JON E. DEGUILIO, District Judge.
On February 13, 2018, Plaintiff Terry Engstrand filed a complaint [DE 1] in this Court seeking review of the final decision of the Defendant Commissioner of Social Security denying his applications for social security disability benefits.
Since 1978, Engstrand has performed very heavy exertional work as either a maintenance supervisor, landscaper, or farm laborer. By the year 2000, he had already undergone two back surgeries as a result. By December 28, 2013, Engstrand claims that he became disabled due to lumbar degenerative disc disease and chronic pain. Administrative Law Judge Kevin Vodak ("the ALJ") disagreed and believed that Engstrand could still perform work as a maintenance supervisor, not as actually performed, but as generally performed at the light exertional level.
The ALJ set forth a chronology of Engstrand's extensive medical records with respect to his various physical impairments, including degenerative disc disease, obesity, coronary artery disease, cervical pain, hypertension, and hyperlipidemia (Tr. 21-26). However, most relevant to this appeal, and thus, the focus of this Order, is the ALJ's discounting of Engstrand's claimed severity of his lumbar pain and resulting limitations. Specifically, Engstrand contends that the ALJ's errors in assessing his credibility adversely impacted the residual functional capacity ("RFC")
In summarizing Engstrand's hearing testimony
The ALJ opined that Engstrand's "statements and hearing testimony regarding the severity and limiting effects of his impairments [were] partially consistent with the totality of the objective medical record." (Tr. at 26-27). In finding Engstrand to be less than fully credible, the ALJ specifically referred to a medical report from December 2015 which documented Engstrand's report of "well controlled" pain, accompanied by a recommendation that Engstrand needed to "stay as active as possible." As a further basis for discounting Engstrand's testimony, the ALJ relied on normal musculoskeletal exam findings from October 2014, March 2015, and June 2015. The ALJ also referred to Engstrand's having "some history of noncompliance with [his] treatment regimen," as a basis for not entirely believing his allegations of disabling pain.
Reviewing state agents opined that as of June and September 2014, Engstrand could perform work at the light exertional level (Tr. 69-93). Accordingly, Engstrand's applications were denied initially and on reconsideration.
Thereafter, in 2016, both a treating pain doctor and a physical therapist of Engstrand's reported that Engstrand suffered from pain and resulting limitations that prevented him from standing, walking, and sitting long enough to perform light exertional work (Tr. 514-618).
Despite this evidence, the ALJ posed a hypothetical to the VE premised on the ALJ's ultimate RFC conclusion, which offered an assigned RFC of light work, limited by various exertional and environmental limitations, including the ability to sit for up to three minutes every hour, then return to standing/walking (Tr. at 59-67). Per the VE, with this RFC in mind, Engstrand would be able to perform his past work as a maintenance supervisor, as generally performed at the light exertional level. The VE's testimony served as the basis for the ALJ's denial of benefits.
This Court will affirm the Commissioner's findings of fact and denial of disability benefits if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence consists of "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). This evidence must be "more than a scintilla but may be less than a preponderance." Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Thus, even if "reasonable minds could differ" about the disability status of the claimant, the Court must affirm the Commissioner's decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).
In this substantial-evidence determination, the Court considers the entire administrative record but does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the Court's own judgment for that of the Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). Nevertheless, the Court conducts a "critical review of the evidence" before affirming the Commissioner's decision. Id. An ALJ must evaluate both the evidence favoring the claimant as well as the evidence favoring the claim's rejection and may not ignore an entire line of evidence that is contrary to the ALJ's findings. Zurawski v. Halter, 245 F.3d 881, 888 (7th Cir. 2001). Consequently, an ALJ's decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues. Lopez, 336 F.3d at 539. Ultimately, while the ALJ is not required to address every piece of evidence or testimony presented, the ALJ must provide a "logical bridge" between the evidence and the conclusions. Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009).
Disability and supplemental insurance benefits are available only to those individuals who can establish disability under the terms of the Social Security Act. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998). Specifically, the claimant must be unable "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). The Social Security regulations create a five-step sequential evaluation process to be used in determining whether the claimant has established a disability. 20 C.F.R. § 404.1520(a)(4)(i)-(v). The steps are to be used in the following order:
Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001).
At step three, if the ALJ determines that the claimant's impairment or combination of impairments meets or equals an impairment listed in the regulations, disability is acknowledged by the Commissioner. 20 C.F.R. § 404.1520(a)(4)(iii). However, if a listing is not met or equaled, then in between steps three and four, the ALJ must assess the claimant's RFC, which, in turn, is used to determine whether the claimant can perform his past work under step four and whether the claimant can perform other work in society at step five of the analysis. 20 C.F.R. § 404.1520(e). The claimant has the initial burden of proof in steps one through four, while the burden shifts to the Commissioner in step five to show that there are a significant number of jobs in the national economy that the claimant is capable of performing. Young v. Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004). In this case, the ALJ did not conduct a step five analysis since he determined that Engstrand was capable of performing his past work as generally performed in the national economy.
Engstrand argues that the RFC is flawed because the ALJ did not properly evaluate his subjective statements or the medical evidence. Engstrand also argues that the ALJ improperly relied on the VE's testimony in finding that he could perform his past relevant work at step four. For the reasons that follow, the Court agrees that remand is required because the RFC analysis was affected by the ALJ's credibility analysis, which itself was not supported by substantial evidence. Given this shortcoming, the Court leaves it to the parties to address any remaining issues on remand.
Because the ALJ is in the best position to determine a witness's truthfulness and forthrightness, the Court will not overturn an ALJ's credibility determination unless it is patently wrong. Shideler v. Astrue, 688 F.3d 306, 310-11 (7th Cir. 2012). The ALJ's decision must, however, provide specific reasons for the weight given to the individual's symptoms, be consistent with and supported by the evidence, and must be sufficiently specific or clearly articulated so the individual and any subsequent reviewers can assess how the adjudicator evaluated the symptoms. SSR 16-3p
With respect to Engstrand's claimed limitations resulting from his back pain, the ALJ failed to adequately support his evaluation of Engstrand's limitations. First, the ALJ provided the often-criticized boilerplate language to summarily discredit all of Engstrand's subjective complaints, by stating:
(Tr. 23). This generic language does not explain or direct this reviewing Court to the information relied on by the ALJ in making his credibility determination. See Pepper, 712 F.3d at 367-68; see also Bjornson v. Astrue, 671 F.3d 640, 644-45 (7th Cir. 2012) (noting that an ALJ's finding a claimant to be `not entirely credible' fails to inform the court of the specific evidence considered in determining the claimant's credibility and fails to link the ALJ's conclusions to the evidence in the record). However, because the ALJ's mere use of boilerplate language does not automatically undermine the ALJ's ultimate conclusion, the Court considers the other information identified by the ALJ as a basis for attempting to justify his credibility determination. See id.
In this case, the ALJ discounted Engstrand's allegations regarding the limiting effects of all of his impairments because of perceived inconsistencies with Engstrand's testimony and several specifically identified medical records (Tr. at 26-27). The ALJ also found Engstrand to be less than fully credible because Engstrand had "some history" of treatment noncompliance. Id.
First, with regard to the ALJ's reliance on documentation that Engstrand's pain was "fairly well controlled," along with a simultaneous recommendation that Engstrand "stay as active as possible," the ALJ plucked these notations from a single pain management visit in December 2015 (Tr. 500-03). But, as plaintiff's counsel points out, other notations on the same record further specify that "today" the pain was fairly well controlled, and that "right now" the pain was well managed. Moreover, the pain assessment and exam conducted that same day indicate that Engstrand continued to suffer from sleep disturbance, gait disturbance, joint pain, joint stiffness, muscle pain, numbness and tingling, an antalgic gait, and pain with motion. Thus, by omitting discussion of these notations, the ALJ impermissibly "cherry-picked" facts that support a finding of non-disability while ignoring evidence that points to a disability finding. See Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010). Moreover, the ALJ's characterization of the pain as "fairly well controlled" is impermissibly selective (especially given the temporallylimiting notations) and fails to recognize the waxing and waning of symptoms.
Next, the ALJ claimed that medical records from Engstrand's primary care physician undermined Engstrand's testimony because normal musculoskeletal exam findings were documented in October 2014, March 2015, and June 2015. But the ALJ failed to recognize the limited value of these sporadic normal exam findings, when two of the three office visits relied on by the ALJ involved notations that were made in the context of examinations wholly unrelated to Engstrand's back pain. Instead, Engstrand presented for treatment in October 2014, to have his cholesterol checked (Tr. 493), and in June 2015, he sought medical care for a cut on his right index finger that had become infected (Tr. 483). In addition, the October 2014 and March 2015 medical records explicitly documented that Engstrand was seeing a separate pain specialist for managing his ongoing back pain (Tr. 488, 493). Even more problematic is the ALJ's reliance on these few records to discount Engstrand's claims without acknowledging the physician's simultaneous notations that Engstrand's "active" problems included lumbar pain and radiculopathy, and without discussing subsequent records indicating a worsening of Engstrand's back pain, particularly in 2016, after Engstrand participated in physical therapy.
Relative to physical therapy, the ALJ also discredited Engstrand's testimony due to his alleged failure to follow through with physical therapy. The ALJ accused Engstrand of being noncompliant with treatment and specifically noted that he had been "discharged from physical therapy for not showing for three scheduled visits." (Tr. 27). However, the ALJ made such a finding without acknowledging that Dr. Quadri, who initially referred Engstrand for physical therapy in March 2016 (Tr. 613-14), deferred that treatment only two months later because it caused Engstrand increased pain (Tr. 612-13). Thus, the ALJ erred in mischaracterizing Engstrand's conduct as "noncompliant" and then holding that against him in evaluating his symptom testimony. See SSR 16-3p; Myles, 582 F.3d at 677 (stating that "the ALJ was required by Social Security Rulings to consider explanations for instances where [the plaintiff] did not keep up with . . . treatment").
Additionally, the ALJ wholly failed to mention Engstrand's solid work history as it pertained to lending to his credibility. See Hill v. Colvin, 807 F.3d 862, 868 (7th Cir. 2015) (quoting Rivera v. Schweiker, 717 F.2d 719, 724 (2d Cir. 1983) ("A claimant with a good work record is entitled to substantial credibility when claiming an inability to work because of a disability."). Engstrand has a long history of performing physical labor, and he even attempted to return to work at a lesser capacity because he was "going broke" and needed money to live (Tr. at 45, 58-59). Yet, the ALJ did not discuss Engstrand's work ethic at the time that he discredited Engstrand's reports of pain.
Finally, to the extent that the ALJ summarily found Engstrand's subjective reports as not being entirely consistent with "the totality of the objective medical record," again, this type of generic language does not supply specific enough information to indicate the evidence relied on by the ALJ in making his credibility determination. See Pepper, 712 F.3d at 367-68. And although it is clear that the ALJ relied on the state agents' opinions that Engstrand could perform light work, the ALJ did not explain why the medical evidence that post-dated their opinions (as identified herein) did not undermine their assessments, especially when the records demonstrated an intensifying of Engstrand's pain. See Staggs v. Astrue, 781 F.Supp.2d 790, 794-96 (S.D. Ind. 2011) (finding that the medical record omitted from review provided "significant substantive evidence" regarding the claimant's medical impairments and that any medical opinion rendered without taking this record into consideration was "incomplete and ineffective.").
Some of that evidence from 2016 included opinions from Engstrand's treating pain doctor and physical therapist which indicated that Engstrand was not able to stand, walk, and sit long enough to perform light exertional work (Tr. 514-618). While the ALJ discounted the therapist's opinion because it was allegedly "unsupported and the basis for [the opinion] . . . unclear" (Tr. at 25), the ALJ drew this conclusion without recognizing that a "detailed narrative report" underlying the therapist's RFC evaluation was "available upon request." (Tr. at 555). And, while the ALJ discounted Dr. Quadri's opinion that Engstrand could not work, the ALJ's doing so merely because the opinion was not consistent "with the record as a whole" or with the "overall objective record" hardly suffices to meet the discussion required under 20 C.F.R. § 404.1527(c)(1)-(5) with respect to treating physician opinions.
As indicated, remand is required (but not an outright award of benefits as requested) because the RFC analysis was affected by the ALJ's credibility analysis, which itself was not supported by substantial evidence. See Pepper, 712 F.3d at 367; Berger, 516 F.3d at 545; Rice, 384 F.3d at 371. An inadequately supported RFC determination prevents the Court from discerning whether the limitations caused by Engstrand's pain (including a loss of concentration) should have been incorporated into the questions posed to the VE. See Herron v. Shalala, 19 F.3d 329, 333-34 (7th Cir. 1994) (indicating that an ALJ must explain his analysis of the evidence with enough detail and clarity to permit meaningful review). This is especially important where limiting Engstrand to sedentary work would have resulted in an award of disability benefits. Ultimately, because the ALJ's assessment of Engstrand's RFC is not supported by substantial evidence, the determination cannot stand.
For the reasons stated above, the Court REVERSES the Commissioner's decision and REMANDS this matter to the Commissioner for further proceedings consistent with this opinion. The Clerk is DIRECTED to prepare a judgment for the Court's approval. See Cooke v. Jackson Nat'l Life Ins. Co., 882 F.3d 630, 631 (7th Cir. 2018).
SO ORDERED.
