Case Name in Social Security Case - Unavailable

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UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
TERRE HAUTE DIVISION
LORI M., 	)
)
Plaintiff, 	)
)
v. 	) 	No. 2:25-cv-00112-MG-JRS
)
FRANK J. BISIGNANO Commissioner of Social
Security Administration,
)
)
)
Defendant. 	)
ENTRY REVIEWING THE COMMISSIONER'S DECISION
On September 8, 2021, Plaintiff Lori M.1 filed a Title II application for a period of disability
and disability insurance benefits, as well as a Title XVI application for supplemental security
income, alleging disability beginning on March 16, 2020. [Filing No. 9-2 at 11.] Following denials
at the initial and reconsideration levels, Plaintiff filed a request for a hearing before an
Administrative Law Judge ("ALJ"). [Filing No. 9-2 at 11.] A hearing was held before the ALJ on
August 24, 2023. [Filing 9-2 at 11.] 	On October 4, 2023, the ALJ issued a decision denying
Plaintiff benefits, [Filing No. 9-2 at 19], and on January 8, 2025, the Appeals Council denied
Plaintiff's request for review, [Filing No. 9-2 at 2.] For the reasons that follow, the Court hereby
REVERSES the ALJ's decision denying Plaintiff benefits and REMANDS this matter for further
consideration.
I. 	Legal Standard
"The Social Security Administration (SSA) provides benefits to individuals who cannot
obtain work because of a physical or mental disability." Biestek v. Berryhill, 587 U.S. 97, 98
1 To protect the privacy interests of claimants for Social Security benefits, the Southern District of Indiana has
chosen to use only the first name and last initial of non-governmental parties in its Social Security review opinions.
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(2019). Disability is the inability "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 twelve
months." Stephens 	v. 	Berryhill, 	888 	F.3d 	323, 	327 	(7th 	Cir. 	2018) (citing 42 	U.S.C. 	§
423(d)(1)(A)).
When an applicant appeals an adverse benefits decision, this Court's role is limited to
ensuring that the ALJ applied the correct legal standard, and that substantial evidence exists for
the ALJ's decision. Id. Substantial evidence is "such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion." Biestek, 587 U.S. at 103. "Although this Court reviews
the record as a whole, it cannot substitute its own judgment for that of the SSA by reevaluating the
facts, or reweighing the evidence to decide whether a claimant is in fact disabled." Stephens, 888
F.3d at 327. Reviewing courts also "do not decide questions of credibility, deferring instead to the
ALJ's 	conclusions 	unless 	'patently 	wrong.'" Zoch 	v. 	Saul, 	981 	F.3d 	597, 	601 	(7th 	Cir.
2020) (quoting Summers v. Berryhill, 864 F.3d 523, 528 (7th Cir. 2017)). The Court does
"determine whether the ALJ built an 'accurate and logical bridge' between the evidence and the
conclusion." Peeters v. Saul, 975 F.3d 639, 641 (7th Cir. 2020) (quoting Beardsley v. Colvin, 758
F.3d 834, 837 (7th Cir. 2014)). In creating a logical bridge, the ALJ must meet the "minimal
articulation requirements" when making the decision. Warnell v. O'Malley, 97 F.4th 1050, 1053
(7th Cir. 2024) ("An ALJ need not address every piece or category of evidence identified by a
claimant, fully summarize the record, or cite support for every proposition or chain of
reasoning."); see Zellweger v. Saul, 984 F.3d 1251, 1252 (7th Cir. 2021) (explaining the court
reviews the ALJ's decision holistically).
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II. 	Factual Background
The ALJ's decision finding Plaintiff not disabled followed the required five step evaluation
process in 20 C.F.R. § 404.1520. Specifically, the ALJ found:
• 	At Step One, that Plaintiff "ha[d] not engaged in substantial gainful activity since
March 16, 2020, the alleged onset date[.]"
• 	At 	Step 	Two, 	that 	Plaintiff 	"ha[d] 	the 	following 	severe 	impairment: 	lumbar
degenerative disc disease[.]"
• 	At Step Three, that Plaintiff "d[id] not have an impairment or combination of
impairments that meets or medically equals the severity of one of the listed impairments
in 20 CFR Part 404, Subpart P, Appendix 1[.]"
• 	At Step Three but before Step Four, that Plaintiff "ha[d] the residual functional capacity
to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except she can
occasionally stoop, kneel, crouch, crawl, and climb ramps and stairs. She can never
climb ladders, ropes, or scaffolds. She cannot work around vibrations, or hazards, such
as unprotected heights or dangerous machinery."
• 	At Step Four, that Plaintiff was "capable of performing past relevant work as a garment
sorter. This work d[id] not require the performance of work-related activities precluded
by the claimant's residual functional capacity[.]"
• 	Alternatively, at Step Five, that Plaintiff was "capable of making a successful
adjustment to other work that exists in significant numbers in the national economy."
[Filing No. 9-2 at 13–19.] For these reasons, the ALJ concluded Plaintiff had "not been under a
disability, as defined in the Social Security Act, from March 16, 2020, through the date of this
decision[.]" [Filing No. 9-2 at 19.]
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III. 	Discussion
Plaintiff argues the ALJ erred in two ways: (1) she impermissibly played doctor by not
including RFC limitations for Plaintiff's shoulder, as well as ignored evidence of Plaintiff's
cervicogenic dizziness and headaches; and (2) her subjective symptom assessment was not
grounded in substantial evidence.
The Court begins with Plaintiff's argument that the ALJ failed to consider evidence of her
cervicogenic dizziness and headaches. As previously noted, on September 8, 2021, Plaintiff filed
a Title II application for a period of disability and disability insurance benefits, as well as a Title
XVI application for supplemental security income, alleging a disability beginning on March 16,
2020. [Filing No. 9-2 at 11.] In the "Medical Conditions," section of her application, Plaintiff was
prompted to identify the physical or mental conditions that formed the basis of her initial claim for
disability. See [Filing No. 9-6 at 3.] Among other conditions, Plaintiff listed cervicogenic dizziness
and headaches. [Id.]
In her brief, Plaintiff cites an emergency room visit for dizziness as well as a physical
therapy evaluation for cervicogenic dizziness, neck pain, and weakness. See [Filing No. 9-7 at 251,
302.] The emergency room visit occurred on September 10, 2020. [Filing No. 9-7 at 302.]
Plaintiff's chief complaint was dizziness, and she described "feeling off balance." [Id.] Plaintiff
also relayed that she had experienced the same symptoms on one previous occasion. [Id.] About a
year later, on September 15, 2021, Plaintiff was evaluated by a physical therapist. [Filing No. 9-7
at 251.] The "Subjective History of Current Complaint" section of the evaluation form stated the
following:
Patient notes dizziness for a few years, notes spinning when first waking up in the
morning along with nausea. Patient notes intermittent headaches 2-3/ week. Patient
notes worst episode a few months ago, with severe vertigo when raising her head
off the bed. Patient was prescribed Meclizine, and notes fatigue as a side effect.
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Patient notes feeling dizzy most of the time, sometime for hours on end, but notes
good days and bad days. Patient notes h/o neck pain, L>R, burning pain in BL
elbows and R shoulder pain over the past few years.
[Id.] At no point in her decision did the ALJ discuss or cite the foregoing evidence. In fact,
there is no mention, even generally, of cervicogenic dizziness or headaches. While the ALJ
need not address every conceivable condition Plaintiff might suffer from, it is troublesome
to the Court that she ignored Plaintiff's cervicogenic dizziness and headaches, particularly
in light of the supporting evidence of those conditions as well as Plaintiff having listed
them on her disability application. Notable too, while the Commissioner characterizes the
above evidence as Plaintiff having "simply described her symptoms," [Filing No. 15 at 6],
the physical therapy evaluation included a "Treatment Diagnosis" box, in which the
physical therapist wrote the following: "[c]ervicogenic dizziness, neck pain with radiating
pain, weakness." [Filing No. 9-7 at 251.] Even when subjective accounts of migraines or
headaches are all that exist in the record, an ALJ must be cautious: Dependence on
objective medical testing when rejecting a claimant's subjective reports of headaches can
be problematic, as "there is no medical test available to confirm the presence or severity of
migraine headaches[.]" Fields v. Colvin, 213 F. Supp. 3d 1067, 1072 (N.D. Ind. 2016); but
see Angela J. B. v. Kijakazi, No. 1:21-cv-2801, 2023 WL 2445442, at *3 (S.D. Ind. Mar. 9,
2023) (noting that in cases involving complaints of migraine headaches, an ALJ can rely
on "objective medical signs," including "whether the claimant's complaints are consistent
with the existence of disabling migraine pain") (citation modified).
The Commissioner's justifications for the ALJ's omissions do not move the needle.
In his response brief, the Commissioner contends that the emergency room visit and
physical therapy evaluation do not demonstrate that Plaintiff's cervicogenic dizziness and
headaches were severe. But the Commissioner has misidentified the issue: Plaintiff has
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challenged the ALJ's failure to acknowledge this evidence, she has not challenged that this
evidence necessitated a severe impairment finding. The Commissioner also notes that
"Plaintiff has not shown any additional RFC limitations were required." [Filing No. 15 at
6.] But again, this sentiment does not iron out the present issue. To be affirmed,
the ALJ must articulate her impressions of the evidence in her decision, and while she "is
not required to address every piece of evidence or testimony," she must "provide some
glimpse into her reasoning." Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001).
Here, the ALJ provided no glimpse into her impressions of the evidence that Plaintiff
suffered from cervicogenic dizziness and headaches, conditions explicitly identified on
Plaintiff's application for benefits. Consequently, the Court is in the dark about whether the
ALJ considered this evidence, and if so, what conclusions she drew. See Minor v. Colvin,
No. 1:15-cv-1017, 2016 WL 4132075, at *5 (S.D. Ind. July 11, 2016), report and
recommendation adopted, No. 1:15-cv-1017, 2016 WL 4088413 (S.D. Ind. Aug. 2, 2016)
("Because the ALJ never mentioned the evidence of headaches and migraines, it appears
he did not consider it, which was error.").
Because the Court is recommending that this case be remanded, it need not address
Plaintiff's remaining arguments, though she may raise those arguments before the ALJ.
IV. 	Conclusion
For the reasons detailed herein, the Court REVERSES the ALJ's decision denying
the Plaintiff benefits and REMANDS this matter for further proceedings. Final judgment
will issue accordingly.
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Distribution to all counsel of record via CM/ECF.
Date: 2/27/2026
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