Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Symitczek v. Berryhill

United States District Court, W.D. Wisconsin

February 15, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Under 42 U.S.C. § 405(g), plaintiff Michael Anthony Symitczek seeks judicial review of a denial of his application for disability insurance benefits by the Commissioner of Social Security. Before the court is plaintiff's motion for summary judgment contending that the Administrative Law Judge (“ALJ”) erred by: (1) failing to give controlling weight to a treating physician opinion without providing satisfactory justification; (2) failing to adequately explain the reasons for finding that Symitczek's impairments did not meet or equal a listed impairment; and (3) discounting Symitczek's credibility by ignoring medical evidence supporting a finding of disability. (Dkt. #8.) Because the court agrees with plaintiff that remand is required for further assessment of his treating physician's opinion, the Commissioner's decision will be reversed and remanded.


         A. Claimant

         Symitczek was born on December 18, 1964, making him 46 years old on his alleged disability onset date, September 1, 2011. (AR 21, 26.) He has at least a high school education, and his past relevant work as a “numerical control machine operator” and “machine set-up operator” was performed as skilled work at the medium level of exertion. (AR 26.) Symitczek claims that he is unable to work due to multiple impairments, including “a left knee replacement; right knee pain; back disc fusion; headaches; possible Potts syndrome; right knee injury from remote military duty; dizziness; nausea; sweating; light sensitivity; and adrenaline syndrome.”[2] (AR 23.)

         B. Relevant Medical History

         Beginning in 2011, plaintiff sought treatment and received multiple medications, including blood pressure and pain medicine, for his various medical conditions. Treatment notes from Dr. Christopher Petersen for a “pain contract” renewal visit, dated May 19, 2011, indicate Symitczek's reports of continued pain in his left knee following a recent surgery, as well as pain in his right knee and continued pain in his back after a lower lumbar fusion, although the latter “seem[ed] to be getting along quite well.” (AR 265.) The following month, Dr. Petersen noted Symitczek's reports of having developed dizziness and nausea, both likely caused by hypertension, as well as increased back pain, accompanied by “a little tingling down the left leg.” (AR 263.)

         On September 13, 2011, Symitczek again visited Dr. Petersen with reports of recent symptoms he had experienced, including swelling of his left eye, facial numbness, dizziness, nausea and fatigue. (AR 237.) In his treatment notes from that same visit, Dr. Petersen remarked that Symitczek “has had a full and complete workup, including CT of the head recently, which was negative, ” and that he had referred Symitczek to the internal medicine department for an appointment. (Id.)

         Internal medicine progress notes from Dr. Thomas Scott Cunningham for Symitczek's visit on September 19, 2011, include Symitczek's reports of having episodic spells involving “a sense of facial flushing or heat, [as well as] symptoms of nausea, with slightly preceding symptoms of dizziness and lightheadedness” that had been recurring nearly daily since June. (AR 290.) During that same visit, Symitczek also reported experiencing an episode of “bright flashing lights in his visual field with transient double vision, and then subsequent return of normal vision to his right eye but with the left eye having an episode of a very tunneled type effect with a small visual hole that lasted about 10 minutes.” (Id.) In addition, he complained of increasingly frequent and severe headaches, as well as “intermittent confusion and difficulty with memory and general cognition.” (AR 290, 292.)

         Doubting that Symitczek's blood pressure problems were directly causing the symptoms that he was experiencing, Dr. Cunningham recommended additional testing to “exclud[e] a cardiac etiology to his spells, ” as well as neurological and visual examinations. (AR 293.) Accordingly, Cunningham referred Symitczek to Dr. Sankar Bandyopadhyay, who saw him for a neurology consultation on October 5, 2011.

         Dr. Bandyopadhyay noted many of the same complaints that Symitczek made to Dr. Cunningham, and he developed an “extensive plan” for testing and follow-up. (AR 328-29, 331.) After a follow-up visit on April 9, 2012, Dr. Cunningham noted his own difficulty “find[ing] a specific cause for many of [Symitczek's] symptoms[, ] particularly the profound fatigue, hot flashes and sweats and other explanations for his headaches, ” advised Symitczek that he lacked any “explanation for his shortness of breath other than the usual etiologies particularly in the context of his chronic tobacco use.” (AR 286.)

         Another physician, Dr. Annette Faller, saw Symitczek for an internal medicine visit on October 16, 2012. Following that visit, Dr. Faller noted many of the same subjective, patternless “roller coaster” symptoms about which Symitczek had complained to other physicians, although this time including that he often wore sunglasses, including when in indoor locations with bright lights, because of headaches triggered by sensitivity to light. (AR 270.) In progress notes, Dr. Faller also remarked that “CT scans, ” “MRI scans, ” a “full evaluation” and “multiple studies” had been “unrevealing, ” concluding her notes with a recap of Symitczek's “fairly comprehensive workup.” (Id.)

         Dr. Faller saw Symitczek again on December 4, 2012. During that visit Symitczek reported largely unchanged symptoms, except for the addition of occasional numbness of his left arm and left leg, as well as additional difficulty sleeping. (AR 525.) After a physical therapy visit six days later at the referral of Dr. Faller, Ralph Tyler, PT, noted that it was “unlikely” that Symitczek's symptoms could be explained by “vestibular hypofunction.”[3](AR 617.)

         Dr. Faller saw Symitczek for another visit on December 21, 2012. She noted his continued complaints of dizziness, nausea, headaches with light sensitivity and problems with his concentration and short-term memory. (AR 521.) Dr. Faller also noted his complaints of “generalized pain” and weakness, including “aching all over in his hands, his knees and his left shoulder to the point where it is difficult to even lift a cup of coffee up to his mouth, ” which he attributed to possible Lyme disease. (Id.) At another visit with Dr. Faller on March 12, 2013, Symitczek complained of having worsening headaches and joint pain among other symptoms, including episodes of “blank[ing] out” and difficulty sleeping. (AR 506-07.) Several months later, after a visit on November 19, 2013, Dr. Faller's progress notes reflected continuing complaints of “spells” and pain with activity. (AR 668.) Dr. Faller also noted informing Symitczek that several of his symptoms, including dizziness, hot flashes and sweating, may be related to him taking oxycodone for pain, although he was reluctant to decrease his dosage, since he felt that his pain was “barely controlled” as it was. (AR 670.)

         C. ALJ's Decision

         ALJ Christopher Inama held a hearing by videoconference on February 6, 2014 (AR 19), and in an opinion dated May 7, 2014, concluded that Symitczek was not disabled for purposes of receiving Social Security disability benefits. (AR 27.) The ALJ found that Symitczek had several severe impairments: “degenerative disc disease, status-post fusion at ¶ 5-S1, with hardware, in 2010; history of total left knee replacement in 2008; and migraine headaches.” (AR 21.) Because Symitczek's obesity (he reported weighing 260 pounds at a height of 5'10”) and other medical conditions were manageable or caused insignificant functional limitations, the ALJ found those ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.