United States District Court, E.D. Wisconsin
DECISION AND ORDER
WILLIAM C. GRIESBACH, Chief District Judge.
Plaintiff filed this action challenging the decision of the Commissioner of Social Security denying her disability benefits. For the reasons given below, the decision of the Commissioner will be reversed and remanded for further proceedings.
Plaintiff suffers from multiple sclerosis, which was diagnosed more than a decade ago, but which was not treated regularly. The ALJ considered the MS but found it did not result in significant motor function disabilities in two extremities, limitations on movements, or vision impairments. (R. 18.) The ALJ noted that the Plaintiff had received only limited and sporadic treatment relating to her MS, the last in 2011 and 2012, when her doctors found that she "generally feels well" and was "stable" on copaxone, a myelin-simulating drug that reduces the frequency of relapses in MS patients. (R. 282, 286.) The January 2, 2012 treatment note also indicated she had not had any severe flare-ups since beginning treatment with copaxone the previous July. (R. 285-89.)
The Plaintiff testified at her June 6, 2013 hearing that she had several flare-ups each week, at which times she could barely walk, but the ALJ discounted that testimony on the grounds that there were no medical records to confirm those symptoms, which appeared to be in contrast with the treatment notes suggesting that copaxone was preventing any severe flare-ups. (R. 21.) Her treating doctor noted in 2012 that she had experienced only two flare-ups, the most recent being two years prior. (R. 289.) Another record indicates about nine flare-ups in recent years. (R. 223.) The ALJ also noted there was no treatment from a neurologist, although he recognized that the Plaintiff's financial limitations appeared to be the main cause-she had no health insurance, and the local free clinic did not have a neurologist on staff. A physical exam in June 2011 showed strength in her extremities intact and she had no neurological deficits. (R. 224.) Although the Plaintiff experienced a flare-up in or around 2011, when her foot went numb after sitting on a couch, evidently that was not considered severe because the symptoms resolved after a few minutes. (R. 285.) She did, however, have chronic numbness in her right foot and "severe symptoms in her right leg." (R. 285-86.) This interfered with her sleep and caused her to stumble frequently. (R. 286.)
The Plaintiff also alleged disability due to back pain, presenting to her primary care provider on a number of occasions between 2005 and 2009. The ALJ noted that her MRI showed mild degenerative changes and accounted for any limitations by restricting her to light work with certain other limitations.
The Plaintiff also alleged mental health issues. She had been in special education programs in school, finishing only the eighth grade, and reported mood problems. Dr. Clarke preformed a consultative psychological evaluation and noted a significantly impaired visual memory, questionable judgment and a poor fund of knowledge. (R. 257-59.) The psychologist noted that the Plaintiff spent most of her time with her mother, who lived in an apartment across the hall. She noted the Plaintiff's spotty work history, her stresses due to having no money or health insurance, and observed some depressive symptoms; she assessed a GAF score of 45, indicating serious impairments. The psychologist concluded the Plaintiff would be "slow" in her work, would have significant trouble remembering tasks, and could no longer perform the physical work she previously did, which included janitorial work. (R. 260.) The examiner also interviewed the Plaintiff's daughter, who painted a grimmer picture of Plaintiff's condition. She stated that the Plaintiff had trouble moving around, frequently needed to grip walls for support, and could not climb stairs. She believed that if the Plaintiff's mother did not cook most of their meals, the Plaintiff might never eat on her own.
State agency reviewers found that the Plaintiff retained the ability to do light, unskilled work. (R. 79.) She would have moderate difficulties maintaining attention and carrying out detailed instructions, maintaining regular attendance, performing on schedule, being punctual, and completing a normal workday. (R. 84.) Ultimately the ALJ found the Plaintiff could perform light work with certain restrictions, including being limited to simple routine, repetitive tasks involving only simple instructions, and with a job not requiring a production rate pace. (R. 20.)
The decision of the Commissioner is conclusive if it is supported by substantial evidence. 42 U.S.C. § 405(g). The question upon judicial review of an ALJ's finding that a claimant is not disabled within the meaning of the Social Security Act is not whether the claimant is, in fact, disabled, but whether the ALJ's findings are supported by substantial evidence and under the correct legal standard. See Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). The ALJ must build an "accurate and logical bridge from the evidence to his conclusion so that, as a reviewing court, we may assess the validity of the agency's ultimate findings and afford a claimant meaningful judicial review." Young v. Barnhart, 362 F.3d 995 (7th Cir. 2004).
A. Medical evidence
The Plaintiff's challenge is based largely on the ALJ's handling of the medical evidence. In 2013, Plaintiff's physician of fifteen years, Dr. Houlihan, filled out a questionnaire indicating that the Plaintiff experienced anxiety and depression, and would need as many as three unscheduled breaks, each lasting one or two hours, if she were forced to work a standard workday. (R. 378.) This was due primarily to the numbness Plaintiff chronically experienced in her right leg and foot. Dr. Houlihan also concluded she would be "off task" more than 25% in a workday due to distractions from her condition. (R. 379.) Plaintiff could experience three "good days" in a month, but would need to be absent from work more than four days a month. (R. 380.)
The ALJ discounted this opinion because "treatment records do not support such a level of restriction." (R. 21.) The ALJ noted that the most recent record indicated Plaintiff was doing well and was stable. The ALJ also noted that Dr. Houlihan opined that these limitations had existed since 2008, and yet the Plaintiff had worked in 2008 and 2009, which suggested the limitations could not have been that serious at that time. The ALJ also found that Dr. Houlihan's restrictions, which would have precluded gainful employment, were in contrast to the state agency reviewers, who found no disability.
The Plaintiff argues that the ALJ erred by failing to give adequate reasons for discounting the treating physician's opinion and failing to give the opinion controlling weight. Here, the ALJ was not obligated to give the treating physician's opinion controlling weight. The ALJ reasonably explained that the rather harsh limitations found in Dr. Houlihan's 2013 form did not seem to reflect the Plaintiff's treatment notes, which told the story of a woman with MS who had occasional flareups but was otherwise doing "well" (at least sometimes) and was "stable" on her drug regimen. And the limitations imposed by Dr. Houlihan were contradicted by the reviewing physicians, who found the Plaintiff's alleged limitations to be "out of proportion w/objective findings on exam.... [T]he clmt's statements about her symptoms and their functional effects [are] only partially credible." (R. 81, 275.) Thus, because there was evidence contradicting Dr. Houlihan's report, the ALJ properly did not find the report to be entitled to controlling weight. ...