome and the accompanying symptoms (e.g., vision changes, sensitivity to light, and 

headaches). (R. 841-49.) Additionally, Plaintiff suffered from problems in both shoulders; MRIs 

showed severe acromioclavicular joint hypertrophy, chronic type tearing on the anterior labrum and 

undersurface fraying of the supraspinatus in the right shoulder, and showed moderate tendinosis with 

partial thickness bursal surface tear of the posterior supraspinatus and moderate acromioclavicular 

joint disease in the left shoulder. (R. 415-16, 427-29.) Ultimately, he had to have surgery on both 

shoulders, but continued to report pain and numbness following surgery. (R. 859-61, 877-78.) 

Meanwhile, Plaintiff’s back continued to deteriorate. Diagnostic imaging showed

degenerative disc disease at L2-L3 and a bulging disc at L4-L5; he was diagnosed with lumbar 

radiculopathy and received injections to relieve his pain. (R. 930, 1935.) Plaintiff also had hip 

injuries. An x-ray and an MRI showed degenerative changes in his hips and bilateral sacroiliac joints, 

and possible tear of the anterior/superior labrum. (R. 1936, 1999.) In September 2018, Plaintiff 

underwent a left hip arthroscopy with labral repair, acetabuloplasty, and femoroplasty with capsular 

closure; however, Plaintiff continued to complain of sharp groin pain in the months following the 

surgery. (R. 2965-67, 3396.)

Plaintiff also has mental impairments. Shortly following the armed robbery, Plaintiff began 

relating flashbacks, nightmares, and confusion to his primary care doctor. (R. 527, 538.) He was 

diagnosed with post-traumatic stress disorder (“PTSD”). (R. 538.) Beginning in August 2017, 

Plaintiff began regular therapy sessions with Hank Exline, MSW, who noted PTSD and depression, 

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including nightmares and sleeplessness. (R. 2196.) Plaintiff attended weekly therapy sessions with 

Mr. Exline, who produced detailed notes regarding Plaintiff’s symptoms, diagnoses, and progress. 

(R. 2196-2225.) 

Mr. Exline provided two Mental Capacity Assessments as part of the record, both of which 

were co-signed by a physician’s assistant. The first, from January 2018, indicated that Plaintiff had 

moderate limitations in the following areas: the ability to ignore or avoid distractions while working, 

understand and respond to social cues, respond to requests, suggestions, criticism, correction, and 

challenges, and to keep social interactions free of excessive irritability, sensitivity, 

argumentativeness, or suspiciousness; Mr. Exline found marked limitations in the following areas: 

the ability to manage psychologically based symptoms and handle conflicts with others.3

 (R. 2404-

2406.) The second form from March 2018 had the same boxes checked but included more narrative 

detail. For example, Plaintiff was diagnosed with PTSD and major depressive order, and Mr. Exline 

noted that Plaintiff’s inability to concentrate and manage his mental health symptoms significantly 

affected his “daily functioning,” and that his “ability to interact with others has been significantly 

impaired due to an inability to de-escalate conflicts and respond appropriately to criticism and social 

cues.” (R. 2409-2411.) 

The ALJ analyzed Mr. Exline’s opinion as follows:

The statement of claimant’s therapist that the claimant is able to 

perform one or two step instructions and multistep sequence activities 

is persuasive. It is consistent with the findings on mental status 

examinations of [two consultative examiners]. The medical records do 

not demonstrate the significant medical findings to support an inability 

to engage in sustained work activity. The claimant is able to perform 

simple repetitive tasks on a sustained basis, as supported by the 

evaluations of [a consultative examiner]. [The consultative examiner]

evaluated the claimant on two occasions and found that the claimant 

could return to full-time work.

3 Mr. Exline found either mild or no limitations in the remaining areas listed on the form, including the ability to perform 

one or two step instructions. (R. 2404-2406.)

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(R. 27.)

The ALJ did not make any mention of Plaintiff’s therapy sessions with Mr. Exline or any of 

Mr. Exline’s findings or observations from treatment, other than a brief statement that “[t]he claimant 

underwent treatment at Family Counseling Services” and an acknowledgement that he “continued 

under therapy at Family Counseling Services with Hank Exline, MSW, a therapist into 2018.” (R. 

19-20.) 

In this appeal, Plaintiff’s argument is limited to his contention that the ALJ erroneously 

rejected the opinions of Mr. Exline and his primary care doctor. 

II. Social Security Regulations and Standard of Review

The Social Security Act requires all applicants to prove they are disabled as of their date last 

insured to be eligible for disability insurance benefits. ALJs are required to follow a sequential fivestep test to assess whether a claimant is legally disabled. The ALJ must determine: (1) whether the 

claimant is currently engaged in substantial gainful activity; (2) whether the claimant has a severe 

impairment; and (3) whether the severe impairment meets or equals one considered conclusively 

disabling such that the claimant is impeded from performing basic work-related activities. 20 C.F.R. 

§ 404.1520; 20 C.F.R. § 416.920(a)(4)(i)-(v). If the impairment(s) does meet or equal this standard, 

the inquiry is over and the claimant is disabled. 20 C.F.R. § 416.920(a)(4). If not, the evaluation 

continues and the ALJ must determine (4) whether the claimant is capable of performing his past 

relevant work. Cannon v. Harris, 651 F.2d 513, 517 (7th Cir. 1981). If not, the ALJ must (5) consider 

the claimant’s age, education, and prior work experience and evaluate whether she is able to engage 

in another type of work existing in a significant number of jobs in the national economy. Id. At the 

fourth and fifth steps of the inquiry, the ALJ is required to evaluate the claimant’s RFC in calculating 

which work-related activities she is capable of performing given his limitations. Young v. Barnhart, 

362 F.3d 995, 1000 (7th Cir. 2004). In the final step, the burden shifts to the Commissioner to show 

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there are significant jobs available that the claimant is able to perform. Smith v. Schweiker, 735 F.2d 

267, 270 (7th Cir. 1984).

In disability insurance benefits cases, a court’s scope of review is limited to deciding whether 

the final decision of the Commissioner of Social Security is based upon substantial evidence and the 

proper legal criteria. Scheck v. Barnhart, 357 F.3d 697, 699 (7th Cir. 2004). Substantial evidence 

exists when a “reasonable mind might accept [the evidence] as adequate to support a conclusion.”

Richardson v. Perales, 402 U.S. 389, 401 (1971); Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 

2001). While reviewing a commissioner’s decision, the Court may not “reweigh evidence, resolve 

conflicts in the record, decide questions of credibility, or substitute [its] own judgment for that of the 

Commissioner.” Young, 362 F.3d at 1001. Although the Court reviews the ALJ’s decision 

deferentially, the ALJ must nevertheless “build an accurate and logical bridge” between the evidence 

and his conclusion. Steele v. Barnhart, 290 F.3d 936, 941 (7th Cir. 2002) (internal citation omitted). 

Even where “reasonable minds could differ” or an alternative position is also supported by substantial 

evidence, the ALJ’s judgment must be affirmed if supported by substantial evidence. Elder v. Astrue, 

529 F.3d 408, 413 (7th Cir. 2008); Scheck, 357 F.3d at 699. On the other hand, the Court cannot let 

the Commissioner’s decision stand if the decision lacks sufficient evidentiary support, an adequate 

discussion of the issues, or is undermined by legal error. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 

535,539 (7th Cir. 2003); see also, 42 U.S.C.§ 405(g).

III. Discussion

The ALJ’s rejection of Mr. Exline’s opinion is not based on substantial evidence and requires 

remand. For claims filed after March 27, 2017, the old “treating physician rule”4 has been replaced 

by 20 C.F.R. § 404.1520c. Treating physicians’ opinions are no longer entitled to presumptive 

controlling weight; the Commissioner “will not defer or give any specific evidentiary weight, 

4 20 C.F.R. § 404.1527.

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including controlling weight, to any medical opinion(s) or prior administrative medical finding(s), 

including those from your medical sources.” 20 C.F.R. § 404.1520c(a). Now, the Commissioner 

does not “articulate in each determination or decision how we considered all of the factors for all of 

the medical opinions and prior administrative medical findings in your record;” instead, the ALJ “will 

articulate how [the ALJ] considered the medical opinions or prior administrative medical findings 

from that medical source together in a single analysis using the factors listed in” the regulation. 20 

C.F.R. § 404.1520c(b)(1). Consistency and supportability “are the most important factors we 

consider when we determine how persuasive we find a medical source's medical opinions or prior 

administrative medical findings to be,” and, “[t]herefore we will explain how we considered the 

supportability and consistency factors for a medical source's medical opinions or prior administrative 

medical findings in your determination or decision.” 20 C.F.R. § 404.1520c(b)(2). The ALJ may 

consider the other factors (e.g., the treating relationship or the provider’s specialty), but is not required 

to do so. Id. Regarding the consistency factor, the regulation states “[t]he more consistent a medical 

opinion . . . is with the evidence from other medical sources and nonmedical sources in the claim, the 

more persuasive the medical opinion . . . will be.” 20 C.F.R. § 404.1520c(c)(2). 

The entirety of the ALJ’s discussion of consistency regarding Mr. Exline’s opinion is the 

observation that “[t]he medical records do not demonstrate the significant medical findings to support 

an inability to engage in sustained work activity,” and a citation to the consultative examiner’s finding 

that Plaintiff is able to perform simple repetitive tasks. “Though the ALJ need not discuss every shred 

of evidence in the record, she ‘may not ignore an entire line of evidence’ that runs contrary to her 

conclusions.” McNeal v. Colvin, 2016 WL 1594992, at *7 (N.D. Ill. Apr. 21, 2016) (quoting 

Golembiewski v. Barnhart, 322 F.3d 912, 917 (7th Cir. 2003)).

Here, the ALJ ignored all the evidence from Mr. Exline’s therapy treatment with Plaintiff. 

Although she acknowledged Plaintiff treated with Mr. Exline for weekly therapy, there is no 

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discussion of what those mental health records show.5 As such, the ALJ did not adequately analyze 

how consistent Mr. Exline’s opinions are “with the evidence from other medical sources and 

nonmedical sources in the claim,” as required by the regulations on determining the persuasiveness 

of medical opinions. Without a discussion of that treatment – the diagnoses, the observations, the 

reported symptoms – the Court cannot find that substantial evidence supports the ALJ’s conclusion 

that Mr. Exline’s opinion was inconsistent with the record. In order to make a finding that a medical 

opinion is consistent (or inconsistent) with the evidence from other medical sources, there has to be 

a collection of documents against which the opinion is being compared. The Court recognizes that 

the ALJ compared Mr. Exline’s opinion against the mental status examinations by the consultative 

examiners. However, the lion’s share of the relevant documents relating to Plaintiff’s mental health 

treatment come from Mr. Exline and the other practitioners at Family Counseling Services. The 

ALJ’s failure to examine these records is more than a decision not to discuss a “shred of evidence,” 

but instead amounts to a failure to analyze one of the most crucial swaths of record regarding 

Plaintiff’s mental health conditions.6 Without an understanding of those documents and a comparison 

of Mr. Exline’s opinions against those documents, the Court cannot meaningfully review the ALJ’s 

finding that Mr. Exline’s opinions were inconsistent with the record. In short, there is not substantial 

evidence to support the ALJ’s finding that Mr. Exline’s opinions regarding Plaintiff’s mental health 

conditions are inconsistent with the record, and remand is required for a more robust discussion of 

the mental health treatment notes in this case. 

IV. Conclusion

For the foregoing reasons, the Commissioner’s Motion for Summary Judgment (dkt. 32) is 

5 Additionally, there were several other mental health care providers at Family Counseling services, including Cindy 

Cook, MHP; Andrea Craig, QMHP; Justin Jelinski, LPA, QMHP, MA; and Lorena Perez, QMHP, MA. (R. 2178-2238.) 6 The Court is slightly puzzled by the ALJ’s decision not to discuss the extremely relevant records from Family Counseling 

Services, as the remainder of the ALJ’s opinion did an admirable job thoroughly analyzing the voluminous medical 

records in this case. 

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denied and Plaintiff’s motion (dkt. 27) is granted. The case is remanded for further proceedings 

consistent with this opinion. 

Entered: 10/13/2021

__________________________________

U.S. Magistrate Judge, Susan E. Cox

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