Kristine S. v. Saul

KRISTINE S., Plaintiff, v. ANDREW SAUL,Commissioner of Social Security, Defendant.

No. 19 C 1485

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

August 10, 2020

Magistrate Judge Jeffrey Cummings

MEMORANDUM OPINION AND ORDER

Claimant Kristine S. ("Claimant")¹ brings a motion for summary judgment to reverse the final decision of the Commissioner of Social Security ("Commissioner") that denied her application for Disability Insurance Benefits ("DIBs") and Supplemental Security Income ("SSI") under the Social Security Act. 42 U.S.C. §§416(i), 402(e), and 423. 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 1383(c)(3). For the reasons stated below, Claimant's motion for summary judgment [12] is granted, and the Commissioner's motion for summary judgment [19] is denied.

I. BACKGROUND

A. Procedural History

In June 2012, Claimant filed a disability application alleging a disability onset date of March 1, 2011. Her claim was denied initially and upon reconsideration. On May 14, 2014, an Administrative Law Judge ("ALJ") issued a written decision denying benefits to Claimant.Claimant appealed her case to this Court, which reversed the ALJ's decision and remanded the case for further consideration. See Suelflow v. Berryhill, No. 15 C 9241, 2017 WL 4467469 (N.D.Ill. Oct. 6, 2017) (Valdez, M.J.). The ALJ held a supplemental hearing, called a medical expert to testify, and again denied benefits on December 12, 2018. The Appeals Council declined to assume jurisdiction, making the ALJ's decision the SSA's final decision. See 20 C.F.R. § 404.984. Claimant subsequently filed this action in District Court on March 1, 2019.

B. Medical Evidence

1. Evidence From Claimant's Treatment History

Claimant suffers from a range of pain-related conditions, including degenerative disc disease and fibromyalgia that cause discomfort in several regions of her body. Her condition is exacerbated by morbid obesity; Claimant weighed as much as 340 pounds at one point, is five feet and six inches tall, and had a body mass index ("BMI") of 50.² (R. 535). She underwent a lumbar fusion for scoliosis in 1993 and later developed lumbar pain that caused her to be hospitalized in March 2011. An MRI showed mild central and right foraminal stenosis at L4-L5 caused by a disc protrusion. (R. 316). She displayed positive straight-leg raising,³ and an x-ray indicated mild degenerative changes in the left hip. (R. 322). Claimant was treated with injections and received additional injections the following month when she again sought emergency treatment for pain in both hips. She was released for care with her primary physician. (R. 333-38).

Claimant was treated by Dr. David Calimag in 2012, who prescribed medications for her pain and for depression. (R. 400). He continued to treat her for sciatica, fibromyalgia, back pain, knee arthritis, and fatigue in 2013. (R. 466-68). Following her diagnosis of fibromyalgia, Claimant was referred to rheumatologist Dr. Maria Sosenko. Dr. Sosenko confirmed the presence of fibromyalgia and began treating Claimant for her related complaint of restless leg syndrome. She also recommended that Claimant exercise and lose weight. (R. 344-45). Claimant told Dr. Sosenko that she could not afford to join the YMCA and that she did not feel steady enough on her feet to exercise on her own. (R. 345, 434). Dr. Sosenko cast a skeptical eye towards these claims, stating in December 2012 that Claimant "has every excuse in the book for not being able to move." (R. 434). In April 2013, Dr. Sosenko again noted that Claimant remained "very inactive" and that Lyrica had not helped her fibromyalgia pain. Dr. Sosenko changed her medication to Gralise and advised her to return in four months. (R. 438-39). Claimant, however, declined to do so.

Claimant was again hospitalized in May 2013 for back and left-leg pain and was discharged after undergoing epidural injections. (R. 487). She continued to be treated by Dr. Calimag but also began treatment in March 2014 with pain specialist Dr. Suleiman Salman. Claimant described her pain as severe and explained that she was afraid to begin physical therapy because she was afraid it would aggravate her pain. (R. 761). Dr. Salman diagnosed low back pain, lumbar radiculopathy on the right, lumbar spinal stenosis, displacement of the lumbar intervertebral disc, arthropathy of the lumbar facet joint, and lumbar post-laminectomy syndrome. (R. 762). He recommended multiple epidural injections, which Claimant later reported had diminished her pain by 50 percent. (R. 764).

Throughout this period and later, Claimant continued to take multiple medications to manage her pain, restless leg syndrome, depression, and other conditions. These included Cymbalta, Lyrica, Gralise, Soma, Flexeril, Naprosyn, Vicodin, Requip, Mirapex, Wellbutrin, Zoloft, Levaquin, Norco, Mobic, Cyclobenzaprine, Celebrex, Gabapentin, and Topiramate. Although Claimant did not return to Dr. Sosenko, she saw Dr. Stephanie Whyte in January 2016. Claimant told her that she had not returned to Dr. Sosenko because she had told Claimant to lose weight. (R. 800). Notwithstanding, Claimant's weight had decreased from over 300 pounds to 262 pounds at that time. Dr. Whyte stated that Claimant was fatigued, nauseous, dizzy, weak, and dysphoric. (R. 803). Dr. Whyte noted with some concern that Claimant had been taking Norco for the past 20 years and only reluctantly prescribed it to Claimant for chronic pain. (R. 804). Claimant did not return to Dr. Whyte but did continue to see Dr. Calimag. He noted in May 2017 that Claimant's weight had further reduced to 233 pounds. (R. 777). It was only 235 in November 2017, and Dr. Calimag noted in his last treatment record of June 2018 that Claimant weighed 257 pounds. (R. 790). The last entry states that Claimant's pain was on a scale of eight out of ten, reduced to five out of ten with medication.

2. Evidence From the State Agency Experts

On November 7, 2012, state-agency psychologist Dr. Michael Schneider issued a report on Claimant's mental condition for the SSA. He found that she suffered from an affective disorder that was not severe but which caused mild restrictions in Claimant's activities of daily living ("ADLs"), social functioning, and ability to maintain concentration, persistence, or pace. No episodes of decompensation were present. (R. 79). Dr. Charles Wabner found the next day that Claimant' severe physical impairments included a spine disorder, obesity, and fibromyalgia. Her spine disorder would permit Claimant to carry out light work. She could lift 20 poundsoccasionally and 10 pounds frequently; could stand and/or walk two hours a day and sit for six; could climb ramps and stairs frequently; stoop, kneel, and crawl occasionally; but could never climb ladders or ropes. (R. 80-82). These findings were affirmed at the reconsideration stage.

On October 13, 2012, Dr. Stanley Simon examined Claimant at the SSA's request and issued a report. Claimant told Dr. Simon that her back pain continued to be 7/10 and that she could only walk about 20 feet without experiencing pain. She can stand for five minutes before needing to change positions and can only lift, push, and pull five pounds. Dr. Simon noted that Claimant could walk 50 feet without assistance and that she had normal grip strength. Claimant had a normal range of motion in her spine and in all of her joints, though she experienced pain in her lumbar spine during the exam. Her straight leg tests were negative bilaterally. Dr. Simon diagnosed chronic low backpain, a history of scoliosis, fibromyalgia, plantar fasciitis, and restless leg syndrome. However, he did not assess any of Claimant's exertional abilities. (R. 424-27).

3. Evidence From the Treating Physician

Dr. Calimag issued an undated medical source statement that formed the basis of the prior remand of this case. He stated that Claimant suffered from severe scoliosis, radiculopathy, "RLS," and fibromyalgia, all of which had a "poor" prognosis. She had a positive straight leg finding at 30 degrees on the right that restricted her activities. Claimant could only sit for five minutes at a time and could not stand. She can sit and stand or walk for less than two hours a day - restrictions that would require her to shift positions at will. Dr. Calimag estimated that would require Claimant to walk up to five minutes every five minutes and that she would need unscheduled breaks throughout the day. (R. 467). She would also require a "cane or otherassistive device" to function throughout the day. She could never lift even less than 10 pounds and could never stoop, crouch, or climb ladders. (R. 465-68).

4. Evidence From Claimant's Testimony

Claimant appeared at an administrative hearing on February 11, 2014 and described her condition to the ALJ. She stated that she currently weighed 305 pounds. The ALJ stressed the weight issue by reminding Claimant that Dr. Sosenko had complained that she had "many excuses" for not losing weight and then asked Claimant, "[w]hat do you say about that?" Claimant explained that she had seen Dr. Sosenko for help but was told to exercise when "I have trouble walking to the bathroom." (R. 55). She stated that she did not return to Dr. Sosenko because "[e]very time I go there, she makes me cry." (R. 56).

The ALJ briefly inquired into Claimant's ADLs and symptoms. Claimant described a number of things that she did on social media but little that involved interpersonal activities. She rarely goes out to dinner or sees friends. (R. 53). She experiences problems with activities like showering and getting dressed. (R. 54). She only sleeps a few hours at a time due to pain. (R. 56). Claimant's medications cause her to lie down during the day with her legs elevated. (R. 58). She can only lift about one...