KENDRA v. COMMISSIONER OF SOCIAL SECURITY (2025)

ORDER

Plaintiff Kendra M. (“Plaintiff”) seeks review under sentence four of 42 U.S.C. § 405(g) of the Social Security Administration's denial of her application for disability insurance benefits. After reviewing the record, administrative transcript, and parties' briefs, the court finds that the Commissioner's decision should be affirmed.

The Supreme Court recently held that, in reviewing disability cases, courts should “defer[ ] to the presiding ALJ, who has seen the hearing up close.” Biestek v. Berryhill, 139 S. Ct. 1148, 1151 (2019). The district court's role is “limited to ensuring that substantial evidence supported the ALJ's decision and that the ALJ applied the correct legal standards.” Morales v. O'Malley, 103 F.4th 469, 472 (7th Cir. 2024). The threshold for substantial evidence “is not high.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). “It means—and means only—such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (internal quotation marks omitted). When reviewing a disability decision for substantial evidence, “[w]e will not reweigh the evidence, resolve debatable evidentiary conflicts, determine credibility, or substitute our judgment for the ALJ's determination so long as substantial evidence supports it.” Gedatus v. Saul, 994 F.3d 893, 900 (7th Cir. 2021).

The ALJ found that Plaintiff had the severe impairments of disorders of the skeletal spine and obesity. (R. 19). As to mental limitations, the ALJ found Plaintiff was mildly limited in her ability to maintain concentration, persistence, and pace. (R. 20.) The ALJ then assessed Plaintiff's RFC and found Plaintiff had the capacity to perform light work with the following additional limitations: occasional climbing of ramps, stairs, and ladders; no climbing ropes and scaffolds; and occasional stooping, kneeling, crouching, and crawling. (R. 22).

I. Analysis

Plaintiff argues the court should reverse the ALJ's decision and remand the case for two reasons. First, Plaintiff argues the ALJ erred in evaluating Plaintiff's RFC. Second, Plaintiff argues the ALJ's assessment of Plaintiff's activities of daily living and treatment history did not comply with SSR 16-3p.

A. RFC

As it relates to Plaintiff's RFC, Plaintiff first argues the ALJ failed to support the conclusion that she could sustain the physical requirements of light or even sedentary work at the full-time level. When assessing a claimant's RFC, the ALJ must include “a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” SSR 96-8p.

Here, the ALJ provided a narrative discussion as to why Plaintiff was not limited by her impairments and could perform light and sedentary work. The ALJ discussed Plaintiff's allegations of pain and other related symptoms. (R. 22–23). The ALJ also engaged the medical record at length, including a review and analysis of the digital images and examination findings. (R. 24–29). He acknowledged that Plaintiff presented to appointments with back tenderness but that digital imaging showed disc-herniation without compromise of her spinal canal, neural foramina, or neural elements (R. 24–25, 350, 406).

In addition, the ALJ noted that the record suggested Plaintiff walked unassisted at some appointments with a steady gait but that during other appointments, Plaintiff required a wheelchair. (R. 25-26, 331, 336, 344). The ALJ noted that Plaintiff told providers gabapentin helped her symptoms and that injections provided some relief. (R. 27, 320, 1258). Further, he summarized and discussed the state-agency consultants' conclusions that the record contained insufficient evidence of physical or mental limitations that would warrant a finding of disability. (R. 31–32).

Based on the above, the ALJ complied with SSR 96-8p. Plaintiff's argument is an improper request for this court to reweigh evidence. It will not do so. Butera v. Apfel, 173 F.3d 1049, 1055 (7th Cir. 1999).

Next, Plaintiff argues the ALJ failed to adequately include the use of a wheelchair or walker when formulating her RFC. A cane must be incorporated in an RFC only if it is medically necessary. Tripp v. Astrue, 489 F. App'x 951, 955 (7th Cir. 2012). For a cane to be medically necessary, there must be “medical documentation establishing the need for [the cane] to aid in walking or standing, and describing the circumstances for which it is needed.” SSR 96-9p. The Seventh Circuit has suggested that a finding of medical necessity requires an “unambiguous opinion from a physician stating the circumstances in which an assistive device is medically necessary.” Tripp, 489 F. App'x at 955. “The mere fact that a claimant has been seen or reported to be using an assistive device is not sufficient.” Limberg v. Kijakazi, 2022 WL 406057, at *6 (W.D. Wis. Feb. 10, 2022) (citing Tripp, 489 F. App'x at 955). “Even a physician's statement that a claimant ‘needs’ such a device may not establish medical necessity if it is unclear whether the doctor is offering a medical opinion or merely restating what the claimant told him.” Limberg, 2022 WL 406057, at *6 (citing Tripp, 489 F. App'x at 955).

Here, Plaintiff did not identify any medical documentation establishing a cane was medically necessary. Plaintiff refers to her own reports, treatment notes showing she used a wheelchair at some medical appointments, and a prescription from her nurse practitioner. These are not “medical documentation” that supports a finding of medical necessity. See SSR 96-9p. The ALJ did not err here.

Plaintiff next argues the ALJ failed to adequately account for and incorporate her obesity into the RFC and instead engaged in a “cursory” discussion. When assessing an RFC, the ALJ must analyze a claimant's obesity and “explain how [they] reached [their] conclusion on whether obesity causes any limitations.” SSR 19-2p.

Here, the ALJ satisfied SSR 19-2p. The ALJ expressly acknowledged Plaintiff's height, weight, and BMI in the decision. The ALJ discussed the existence and impact of her obesity classification throughout the RFC analysis and in combination with her other impairments and treatment history. (R. 21–22, 23, 29). The ALJ engaged in “adequate discussion of the issues,” such that remand is unwarranted. Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009).

As it relates to her mental RFC, Plaintiff argues the ALJ did not reasonably engage with or consider the limitations that accompany her mental impairments. At step-two, the ALJ found that Plaintiff's bipolar and anxiety disorders were non-severe because they caused no more than minimal limitations in Plaintiff's ability to perform basic mental activities. (R. 20-21). The ALJ then evaluated Plaintiff's mental health record and concluded that while “the record does include some abnormal mental signs and findings, [ ] for the most part, mental status exams do not fully support the severity of the symptoms alleged by the claimant.” (R. 29).

The ALJ elaborated that Plaintiff had sparse mental health treatment and failed to respond to the agency's efforts to schedule a consultative psychological examination. (R. 29). The ALJ also considered appointments from 2020-2022, explaining why each appointment suggested Plaintiff was presenting as a patient with no more than mild mental limitations. (R. 29-31). In addition, the ALJ considered the state-agency psychologist Dr. Voss's prior administrative medical finding that insufficient evidence existed to evaluate the record (R. 32, 79). The ALJ noted documentation suggesting Plaintiff failed to show up for a consultative psychological examination and failed to respond to the agency-attempts at rescheduling that missed examination. (R. 32).

Much of Plaintiff's argument simply disagrees with how the ALJ weighed the evidence. However, it is not this court's role to “reweigh evidence, even where reasonable minds might disagree about the outcome.” Bakke v. Kijhakazi, 62 F.4th 1061, 1068 (7th Cir. 2023). The ALJ's evaluation was reasonable and minimally articulated the rationale for the mental RFC.

Plaintiff also argues the ALJ was required to automatically accommodate mild mental impairments into the mental RFC. While an “ALJ's RFC assessment must incorporate all of the claimant's limitations supported by the medical record,” Yurt v. Colvin, 758 F.3d 850, 857 (7th Cir. 2014), it is possible that a limitation is unnecessary to include in the RFC assessment. See Sawyer v. Colvin, 512 F. App'x 603, 611 (7th Cir. 2013) (noting that “a mild, or even a moderate, limitation in an area of mental functioning ‘does not prevent an individual from functioning satisfactorily.’ ”) (internal citations omitted).

Here, the ALJ found that while Plaintiff did have some mild mental limitations, they did not affect her ability to work. The ALJ's analysis was well supported, and this court does not reweigh the evidence to come to a different conclusion.

B. Plaintiff's Activities

Finally, Plaintiff argues the ALJ's assessment of Plaintiff's activities of daily living and treatment history did not comply with SSR 16-3p. SSR 16-3p provides that an ALJ's symptom evaluation must be “consistent with and supported by the evidence, and be clearly articulated so the individual and any subsequent reviewer can assess how the adjudicator evaluated the individual's symptoms[.]”

Here, the ALJ expressly considered Plaintiff's assertions that her fiancé took care of all her daily personal and household needs. (R. 22–23). When he compared those assertions to the medical record, the ALJ reasoned that the objective record evidence did not suggest Plaintiff was an individual with a high degree of limitations. (R. 26–27).

Courts defer to an ALJ's assessment where they do not “ignore an entire line of evidence,” and “gives specific reasons supported by the record” to support that credibility determination. Grotts v. Kijakazi, 27 F.4th 1273, 1278-79 (7th Cir. 2022). Plaintiff “fails to recognize [that] the ALJ did not entirely disregard her allegations” but instead “found the objective medical evidence did not more fully corroborate” her assertions. Sheri W. v. Kijakazi, 2022 WL 4448906, at *4 (C.D. Ill. Sept. 23, 2022). The ALJ did not err here.

II. Conclusion

In conclusion, the court has reviewed Plaintiff's arguments and holds the ALJ did not err. Thus, the ALJ's decision is upheld.

COLIN S. BRUCE, UNITED STATES DISTRICT JUDGE