Source: http://il.findacase.com/research/wfrmDocViewer.aspx/xq/fac.20130606_0001270.SIL.htm/qx
Timestamp: 2017-01-17 17:46:09
Document Index: 704672444

Matched Legal Cases: ['§423', '§423', '§ 405', '§404', '§404', '§404', '§404', 'art, 357', '§405']

Plaintiff raises several points, including that the ALJ improperly rejected the opinion of the consultative examiner regarding her ability to crouch and crawl. Because of this error, she contends, the ALJ’s assessment of her residual functional capacity was not supported by substantial evidence.
To qualify for DIB or SSI, a claimant must be disabled within the meaning of the applicable statutes.[3] For these purposes, “disabled” means 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).
A “physical or mental impairment” is an impairment resulting from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C. §423(d)(3).
If the answer at steps one and two is “yes, ” the claimant will automatically be found disabled if he or she suffers from a listed impairment, determined at step three. If the claimant does not have a listed impairment at step three, and cannot perform his or her past work (step four), the burden shifts to the Secretary at step five to show that the claimant can perform some other job. Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984). See also, Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001)(Under the five-step evaluation, an “affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled…. If a claimant reaches step 5, the burden shifts to the ALJ to establish that the claimant is capable of performing work in the national economy.”).
This Court reviews the Commissioner’s decision to ensure that the decision is supported by substantial evidence and that no mistakes of law were made. The scope of review is limited. “The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive. . .” 42 U.S.C. § 405(g). Thus, this Court must determine not whether Ms. Tego was, in fact, disabled during the relevant time period, but whether the ALJ’s findings were supported by substantial evidence and whether any errors of law were made. See, Books v. Chater, 91 F.3d 972, 977-78 (7th Cir. 1996) (citing Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995)). This Court uses the Supreme Court’s definition of substantial evidence, i.e., “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971).
D. The Decision of the ALJ ALJ Janney followed the five-step analytical framework described above. He determined that Ms. Tego had not been engaged in substantial gainful activity since the alleged onset date and that she was insured for DIB through December 31, 2009. He found that plaintiff had severe impairments of status post Burkitt lymphoma, obesity, hernia, diabetes, congestive heart failure, degenerative changes in the knee, degenerative disc disease in the lumbar spine, depression, and anxiety. He found that these impairments did not meet or equal a listed impairment.
Plaintiff was born in 1980, and was 25 years old when she allegedly became disabled on December 31, 2005. She was insured for DIB through December 31, 2009. (Tr. 232). She said that she became disabled on December 31, 2005, because of Burkitt lymphoma.[4] She had stopped working in June, 2005, because of “transportation problems.” (Tr. 236).
Ms. Tego was 29 years old at the time of the hearing. She was 5’4” tall and weighed 270 pounds. (Tr. 1296). Her doctor put her on a diet and she lost 30 pounds. (Tr. 1315). She got married in 2009, and she lived with her husband and 13 year-old stepdaughter. Ms. Tego left school in the 11th grade. (Tr. 1296-1297).
On December 31, 2005, the alleged date of disability, plaintiff was pregnant with a daughter. She was having complications, and, after the baby was delivered, it was discovered that Ms. Tego had cancer. (Tr. 1298). Her cancer was Burkitt lymphoma, and it has been in remission since May of 2006. She was not taking any medications for her cancer at the time of the hearing. She testified that her heart was “weakened” by the chemotherapy. She had chest pain on exertion. She was taking Lisinopril for heart problems. She also had leg problems, diabetes, a hernia and depression. She had sharp pains in her legs and her legs felt weak. (Tr. 1301-1303). She had been having back pain for the past 2 or 3 years. She had not seen a specialist for that. (Tr. 1311). She started having daily headaches about two months before the hearing. (Tr. 1316).
A vocational expert (VE) also testified. The ALJ asked him to assume a person who could lift less than 10 pounds frequently and 10 pounds occasionally, sit for a total of 6 out of 8 hours, stand and/or walk for 2 out of 8 hours, and was limited to only occasional postural activities, including crouching and crawling, with no climbing of ladders, ropes and scaffolds and no work at unprotected heights or with dangerous machinery. She was further limited to work involving only one- and two-step instructions and only minimal close teamwork. The VE testified that this person could not do plaintiff’s past work, but she could do a variety of sedentary, unskilled jobs such as assembler, hand sorter/packer, and machine tender. (Tr. 1321-1322). However, if she were unable to crouch or crawl, she would not be able to do those jobs. The VE testified that, generally, unskilled work requires the ability to occasionally crouch and crawl. (Tr. 1324).
Ms. Tego was diagnosed with Burkitt lymphoma of the abdomen. She received several cycles of chemotherapy at St. John’s Hospital in Springfield, Illinois from January through May, 2006. (Tr. 545-558). She was diagnosed with cardiomyopathy in March, 2006. (Tr. 655-657). She was hospitalized from March 22, 2006, through April 29, 2006. During that hospitalization, she was also diagnosed with gall bladder disease. A cholecystectomy tube was placed. (Tr. 658-659). Her gallbladder was removed and a hernia repaired in an open surgical procedure on June 9, 2006. (Tr. 718-720).
In January, 2007, Dr. Jenson noted that plaintiff had been hospitalized after taking an overdose of Xanax. She had begun seeing a counselor. She was still depressed and crying. (Tr. 778). She was again hospitalized after taking “a handful of various pills” in September, 2007. She told Dr. Jenson that she realized that was a mistake, and she just wanted to “get well and get her daughter back from DCFS.” (Tr. 815-817).
She was admitted to the hospital for uncontrolled diabetes in April, 2010. She reduced her dosage of insulin because, when she took it as prescribed, her blood sugar dropped to 200 to 300, and she had dizziness and numbness. She was also anxious and depressed, with multiple panic attacks and occasional visual hallucinations. (Tr. 969-973). She returned to the emergency room in July, 2010, with hyperglycemia. The doctor’s note indicates that she had “poor control/compliance.” (Tr. 980).
The medical records at Tr. 1085-1289 cannot be considered by this Court in determining whether the ALJ’s decision was supported by substantial evidence. Records “submitted for the first time to the Appeals Council, though technically a part of the administrative record, cannot be used as a basis for a finding of reversible error.” Luna v. Shalala, 22 F.3d 687, 689 (7th Cir. 1994). See also, Getch v. Astrue, 539 F.3d 473, 484 (7th Cir. 2008).
6. Treating Doctor’s Opinion
7. State Agency Consultant’s RFC Assessment
In August, 2006, a state agency consultant assessed plaintiff’s RFC based on a review of the records. She opined that plaintiff was able to do work at the sedentary exertional level, limited to only occasional postural activities, but no climbing of ladders, ropes or scaffolds. She found that she could occasionally crouch and crawl. The doctor noted that plaintiff had undergone rehab in a nursing home, but said that “it is anticipated that with continuing rehab that she will be able to return to work level previously outlined within 12 mo. [months] of the onset of her illness.” (Tr. 656-663).
The vocational expert’s testimony established that, if plaintiff were unable to crouch or crawl, she would be unable to do unskilled, sedentary work. That kind of work requires the ability to crouch and crawl at least occasionally (Tr. 1324).
Plaintiff argues that the ALJ erred in accepting the opinion of the state agency consultant and rejecting Dr. Chapa’s opinion. Because of conflicting and inaccurate statements about Dr. Chapa’s opinion and the record as a whole, this case must be remanded.
At Tr. 31, the ALJ summarized Dr. Chapa’s findings, including his opinion that she could never crouch or crawl. The ALJ characterized Dr. Chapa’s opinion as “generally consistent with the case record” and “consistent with the clinical findings Dr. Chapa reported.” Three pages later, however, the ALJ rejected Dr. Chapa’s opinion in favor of the state agency consultant’s assessment. The ALJ characterized the state agency consultant’s assessment as “more restrictive” than Dr. Chapa’s, which is not entirely accurate. It was more restrictive with respect to the amount of weight that plaintiff could lift, but it was less restrictive with respect to the crucial issue of ability to crouch and crawl.
The ALJ attempted to distinguish Dr. Chapa’s opinion from that of the state agency consultant by saying that “Dr. Chapa did not have the opportunity to consider more recent findings showing a left ventricular ejection fraction of 49 percent.” However, both the state agency consultant and Dr. Chapa relied on a record that showed plaintiff had cardiomyopathy with an ejection fraction of 35 percent. See, Tr. 737, 883. In 2010, testing showed that she had only mildly reduced left valve systolic function and an ejection fraction of 49 percent. See, Tr. 921. The state agency consultant’s assessment was done in August, 2006. Dr. Chapa examined plaintiff in July, 2009. Obviously, neither doctor saw the results of the 2010 testing. Thus, the ALJ’s attempt to distinguish between the two assessments on that basis was misguided.
The ALJ also said that the medical evidence of plaintiff’s hernia, obesity and degenerative changes was more consistent with the state agency consultant’s opinion than with “Dr. Chapa’s less restrictive opinion.” This statement contradicts the ALJ’s earlier statement that Dr. Chapa’s opinion was consistent with the record and with his clinical findings.
The ALJ’s determination can be upheld only if it is supported by substantial evidence, which means “evidence a reasonable person would accept as adequate to support the decision.” Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012). Further, the ALJ is required to build “an accurate and logical bridge” between the evidence and his conclusion. Ibid.
Here, it is difficult to glean any adequate reason for rejecting Dr. Chapa’s opinion in favor of that of the state agency consultant. 20 C.F.R. §404.1527(d) provides that all medical opinions will be evaluated according to the factors set forth in that section.[5] As Dr. Chapa did not treat Ms. Tego, his opinion is not entitled to “controlling weight.” Simila v. Astrue, 573 F.3d 503, 514 (7th Cir. 2009). However, §404.1527(d)(1) provides that more weight is generally given to the opinion of an examining doctor than to one who has only reviewed records. The ALJ is “required to determine the weight a nontreating physician's opinion deserves” by applying the factors specified in §404.1527(d)(3) through (d)(6). Simila, 573 F.3d at 515. Those factors are supportability, consistency, specialization, and any other factor of which the ALJ is aware. Here, the ALJ said that Dr. Chapa’s opinion was consistent with, i.e., supported by, his clinical findings and was consistent with the record as a whole. He did not give any reason supported by the record for favoring the state agency consultant over Dr. Chapa.
The Commissioner admits that the ALJ’s explanation of why he rejected Dr. Chapa’s opinion was not perfect, but argues that the ALJ reasonably found that the state agency consultant’s opinion was more consistent with the record as a whole. Doc. 38, pp. 7-8. However, her argument completely ignores the ALJ’s explicit finding that Dr. Chapa’s opinion was consistent with the record and with his clinical findings.
The Commissioner defends the ALJ’s decision by arguing that he relied on lack of objective evidence of nerve impingement, negative straight leg raising, normal strength and sensation, and the effectiveness of an abdominal binder. Doc. 38, p. 7. In fact, while the ALJ did cite these factors, it was in the context of his analysis of the opinion of Dr. Jenson, not that of Dr. Chapa.
The Commissioner also points out that §404.1527(d)(2) requires the ALJ to give “good reasons” for the weight he gives to a treating doctor’s opinion, but does not require “good reasons” with respect to an examining doctor. This is a curious argument. The suggestion that the ALJ does not have to give “good reasons” for rejecting an examining doctor’s opinion flies in the face of the well-established rules that the ALJ may not ignore evidence favorable to the claimant, Hughes v. Astrue, 705 F.3d 276, 277-278 (7th Cir. 2013), and must build an “accurate and logical bridge” between the evidence and his conclusion, Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012).
Lastly, the Commissioner argues that any error in weighing Dr. Chapa’s opinion is harmless since plaintiff has not demonstrated that the ALJ would likely reach a different result regarding her ability to crouch and crawl on remand. Doc. 38, pp. 8-9. The Commissioner cites Spiva v. Astrue, 628 F.3d 346 (7th Cir. 2010) in support of her argument, but Spiva actually undermines her position:
If it is predictable with great confidence that the agency will reinstate its decision on remand because the decision is overwhelmingly supported by the record though the agency's original opinion failed to marshal that support, then remanding is a waste of time. But that is not the government's understanding of the doctrine of harmless error, if we may judge from its brief and oral argument in this case (and not only this case—see, e.g., Terry v. Astrue, 580 F.3d 471, 475–77 (7th Cir.2009) (per curiam); Villano v. Astrue, 556 F.3d 558, 562–63 (7th Cir.2009) (per curiam); Craft v. Astrue, 539 F.3d 668, 675, 678– 79 (7th Cir.2008); Stout v. Commissioner, Social Security Administration, 454 F.3d 1050, 1054–56 (9th Cir.2006); Allen v. Barnhart, 357 F.3d 1140, 1145 (10th Cir.2004)). The government seems to think that if it can find enough evidence in the record to establish that the administrative law judge might have reached the same result had she considered all the evidence and evaluated it as the government's brief does, it is a case of harmless error. But the fact that the administrative law judge, had she considered the entire record, might have reached the same result does not prove that her failure to consider the evidence was harmless. Had she considered it carefully, she might well have reached a different conclusion.
Here, it cannot be predicted with great confidence that the agency would reach the same decision on remand. According to the ALJ, Dr. Chapa’s opinion was consistent with the record and with his clinical findings. The ALJ offered no valid reason for rejecting his conclusion that Ms. Tego could not crawl or crouch. If she cannot crawl or crouch at least occasionally, she cannot do unskilled sedentary work. Thus, while the ALJ might reach the same conclusion if he evaluated the evidence in the same way as the Commissioner’s brief does, he might well reach a different conclusion upon careful consideration of the evidence. Therefore, this is not case of harmless error.
Because of the ALJ’s errors, this case must be remanded. The Court wishes to stress that this Memorandum and Order should not be construed as an indication that the Court believes that Ms. Tego is disabled or that she should be awarded benefits. On the contrary, the Court has not formed any opinions in that regard, and leaves those issues to be determined by the Commissioner after further proceedings.
The Commissioner’s final decision denying Jessica McWhorter Tego’s application for social security disability benefits is REVERSED and REMANDED to the Commissioner for rehearing and reconsideration of the evidence, pursuant to sentence four of 42 U.S.C. §405(g).