UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

ANDREA H.,

Plaintiff,

v.

KILOLO KIJAKAZI,

ACTING COMMISSIONER OF SOCIAL 

SECURITY,

1

Defendant.

No. 20 CV 1828

Magistrate Judge McShain

MEMORANDUM OPINION AND ORDER

Plaintiff Andrea H. brings this action under 42 U.S.C. § 405(g) for judicial 

review of the Social Security Administration’s (SSA) decision denying her application 

for benefits. For the following reasons, the Court grants plaintiff’s request to reverse 

the SSA’s decision and remand this case to the agency [16],2 denies the Commissioner 

of Social Security’s request to affirm the SSA’s decision [17], and reverses the SSA’s 

decision. 

Background

In late December 2016, plaintiff filed a Title II application for a period of 

disability and disability insurance benefits and a Title XVI application for 

supplemental security income, both alleging an onset date of September 19, 2016. 

[12-1] 15. Plaintiff’s claims were denied initially and on reconsideration. [Id.]. 

Plaintiff requested a hearing, which was held by an administrative law judge (ALJ) 

on October 31, 2018. [Id.]. In a decision dated March 28, 2019, the ALJ ruled that 

plaintiff was not disabled. [Id.] 28. The Appeals Council denied review on January 

24, 2020, making the ALJ’s decision the agency’s final decision. [Id.] 1-3. See 20 C.F.R. 

§§ 404.955, 404.981. 

1 In accordance with Fed. R. Civ. P. 25(d), Kilolo Kijakazi, the Acting Commissioner of Social 

Security is substituted as the defendant in this case in place of the former Commissioner of 

Social Security, Andrew Saul.

2 Bracketed numbers refer to entries on the district court docket. Referenced page numbers 

are taken from the CM/ECF header placed at the top of filings, with the exception of citations 

to the administrative record [12], which refer to the page numbers in the bottom right corner 

of each page.

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Plaintiff timely appealed to this Court [1]. The Court has jurisdiction to review 

the Acting Commissioner’s decision under 42 U.S.C. § 405(g), and the parties have 

consented to my jurisdiction over the case in accordance with 28 U.S.C. § 636(c). [9].

Legal Standard

Under the Social Security Act, disability is defined as “the inability 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. §423(d)(1)(A).

To determine whether a claimant is disabled, the ALJ conducts a sequential

five-step inquiry: (1) whether the claimant has performed any substantial gainful 

activity during the period for which he claims disability; (2) whether the claimant has 

a severe impairment or combination of impairments; (3) whether the claimant’s 

impairment meets or equals any listed impairment; (4) whether the claimant can 

perform his past relevant work (i.e., the claimant retains the residual functional 

capacity (RFC) to perform his past); and (5) whether the claimant is unable to perform 

any other available work in light of his age, education, and work experience (i.e., able 

to perform any other work existing in significant numbers in the national economy). 

See 20 C.F.R. §§ 404.1520(a)(4) & 416.920(a). “An affirmative answer leads either to 

the next step, or on Steps 3 and 5, to a finding that the claimant is disabled. A 

negative answer at any point, other than Step 3, ends the inquiry and leads to a 

determination that the claimant is not disabled.” Clifford v. Apfel, 227 F.3d 863, 868 

(7th Cir. 2000).

“The Court reviews the ALJ’s decision deferentially to determine if it is 

supported by substantial evidence.” 42 U.S.C. §405(g). Substantial evidence is a 

standard that “requires more than a mere scintilla of proof and instead such relevant 

evidence as a reasonable mind might accept as adequate to support a conclusion.” 

Walker v. Berryhill, 900 F.3d 479, 482 (7th Cir. 2018). Substantial evidence is “not a 

high threshold: it means only ‘such relevant evidence as a reasonable mind might 

accept as adequate to support a conclusion.’” Karr v. Saul, 989 F.3d 508, 511 (7th Cir. 

2021) (quoting Biestek v. Berryhill, 139 S. Ct. 1148, 1152 (2019)). But the standard 

“is not entirely uncritical. Where the Commissioner’s decision lacks evidentiary 

support or is so poorly articulated as to prevent meaningful review, the case must be 

remanded.” Brett D. v. Saul, No. 19 C 8352, 2021 WL 2660753, at *1 (N.D. Ill. June 

29, 2021) (internal quotation marks and citation omitted); see also Berger v. Astrue,

516 F.3d 539, 544 (7th Cir. 2008) (“When an ALJ recommends that the agency deny

benefits, it must first ‘build an accurate and logical bridge from the evidence to the

conclusion.’”) (internal citation omitted).

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The ALJ’s Decision

At Step One, the ALJ found that plaintiff had not performed substantial 

gainful activity since her alleged onset date of September 19, 2016. [12-1] 17. At Step 

Two, the ALJ determined that plaintiff had the following severe impairments: 

obesity; thrombophlebitis; hypertension; gastrointestinal stromal tumor status post 

resection and treatment; depressive disorder; and migraines. [Id.] 18. 

At Step Three, the ALJ ruled that plaintiff did not have an impairment or 

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

impairments in 20 C.F.R. Part 404, Subpart P, App’x 1. [Id.]. During Step Three, the 

ALJ considered whether plaintiff’s mental impairments satisfied the “Paragraph B” 

criteria. [Id.] 20-21. The ALJ found plaintiff had moderate limitations in

concentrating, persisting, or maintaining pace and interacting with others. [Id.] 20. 

The ALJ additionally found plaintiff had a mild limitation with regard to adapting or 

managing oneself and no limitation in understanding, remembering, or applying 

information. [Id.] 20-21.

Before turning to Step Four, the ALJ found that, considering the entire record, 

plaintiff had the RFC to perform sedentary work as defined in 20 C.F.R. §§ 

404.1567(a) and 416.967(a) except plaintiff cannot: climb ladders, ropes, or scaffolds; 

kneel, crouch, or crawl; or be exposed to unprotected heights or hazardous machinery. 

[Id.] 21. The ALJ also found plaintiff could occasionally climb ramps and stairs, and 

that she retained the capacity to understand, remember, concentrate, persist, and 

perform simple, routine, and repetitive work in a low stress environment, which is 

defined as having few, if any, work-related decisions and changes in the work setting. 

[Id.]. The ALJ then added two limitations to the RFC: plaintiff requires a sit-stand 

option, explaining she will need to stand every hour for two minutes and sit again, 

and she must have only occasional interactions with coworkers and the public. [Id.]

In making this finding, the ALJ considered plaintiff’s administrative hearing 

testimony and medical evidence, specifically: (a) plaintiff’s function report; (b) 

plaintiff’s work history report; (c) treatment notes; and (d) physical RFC assessments 

of plaintiff conducted by treating physician Dr. Sachit Sharma and non-examining 

state agency physician consultants Dr. Phillip Galle and Dr. Calixto Aquino. [Id.] 18, 

20, 23, 25. Regarding plaintiff’s physical issues, the ALJ focused on plaintiff’s 

conservative treatment regimen and plaintiff’s denial of common cardiovascular or 

neurological symptoms. [Id.] 23-24. The ALJ found plaintiff’s alleged symptoms were 

inconsistent with medical records that demonstrated “overall . . . normal or only 

slightly diminished cardiovascular, gastrointestinal, musculoskeletal, and 

neurological functioning.” [Id.] 24. Regarding plaintiff’s depression, the ALJ focused 

on treatment notes that indicated plaintiff’s mental health difficulties stemmed from 

situational stressors rather than unpredictable psychiatric pathologies. [Id.]. The 

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ALJ pointed out that plaintiff was not always compliant with her counseling regimen 

and regularly displayed normal behavior and overall psychiatric functioning. [Id.].

The ALJ then detailed the weight she gave to the opinions of medical experts

in this matter, and her reasoning for such weight, as follows: 

• The ALJ gave little weight to the opinion of treating physician Dr. Sharma who 

concluded plaintiff cannot sit more than thirty minutes at one time and would 

be absent from work about three days per month due to her physical 

impairments. [Id.] 25 (citing [12-8] 773-75). The ALJ explained Dr. Sharma’s 

conclusion was inconsistent with the medical evidence such as treatment notes 

that routinely reported plaintiff had normal or only slighted diminished 

physical functioning. [Id.]. The ALJ also found Dr. Sharma’s conclusion that 

plaintiff would be absent three days a month undermined by plaintiff telling 

her counselor in June 2018 that she was actively looking for a job. [Id.] (citing 

[12-11] 1085). While the ALJ acknowledged Dr. Sharma had opportunities to 

observe plaintiff’s physical functioning, the ALJ pointed out these 

opportunities occurred once every few months and Dr. Sharma’s treatment of

plaintiff began only six months prior to Dr. Sharma’s completion of the physical 

RFC questionnaire. [Id.] (citing [12-8] 773).

• The ALJ also gave little weight to the opinions of non-examining state agency 

physician consultants who determined plaintiff could effectively perform work 

activities at the medium or light exertional level with some limitations. [Id.] 

25 (citing [12-1] 74-89, 92-100; [12-2] 101-09). The ALJ recognized the 

consultants are medical specialists aware of the available medical evidence in 

the record and who understand social security disability programs and 

evidentiary requirements. [Id.]. However, the ALJ concluded the opinions are 

entitled to little weight because the consultants did not have access to the 

entire medical record or perform an in-person evaluation of plaintiff. [Id.]. For 

this reason, the ALJ found the consultants did not address plaintiff’s alleged 

pain in her lower extremities that demonstrates plaintiff cannot perform work 

activities at greater than the sedentary exertional level. [Id.].

At Step Four, the ALJ ruled that plaintiff was unable to perform her past 

relevant work. [Id.] 26. At Step Five, the ALJ found plaintiff could perform jobs that 

exist in significant numbers in the national economy. [Id.] 27. The ALJ therefore 

concluded a finding of “not disabled” was appropriate. [Id.] 28. 

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Discussion

Plaintiff contends the ALJ’s physical RFC assessment is unsupported by

substantial evidence because after the ALJ rejected every medical opinion in the 

record she constructed a “middle ground” between these opinions, “averaging” them, 

to come up with her own assessment. [16] 10-11. Plaintiff argues this is reversible 

error. [Id.] 11 (citing Bailey v. Barnhart, 473 F.Supp.2d 822, 838-39 (N.D. Ill. 2006)).

The Commissioner replies that the ALJ did not merely average the medical opinions 

but considered and discussed the evidence of plaintiff’s thrombophlebitis, migraines, 

gastrointestinal stromal tumor, and obesity in crafting her RFC assessment. [17] 10.

The Commissioner adds that the ALJ is not required to rely entirely on a particular 

physician’s opinion, choose between the opinions of any of plaintiff’s physicians, or 

call a medical expert or obtain additional medical opinion evidence whenever she does 

not rely on a specific physician’s opinion. [Id.] 4-5 (citing Schmidt v. Astrue, 496 F.3d 

833, 845 (7th Cir. 2007); Luna v. Shalala, 22 F.3d 687, 692-93 (7th Cir. 1994)). The 

Court agrees with plaintiff and finds that, due to errors made by the ALJ, substantial 

evidence does not support the decision to deny benefits and that the case must be 

remanded for further proceedings.

3

“A disability claimant’s RFC describes the maximum she can do in a work 

setting despite her mental and physical limitations.” Thomas v. Colvin, 745 F.3d 802, 

807 (7th Cir. 2014). “An ALJ must evaluate all relevant evidence when determining 

an applicant’s RFC[.]” Arnett v. Astrue, 676 F.3d 586, 591 (7th Cir. 2012). “Although 

an ALJ need not mention every snippet of evidence in the record, the ALJ must 

connect the evidence to the conclusion; in doing so [she] may not ignore entire lines 

of contrary evidence.” Id. at 592. An ALJ “must explain [her] analysis of the evidence 

with enough detail and clarity to permit meaningful appellate review.” Moira L. v. 

Kijakazi, No. 19 C 2687, 2022 WL 846469, at *2.

An ALJ’s duty to consider both medical and non-medical evidence in 

determining an applicant’s RFC may require an ALJ to evaluate conflicting medical 

evidence but never to make independent medical findings. See Bailey v. Barnhart, 

473 F.Supp.2d 842, 849 (N.D. Ill. 2006) (citing Rohan v. Chater, 98 F.3d 966, 970 (7th 

Cir. 1996)). The latter is considered “playing doctor” and is reversible error where the 

ALJ fails to rely on other medical evidence or authority in the record. See Dixon v. 

Massanari, 270 F.3d 1171, 1177-78 (7th Cir. 2001) (citing Clifford, 227 F.3d at 870). 

That said, an ALJ’s RFC assessment is not required to match the opinion of at least 

one physician of record. See Schmidt, 496 F.3d at 845. Where the ALJ has rejected 

the medical opinion evidence, the rest of the record must support her RFC 

assessment. See Suide v. Astrue, 371 Fed. Appx. 684, 690 (7th Cir. 2010). The ALJ 

“must build an accurate and logical bridge from the evidence to her conclusion.” 

Clifford, 227 F.3d at 872. She may not “’play doctor’ by using her own lay opinions to 

3 Because the errors discussed herein are dispositive, the Court need not address the other 

issues raised by plaintiff.

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fill evidentiary gaps in the record.” Suide, 371 Fed. Appx. at 690 (citing Blakes v. 

Barnhart, 331 F.3d 565, 570 (7th Cir. 2003). Instead, the ALJ must “develo[p] the 

record to a sufficient degree to enable her to conduct a reasonable RFC based on 

objective evidence.” Bailey, 473 F.Supp.2d at 850; see also Suide, 371 Fed. Appx. at 

690 (“[I]t was the ALJ’s responsibility to recognize the need for further medical 

evaluations of [applicant’s] conditions before making her [RFC] . . . determinatio[n].”). 

At minimum, the ALJ is required to “provide adequate citation to the record in 

support of the RFC [she] constructed.” Alexander v. Astrue, No. 09 C 3406, 2010 WL 

3199356, at *11 (N.D. Ill. Aug. 10, 2010). Constructing a “middle ground” RFC 

assessment from rejected medical opinions, without a medical basis, does not fulfill 

an ALJ’s duty and is grounds for remand. Desiree B. v. Saul, No. 18-cv-8129, 2019 

WL 6130814, at *6 (N.D. Ill. Nov. 19, 2019); see also Bailey, 473 F.Supp.2d at 850. 

Here, the ALJ rejected all medical opinion evidence in the record, assigning 

the opinions of treating physician Dr. Sharma and non-examining state agency 

physicians Dr. Galle and Dr. Aquino, “little weight.” [12-1] 25. See Suide, 371 Fed. 

App’x at 688, 690 (ALJ effectively rejected opinion reports that he did not give

“significant weight”); see also Alexander, 2010 WL 3199356, at *11 (same). Based on 

the remaining record medical evidence, the ALJ made the following RFC assessment: 

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

claimant has the [RFC] to perform sedentary work as defined in 20 C.F.R. §§ 

404.1567(a) and 416.967(a) except the claimant cannot climb ladders, ropes, or 

scaffolds. She can occasionally climb ramps and stairs. She cannot kneel, 

crouch, or crawl. She cannot have exposure to unprotected heights or 

hazardous machinery. She requires a sit-stand option. She will need to stand 

every hour for two minutes and sit again. She retains the capacity to 

understand, remember, concentrate, persist, and perform simple, routine, and 

repetitive work in a low stress environment, which is defined as having few, if 

any, work-related decisions and changes in the work setting. She can 

occasionally interact with the public and coworkers. 

[12-1] 21.

The Court finds the ALJ’s RFC assessment adopts an impermissible middleground between the rejected medical opinions, is unsupported by the remaining 

evidence in the record, and thus, warrants remand.

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I. The ALJ’s Adoption of a Sedentary RFC Crafts a Middle-Ground 

Between Rejected Medical Opinions without a Medical Basis. 

An ALJ’s RFC assessment that adopts limitations less restrictive than a 

treating physician’s opinion but more restrictive than a state agency physician’s 

opinion, or vice versa, strongly suggests the ALJ assessed a middle-ground without a 

medical basis. See Desiree B., 2019 WL 6130814, at *6; see also Lee v. Kijakazi, 2:20-

cv-306 DRL, 2022 WL 336812, at *6 (N.D. Ind. Feb. 4, 2022) (“What is problematic 

though, is that the ALJ assessed an RFC that was more restrictive than [some 

medical providers] but less restrictive than other providers . . . without building the 

logical bridge as to why.”); Lashaun B. v. Saul, 2:19-cv-38, 2019 WL 6112561, at *7-8

(N.D. Ind. Nov. 18, 2019) (same). Here, the ALJ’s adoption of a sedentary RFC for 

plaintiff with a sit-stand option appears to do just that. [12-1] 21. Plaintiff’s treating 

physician Dr. Sharma found plaintiff must walk every fifteen minutes for at least six 

minutes, and thus needs a job that permits shifting positions from sitting, standing, 

or walking. [12-8] 774. In contrast, both non-examining state agency physicians found 

plaintiff capable of nearly full ability to walk and stand (6 out of 8 hours in a normal 

workday); neither physician required a sit-stand option. [12-1] 78; [12-2] 97. The ALJ

adopted no opinion of record and limited plaintiff to sedentary work, with a sit-stand 

option where plaintiff will need to stand every hour for two minutes and sit again. 

[12-1] 21, 25. Thus, the ALJ found that plaintiff could perform more than plaintiff’s 

treating physician opined, but less than the state agency physicians opined –

indicating to the Court that the ALJ crafted a middle ground between the rejected 

physicians’ RFCs.

The issue then is whether the ALJ relied on and cited other medical evidence 

or authority in the record to support her constructed RFC. See Dixon, 270 F.3d 1171, 

1177-78. The ALJ did not. The ALJ made this assessment without any citation to the 

record, and on review of the record, excluding the rejected medical opinions, the Court 

is unable to identify any medical evidence to support the ALJ’s findings. The ALJ’s 

summary of plaintiff’s medical history that follows her RFC assessment is not 

adequate explanation for the limitations the ALJ found. [12-1] 22-24; see Lashaun B., 

2019 WL 6112561, at *7 (“It was not enough to summarize impairments, then give 

her conclusion. The ALJ had to explain what limitations those conditions imposed on 

plaintiff, and explain why the evidence supported the limit to sedentary work”). The 

ALJ did not explain why plaintiff’s medical history led the ALJ to conclude that 

plaintiff was more limited than the state agency physicians found and less limited 

than her treating physician found. Id. In failing to point to specific evidence to support 

her conclusion that plaintiff could sustain full-time sedentary work, “the ALJ did not

build the necessary logical bridge between her RFC finding and the medical 

evidence.” Latanzio v. Colvin, No. 15 C 11868, 2017 WL 218826, at *4 (N.D. Ill. Jan. 

19, 2017) (“The Court is left in the dark in attempting to determine how the ALJ 

applied this new medical evidence to reach her conclusion regarding the RFC; it does 

not appear to [be] supported by the medical evidence . . . .”). The ALJ’s failure to point 

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to specific evidence to support her conclusion that plaintiff could sustain full-time 

sedentary work, warrants remand.

The Commissioner contends that the ALJ’s RFC assessment is supported by 

substantial evidence despite the ALJ affording little weight to the medical opinion 

evidence because it is well established that an ALJ is not required to rely entirely on 

a physician’s opinion or choose between the opinions of any of plaintiff’s physicians. 

[17] 5 (citing Schmidt, 496 F.3d at 845). The Commissioner adds that under 20 C.F.R. 

§ 404.1545 an ALJ is required to consider both medical and non-medical evidence in 

making an RFC determination and the final disability determination is left to the 

agency. [Id.] 4-5 (citing Thomas v. Colvin, 745 F.3d 802, 808 (7th Cir. 2014)). But the 

Court’s decision does not rest on the proposition that an ALJ’s assessment must 

match that of a physician in the record. The Court’s conclusion rests on the ALJ’s 

failure to adequately explain and support her RFC determination with supporting 

evidence. See Clifford, 227 F.3d at 872; see also Bailey, 473 F.Supp. at 850. This is 

not to say, to the Commissioner’s point, that an ALJ must in every case call a medical 

expert or obtain additional medical opinion evidence whenever she does not rely on a 

specific physician opinion. See Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995). In 

Diaz, the Court affirmed the ALJ’s disability determination, noting that the ALJ was 

not required to rely solely on the physicians’ opinions where the ALJ relied on 

detailed medical records, the claimant’s testimony about his physical abilities, and 

the claimant’s work history to reach his RFC determination. 55 F.3d at 306-307, n.2. 

Here, in stark contrast, the ALJ failed to cite to any evidentiary support for her RFC 

assessment. Further, as discussed above and below, the remaining medical and nonmedical evidence simply did not support the ALJ’s specific medical findings. 

II. The ALJ’s Adoption of Environmental Limitations Endorses a

Conclusion of a Rejected Medical Opinion without the Required

Explanation. 

Additionally, the ALJ appears to adopt in part the opinion of non-examining 

state agency physician Dr. Aquino, whose opinion she gave little weight, when the 

ALJ concluded that plaintiff “cannot have exposure to unprotected heights or 

hazardous machinery.” [12-1] 21, 25. Dr. Aquino found on reconsideration that 

plaintiff should avoid concentrated exposure to machinery and heights. [12-2] 98. As 

stated throughout, the ALJ rejected Dr. Aquino’s opinion when she gave the state 

agency physicians’ opinions little weight. [12-1] 15. While the ALJ was free to accept 

or reject the different conclusions expressed by Dr. Aquino, the ALJ needed to 

“explain the logical bridge between the evidence and a decision to give different 

weights to different parts of a medical opinion so as to allow for meaningful review.”

Brett D., 2021 WL 2660753, at *3. The ALJ did not explain why she accepted or 

credited this part of Dr. Aquino’s opinion, nor did the ALJ cite any other evidence in 

the record that would support a finding that plaintiff had environmental limitations. 

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Excluding the rejected medical opinions, the rest of the record “does not 

support the parameters included in the ALJ’s [RFC] determination.” See Suide, 371 

Fed. App’x at 690. Without Dr. Sharma’s and the state agency physicians’ opinions, 

the remaining medical evidence in the record consists predominately of treatment 

notes from other medical providers. [12-4] 350-57, 370-74, 379, 382-85; [12-5] 413-19, 

425-30; [12-6] 524-31; [12-7] 616. However, on review of these notes, these other 

treatment providers did not opine about any limitations plaintiff’s impairments may 

have caused, let alone environmental limitations, so the remaining medical records 

could not have been used to support these specific limitations included in the ALJ’s 

RFC assessment. [Id.]; see Suide, 371 Fed. App’x at 690. Thus, the ALJ’s assessment 

of plaintiff’s RFC is not supported by substantial evidence, and that determination 

cannot stand.

For that reason, as well as the other reasons discussed above, the case must be 

remanded.

Conclusion

The decision of the SSA is reversed, and in accordance with the fourth sentence 

of 42 U.S.C. § 405(g), this case is remanded for further proceedings consistent with 

this Memorandum Opinion and Order.

_____________________________________

HEATHER K. McSHAIN

United States Magistrate Judge

DATE: March 8, 2023

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