Jose L. v. Saul

JOSE L., Plaintiff, v. ANDREW M. SAUL,Acting Commissioner of Social Security, Defendant.

No. 18 C 4904

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

January 17, 2020

Magistrate Judge Jeffrey Cummings

MEMORANDUM OPINION AND ORDER

Claimant Jose L. ("Claimant")¹ brings a motion for summary judgment to reverse the final decision of the Commissioner of Social Security ("Commissioner") that denied Claimant's claim for a period of disability and Disability Insurance Benefits ("DIB") under 42 U.S.C. §§ 416(i) and 423(d) of the Social Security Act. The Commissioner has brought a cross-motion for summary judgment seeking to uphold the Social Security Agency's decision to deny benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 138(c)(3). For the reasons stated below, Claimant's motion for summary judgment [14] is granted and the Commissioner's motion for summary judgment [26] is denied.

I. BACKGROUND

A. Procedural History

On August 19, 2015, Claimant filed a Title II application alleging a disability onset date of September 13, 2013. (R. 140). His claim was denied initially on November 25, 2015 andupon reconsideration on February 17, 2016. (R. 140). On June 27, 2017, an Administrative Law Judge ("ALJ") issued a written decision denying benefits to Claimant. (R. 140-150). The Appeals Council denied review on July 7, 2017, making the ALJ's decision the Commissioner's final decision. (R. 1). Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in District Court.

B. Medical Evidence

1. Evidence From the Medical Records

Claimant was involved in an automobile accident on September 13, 2013 that resulted in elbow, back, muscle, neck, and joint pain. An MRI was carried out on September 25, 2013 that showed disc dessication at C4-C5, C5-C6, and C6-C7. Diffuse disc protrusion with an annular tear was present at C4-C5. A profuse disc protrusion with an annular tear was also found at L3-L4. Protrusion with spinal canal and neural foramina were present at L4-L5, with protrusion and facet joint hypertrophy at L5-S1. (R. 502-05). Claimant was further diagnosed with spondylolisthesis, lumbrosacral spondylosis, and lower back pain radiating down his legs on January 29, 2014 by Dr. Sean Salehi.² (R. 398-99). Five epidural injections followed during the year after Claimant's accident that provided minimal relief. (R. 397). Pain medications such as Norco and Soma were also prescribed. In addition, Claimant underwent physical therapy to help relieve his discomfort. (R. 414-32).

By May 21, 2014, Claimant's condition was such that Dr. Krysztof Siemionow recommended that he undergo a surgical spinal fusion to remedy the L5-S1 spondylolisthesis. (R. 475-77). Claimant declined to have the surgery, however, and continued treatment with painspecialist Dr. Anas Alzoobi to manage his pain. Dr. Alzoobi noted on May 8, 2015 that Claimant was unable to stand up straight and was positive for pain at 40 degrees of flexion, 10 degrees extension, and 15 degrees of lateral rotation. (R. 559). Claimant also sought treatment from pain specialist Dr. Yasser Alhaj-Hussein. Dr. Alhaj-Hussein stated on March 30, 2016 that Claimant continued to take Norco daily and complained of numbness and weakness in his legs. Claimant was doing "reasonably well" on Norco though he continued to have sharp and stabbing pain that was 8-9 out of 10 at its worst. (R. 732). Dr. Alhaj-Hussein again noted on June 22, 2016 that Claimant was doing well on Norco every six hours for breakthrough pain and the anti-inflammatory medication diclofenac. (R. 727). Norco continued to be prescribed to Claimant through the date of the administrative hearing. (R. 754).

2. Evidence From the State-Agency Experts

On November 24, 2015, state-agency physician Dr. Towfig Arjmand found that Claimant could perform medium work by carrying and lifting up to 25 pounds frequently and 50 pounds occasionally. He had an unlimited capacity for pushing and pulling, balancing, and climbing stairs. Claimant could occasionally balance, stoop, crouch, and kneel. (R. 105-07).

Dr. Bernard Stevens revised that finding at the reconsideration stage by determining that Claimant could only carry out light work. His February 15, 2016 report states that Claimant could only carry 10 pounds frequently and 20 pounds occasionally. Dr. Stevens also stated that Claimant could only occasionally balance and climb stairs. He otherwise agreed with Dr. Arjmand's findings that Claimant could occasionally stoop, crouch, and kneel. (R. 120-22).

3. Evidence From the Consulting Expert

Dr. Thomas Oryszczak examined Claimant at the SSA's request on November 11, 2015 and issued a report. Claimant told Dr. Oryszczak that he experienced daily lower back pain thatradiated through both legs. Physical therapy and several epidural injections had not been helpful. Claimant stated that he could only walk approximately five blocks and that sitting for too long made his condition worse. Dr. Oryszczak's examination showed that Claimant had a normal range of motion in his lower extremities with normal muscle strength in both legs. The doctor noted that Claimant had a positive straight leg test on the left side at 80 degrees.³ Claimant also had a normal range of motion and full flexion in his spine. Dr. Oryszczak diagnosed Claimant with chronic lower back pain, a partial articular fracture at L5, and a right superior articular process fracture at S1.⁴ He concluded that Claimant would "have difficulty with prolonged sitting, standing, prolonged periods of walking, and repetitive lifting or carrying of heavy objects." (R. 522-25).

C. Evidence From Claimant's Testimony

Claimant appeared at an administrative hearing on April 12, 2017 and described a limited range of activities due to his lower back pain. Claimant told the ALJ that he could stand for two to three minutes without pain and could sit for only 25 minutes at a time. (R. 79). He can only drive for 30 minutes. (R. 69). Claimant can dress and bathe himself "at times" but periodically requires assistance. Claimant is able to do the dishes as part of his daily chores but cannot do laundry. (R. 81). He described his pain at a level of six to seven out of ten every day. (R. 84). Multiple epidural injections had not been helpful in alleviating his discomfort. (R. 74). Claimant takes Norco pain pills up to five times a day to reduce his pain to the level of five out of ten. (R. 76). Lack of movement exacerbates his condition. (R. 74). The ALJ noted thatsurgery had been recommended to Claimant. He explained, however, that the information packet given to him by his neurosurgeon notified him of risk factors such as death or possible paralysis. (R. 74).

D. The ALJ's Decision

On June 27, 2017, the ALJ issued a decision finding that Claimant was not disabled. Applying the five-step sequential analysis that governs disability decisions, the ALJ found at Step 1 that Claimant had not engaged in substantial gainful activity since his alleged onset date of September 13, 2013. His severe impairments at Step 2 were lumbar and cervical spine disc protrusions, spondylolisthesis, and lumbrosacral spondylosis. Claimant also had the non-severe impairment of a left elbow disorder. The ALJ found that none of these impairments met or medically equaled a listing at Step 3 either singly or in combination.

Before moving to Step 4, the ALJ determined that the record did not fully support Claimant's testimony concerning the severity and frequency of his symptoms. The ALJ also assessed the reports of the state-agency and consulting physicians. She gave "greater" weight to the reconsideration evaluation of Dr. Stevens than to Dr. Arjmand's initial evaluation. "Some" weight was given to Dr. Oryszczak's report. Based on these findings, the ALJ concluded that Claimant had the residual functional capacity ("RFC") to perform light work as that term is defined under 20 C.F.R. § 404.1567(b), except that he could only occasionally climb ramps or stairs, balance, stoop, kneel, crouch, or crawl. Claimant could have occasional exposure to vibrations, hazards, and extreme cold. He could never climb ladders, ropes, or scaffolds.

The ALJ then concluded at Step 4 that Claimant's RFC would not permit him to perform any of his past relevant work as a construction worker. A vocational expert ("VE") told the ALJthat jobs existed in the national economy for a person with Claimant's RFC. Based on that testimony, the ALJ found at Step 5 that Claimant was not disabled. (R. 140-50).

II. LEGAL ANALYSIS

A. The Social Security Administration Standard

In order to qualify for disability benefits, a claimant must demonstrate that he is disabled. An individual does so by showing that he cannot "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. § 4243(d)(1)(A). Gainful activity is defined as "the kind of work usually done for pay or profit, whether or not a profit is realized." 20 C.F.R. § 404.1572(b).

The Social Security Administration ("SSA") applies a five-step analysis to disability claims. 20 C.F.R. § 404.1520. The SSA first considers whether the claimant has engaged in substantial gainful activity during the claimed period of disability. 20 C.F.R. § 404.1520(a)(4)(i). It then determines at step two whether the claimant's physical or mental impairment is severe and meets the twelve-month duration requirement noted above. 20 C.F.R. § 404.1520(a)(4)(ii). At step three, the SSA compares the impairment or combination of impairments found at step two to a list of impairments identified in the regulations ("the listings")....