Case Name in Social Security Case - Unavailable

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
EVANSVILLE DIVISION
CHRISTINE ANN D1., 	)
)
Plaintiff, 	)
)
v. 	) 	No. 3:25-cv-00077-RLY-CSW
)
FRANK BISIGNANO Commissioner of the
Social Security Administration,
)
)
)
Defendant. 	)
R EPORT AND R ECOMMENDATION ON A PPROPRIATE
DISPOSITION OF THE A CTION
This matter is before the Honorable Crystal S. Wildeman, United States
Magistrate Judge, pursuant to an Entry Referring Matter to Magistrate Judge, to
conduct and issue a report and recommendation regarding the appropriate
disposition of this matter. (Dkt. 13). Claimant, Christine D., seeks judicial review
of the Social Security Administration’s (“SSA”) decision denying her application for
Title XVI Supplemental Security Income (“SSI”) Benefits under 42 U.S.C. §
1383(c)(3). (Dkt. 1). For the following reasons, the Magistrate Judge recommends
that the Commissioner’s decision be AFFIRMED.
I. 	B ACKGROUND
On November 3, 2022, Claimant filed her application for SSI benefits,
alleging a disability beginning on January 1, 2021. (Dkt. 10-2 at 11; Dkt. 10-5 at 7–
17, 18–23; R. 10, 178–88, 189–94). Her application was denied initially and on
reconsideration. (Dkt. 10-3 at 9–10; R. 86–87). Following a hearing, the ALJ issued
1 To protect the privacy interests of claimants for Social Security benefits, consistent with the
recommendation of the Court Administration and Case Management Committee of the
Administrative Office of the United States Courts, the Southern District of Indiana has opted to use
only the first name and last initial of non-governmental parties in its Social Security judicial review
opinions.
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an unfavorable decision on July 17, 2024. (Dkt. 10-2 at 11–30, 44–79; R. 10–29, 43–
78). The Appeals Council denied review of the ALJ’s decision, making the ALJ’s
decision the final decision of the agency for purposes of judicial review. (Id. at 2–5;
R. 1–4); see 20 C.F.R. § 416.1481. On April 3, 2025, Claimant filed this action
pursuant to 42 U.S.C. § 405(g), seeking judicial review of the denial of her benefits.
(Dkt. 1).
The ALJ applied the five-step sequential evaluation process to determine
whether the Claimant met the standard for “disabled” as defined under the Social
Security Act. (Dkt. 10-2 at 35–51; R. 11–28)
In his decision, the ALJ found that:
• 	At Step One, Claimant has not engaged in substantial gainful activity
since November 3, 2022, the application date. (Id. at 35; R. 12).
• 	At Step Two, Claimant had the following severe impairments: chronic
obstructive pulmonary disease (COPD), emphysema, lumbar spine
degenerative disc disease with history of lumbar spine fusion,
sacroiliitis, elevated blood pressure, and syncope. (Id. at 36; R. 13).
• 	At Step Three, Claimant did 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. (Id. at
38; R. 15).
• 	After Step Three but before Step Four, Claimant had the residual
functional capacity (“RFC”) to perform light work as defined in 20 CFR
416.967(b) except she can lift/carry 20 pounds occasionally and 10
pounds frequently, sit for at least 6 out of 8 hours and stand/walk for
about 6 out of 8 hours. She can occasionally climb, stoop, kneel, crouch,
and crawl. She can frequently balance. She should avoid concentrated
exposure to fumes, dusts, odors, gases, and areas or poor ventilation,
humidity, temperature extremes of heat and cold, and dangerous
workplace hazards such as exposed moving machinery and unprotected
heights. (Id. at 50; R. 27).
• 	At Step Four, the Claimant had no past relevant work. (Id. at 50; R.
27).
• 	At Step Five, the ALJ noted that considering the claimant’s age,
education, work experience, and RFC, there are jobs that exist in
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significant numbers in the national economy that the claimant can
perform. (Id.)
Ultimately, the ALJ concluded that the Claimant was not disabled as defined
in the Social Security Act. (Id. at 51; R. 28).
II. 	S TANDARD OF R EVIEW
“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 (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 standards and that
substantial evidence exists for the ALJ’s decision. Stephens, 888 F.3d at 327.
“[S]ubstantial evidence” is such relevant “evidence that ‘a reasonable mind might
accept as adequate to support a conclusion.’” Zoch v. Saul, 981 F.3d 597, 601 (7th
Cir. 2020) (quoting Biestek, 139 S. Ct. at 1154). “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, 981 F.3d at 601 (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)).
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The SSA applies a five-step evaluation to determine whether the claimant is
disabled. Stephens, 888 F.3d at 327 (citing 20 C.F.R. § 404.1520(a)(4); 20 C.F.R. §
416.920(a)(4)). The ALJ is tasked with evaluating the following, in sequence:
(1) whether the claimant is currently [un]employed; (2) whether the
claimant 	has 	a 	severe 	impairment; 	(3) 	whether 	the 	claimant’s
impairment meets or equals one of the impairments listed by the
[Commissioner]; (4) whether the claimant can perform her past work;
and (5) whether the claimant is capable of performing work in the
national economy.
Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000), as amended (Dec. 13, 2000)
(citations omitted).2 “If a claimant satisfies steps one, two, and three, she will
automatically be found disabled. If a claimant satisfies steps one and two, but not
three, then she must satisfy step four. Once step four is satisfied, the burden shifts
to the SSA to establish that the claimant is capable of performing work in the
national economy.” Knight v. Chater, 55 F.3d 309, 313 (7th Cir. 1995).
After Step Three, but before Step Four, the ALJ must determine a claimant’s
residual functional capacity (“RFC”) by evaluating “all limitations that arise from
medically determinable impairments, even those that are not severe.” Villano v.
Astrue, 556 F.3d 558, 563 (7th Cir. 2009). In doing so, the ALJ “may not dismiss a
line of evidence contrary to the ruling.” Id. The ALJ uses the RFC at Step Four to
determine whether the claimant can perform her past relevant work and, if not, at
Step Five to determine whether the claimant can perform other work. See 20 C.F.R.
§ 416.920.
If the ALJ committed no legal error and substantial evidence exists to
support the ALJ’s decision, the Court must affirm the denial of benefits. Stephens,
888 F.3d at 327. When an ALJ’s decision does not apply the correct legal standard,
a remand for further proceedings is usually the appropriate remedy. Karr v. Saul,
2 The Code of Federal Regulations contains separate, parallel sections concerning SSI and disability
insurance benefits (“DIB”), which are identical in most respects. Cases may reference the section
pertaining to DIB, such as in Clifford, which cites 20 C.F.R. § 404.1520. 227 F.3d at 868. Generally,
a verbatim section exists establishing the same legal point with both types of benefits. See, e.g., 20
C.F.R. § 416.920.
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989 F.3d 508, 513 (7th Cir. 2021). Typically, a remand is also appropriate when the
decision is not supported by substantial evidence. Briscoe ex rel. Taylor v.
Barnhart, 425 F.3d 345, 355 (7th Cir. 2005). “An award of benefits is appropriate
only where all factual issues have been resolved and the ‘record can yield but one
supportable conclusion.’” Id. (quoting Campbell v. Shalala, 988 F.2d 741, 744 (7th
Cir. 1993)).
III. 	DISCUSSION
Substantial evidence supports the ALJ’s determination that Claimant can
perform light work. Claimant contends that the ALJ improperly formulated the
RFC because the ALJ “substituted his own judgment for medical opinions.” (Dkt.
16 at 7). Claimant challenges the ALJ’s interpretation of the medical opinion
evidence and the Claimant’s own subjective statements. In sum, Claimant contends
that the ALJ’s conclusions were legally and factually unsupported as a result of that
erroneous interpretation of the evidence. (Id. at 3).
The determination of a Claimant’s RFC “is a matter for the ALJ alone – not
a treating or examining doctor – to decide.” Thomas v. Colvin, 745 F.3d 802, 808
(7th Cir. 2014). Additionally, while the Court reviews the entire record, it does not
“reweigh the evidence, resolve debatable evidentiary conflicts, determine credibility,
or substitute [its] judgment for the ALJ’s determination.” Gedatus v. Saul, 994 F.3d
893, 900 (7th Cir. 2021). Here, contrary to Claimant’s contention, the ALJ properly
evaluated Claimant’s physical impairments, mental impairments, and subjective
statements when formulating Claimant’s RFC.
A. C LAIMANT ’S P HYSICAL IMPAIRMENTS
The ALJ properly evaluated Claimant’s physical impairments in determining
Claimant’s RFC to perform light work. It is the Claimant’s “burden to establish not
just the existence of the conditions, but to provide evidence that they support
specific limitations affecting her capacity to work.” Weaver v. Berryhill, 746 F.
App’x 574, 579 (7th Cir. 2018). Claimant has not shown that the record compelled
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greater functional limitations than those the ALJ assigned. Additionally, while
Claimant contends that the ALJ “crafted an RFC unsupported by any medical
source,” (Dkt. 16 at 7) the record reflects that the ALJ considered the findings of the
State Agency consultant physicians, as well as the treatment record, in formulating
Claimant’s RFC.3 (Dkt. 10-2 at 13–28; R. 12–27).
Claimant underwent two examinations with State Agency consultant
physicians on May 11, 2023, and October 30, 2023. (Dkt. 10-2 at 28; R. 27). The
May 11, 2023, examination found “insufficient evidence to assess the claimant’s
medically determinable physical health impairments.” (Id.). As a result, the
physician “made no findings as to the claimant’s residual functional capacity.” (Id.).
The second examination on October 30, 2023, resulted in identical findings
because “Claimant did not complete reports regarding performance of her activities
of daily living.” (Id.; Dkt. 10-3 at 11–16; R. 88–90). Accordingly, the ALJ
determined the findings were not persuasive. (Id.). However, the ALJ also noted
that he considered the treatment record and found that there was “sufficient
evidence of record to support a finding of severe medically determinable
impairments that limit the claimant’s ability to engage in basic work activities.”
(Dkt. 10-2 at 28; R. 27).
In a similar case, the Court found the ALJ’s RFC determination was based on
substantial evidence, despite conclusions by state agency medical consultants that
there was “insufficient evidence to evaluate and assess any impairments or
limitations.” Patty J. L. v. Kijakazi, No. 4-22-CV-00116-TWP-KMB, 2023 WL
5607640, at *10 (S.D. Ind. Aug. 30, 2023). In affirming the Commissioner’s
decision, the Court noted the claimant’s medical providers “gave a substantial
medical record for the ALJ to review and upon which to base her RFC findings” and
3 The ALJ also highlighted Claimant was scheduled for consultative pulmonary function testing on
April 3, 2023, and a physical consultative examination on April 29, 2023, but she failed to attend
both appointments. (Id. at 23; R. 22). However, the ALJ noted Claimant underwent consultative
pulmonary function testing on April 25, 2023 and discussed the results of the testing. (Id. at 24; R.
23). As the Commissioner notes, “[a]t the hearing, the ALJ asked Plaintiff why she did not attend
her physical consultative examination, and she said she ‘didn’t realize she had another one.’ Neither
her nor her attorney requested a new consultative examination.” (Dkt. 15 at 9 n.3).
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rejected the claimant’s contention that the ALJ played “doctor in interpreting raw
imaging or other raw medical data.” (Id.). Additionally, in this case, Claimant was
represented by counsel. (Dkt. 15 at 9 n.3). While “ALJs bear some responsibility
for developing the administrative record, they are also free to assume that a
claimant represented by counsel has presented her strongest case for benefits.”
Buckhanon ex rel. J.H. v. Astrue, 368 F. App’x 674, 679 (7th Cir. 2010); see also
Vivian M. v. Kijakazi, No. 1-21-CV-00686-DML-JRS, 2022 WL 4298264, at *4 (S.D.
Ind. Sept. 16, 2022) (rejecting claimant’s contention that the ALJ was required to
rely on a medical opinion, noting the claimant failed to explain “why the ALJ had
the duty rather than her counsel to seek a medical opinion from one of her treating
sources,” and finding the “ALJ cannot be faulted for failing to develop the record.”).
Here, although Claimant argues the “ALJ faced an evidentiary deficit
without the support of any medical opinion,” (Dkt. 12 at 8 (emphasis removed)), the
ALJ relied on evidence and treatment history from Claimant’s medical providers
when assessing Claimant’s physical impairments. Specifically, the ALJ discussed
the results of x-ray, computed tomography, and magnetic resonance imaging of
Claimant’s spine, (Dkt. 10-2 at 19; R. 18), as well as the reports from Claimant’s
visits to her pain management provider, (Id. at 20; R. 21), and findings from her
providers regarding Claimant’s standing and walking limitations, (Id. at 26; R. 25).
Overall, the ALJ relied on substantial evidence regarding Claimant’s physical
impairments to determine Claimant’s RFC. If Claimant believed there was an
evidentiary deficit in the record, Claimant should have supplemented the record or
more fully developed the evidence.
B. C LAIMANT ’S MENTAL IMPAIRMENTS
The ALJ also relied upon substantial evidence to support his finding that
Claimant’s mental impairments were non-severe and did not result in any RFC
limitation. While Claimant contends that the RFC should have included mental
limitations, (Dkt. 12 at 14–22), the record did not document ongoing mental health
complaints to providers, nor abnormal mental status examinations. Additionally,
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while the ALJ did consider Claimant’s subjective statements as to her mental
health state, such statements “are not alone conclusive evidence of disability and
must be supported by other objective evidence.” Grotts v. Kijakazi, 27 F.4th 1273,
1278 (7th Cir. 2022).
The ALJ found Claimant had “medically determinable mental impairments of
anxiety, major depressive disorder with anxious features, and post-traumatic stress
disorder (PTSD),” but nonetheless concluded they were non-severe. (Dkt. 10-2. at
15; R. 14). He went on to consider Claimant’s limitations in the paragraph B
categories of functioning and determined that she had mild limitations. (Id. at 15–
16; R. 14–15). This determination is consistent with the opinions of a State Agency
psychologist who reviewed the record. (Id.). Additionally, the ALJ summarized a
treatment record which showed Claimant complained of anxiety and depression
symptoms while being treated for physical conditions, but that she did not
specifically seek any treatment from mental health providers. (Id. at 15-28; R. 14-
27).
Claimant argues that the RFC should have incorporated an off-task
limitation to address impairments to duration, consistency, and sustainability.
(Dkt. 12 at 15-16). However, Claimant does not demonstrate how an off-task
limitation is supported by the record. Similarly, Claimant’s contentions regarding
social interaction, adapting, and managing limitations are also unsupported by the
record. (Id. at 19-22). She contends the ALJ “overlooked critical, relevant evidence”
of social limitations, but the evidence of which she complains as having been
omitted corresponds with the same examinations that the ALJ also reviewed and
cited. (Compare id. at 19–20 with Dkt. 10-2 at 15–28; R. 14–27). Moreover,
Claimant references her own reports of difficulty handling stress and some
examination findings showing anxiety as support for an adaptation limitation.
(Dkt. 12 at 20–21). However, in declining to incorporate an adaptive skills
limitation, the ALJ expressly acknowledged Claimant showed mild distress on
occasion (Dkt. 10-2 at 15; R. 14).
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On the whole, then, the ALJ demonstrated by analysis of the record the
reasons he determined Claimant’s mental impairments were non-severe. Therefore,
his finding that Claimant should not be assigned any RFC limitation in that regard
was justified.
C. C LAIMANT’S S UBJECTIVE S TATEMENTS
The ALJ properly evaluated Claimant’s subjective statements. A reviewing
court “will overturn the ALJ’s evaluation of a claimant’s subjective symptoms only if
it is ‘patently wrong, which means that the decision lacks any explanation or
support.’” Hess v. O’Malley, 91 F.4th 671, 679 (7th Cir. 2024), citing Murphy v.
Colvin, 759 F.3d 811, 816 (7th Cir. 2014).
Here, Claimant contends the ALJ’s subjective symptom analysis was patently
wrong because he “overlooked, mischaracterized, and rejected evidence” that
supported Claimant’s statements. (Dkt. 12 at 22–23). However, the ALJ discussed
Claimant’s subjective symptoms and considered them in the context of the
treatment record of physical examinations, a lack of mental health treatment, and a
consultative psychological examiner’s opinion. (Dkt. 10-2 at 17–28; R. 16–27).
Specifically, the ALJ noted that Claimant testified to experiencing fatigue,
the need to lie down for two hours during the day, and her monthly use of vitamin
B12 injections. (Id. at 26; R. 25). The ALJ also summarized Claimant’s testimony
regarding limitations in her activities, including that she had trouble with personal
care, did not cook full meals, and took a long time to complete household chores.
(Dkt. 10-2 at 18; R. 17).
While Claimant contends the ALJ “mischaracterized evidence” (Dkt. 12 at
23–24) related to her activities because the ALJ did not mention that Claimant has
assistance in caring for her pet and with performing personal care tasks as well as
trouble following instructions, “[t]he ALJ’s failure to mention a few limitations on
some of [Claimant’s] activities, if wrong at all, was not so ‘patently wrong’ as to
warrant reversal.” Deborah M. v. Saul, 994 F.3d 785, 791 (7th Cir. 2021).
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Additionally, Claimant contends the ALJ’s characterization of the Claimant’s
treatment as conservative was an “unsupported assumption.” (Dkt. 12 at 25).
However, an ALJ is entitled to consider overall the entire course of a claimant’s
treatment and to make determinations based on that treatment history, including
whether such treatment should be deemed conservative.
In Prill, the Court found that the claimant’s treatment – consisting of
injections, orthotics, and physical therapy – was conservative. Prill v. Kijakazi, 23
F.4th 738, 749 (7th Cir. 2022). The Court further noted that injections have been
characterized as conservative treatment. Id. In contrast, the Prill Court
distinguished a case where the ALJ incorrectly determined that a claimant was
treated conservatively” because the claimant in that case “underwent major
surgery.” Id. at n. 2.
Similarly, in this case, the ALJ outlined Claimant’s statements regarding her
use of injections, pain medications, a nebulizer, inhalers, a cane, and a walker, (Dkt.
10-2 at 25–26; R. 24–25). Then, the ALJ analyzed those statements, as well as
testimony about the intensity, persistence, and limiting effects of her symptoms
against the backdrop of treatment. He concluded that her statements describing
the intense symptomology and limiting effects of her conditions were unconvincing
overall, because the objective medical evidence of record did not fully support such
statements. (Id. at 25; R. 24). The ALJ is entitled to make such credibility
determinations in weighing the objective and subjective evidence.
While the ALJ found the Claimant’s testimony to be not entirely supported
by the record, importantly, the ALJ also acknowledged that despite the
inconsistencies, Claimant “does have severe COPD, emphysema, lumbar spine
degenerative disc disease with history of lumbar spine fusion, sacroiliitis, elevated
blood pressure, and syncope resulting in residual functional capacity limitations.”
(Id. at 26; R. 25).
Claimant also takes umbrage with the ALJ’s reliance on the lack of mental
health treatment in the record. (Dkt. 12 at 24–25). However, the nature and
frequency of treatment sought by a claimant is an appropriate consideration for the
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ALJ when evaluating a claimant’s stated symptoms. Here, the ALJ considered
Claimant’s testimony “that she did not receive counseling for her depression,
anxiety, or PTSD and managed the same with medication.” The ALJ also noted
that Claimant’s November 2023 report provided that her mental health medication
was not helping, and that report was followed by a medication adjustment in March
2024 after which Claimant reported improvement in her mental health symptoms.
(Dkt. 10-2 at 26–27; R. 25–26). Accordingly, the ALJ did not just summarily
discount Claimant’s mental health symptoms based on a lack of treatment. Instead,
the ALJ considered Claimant’s subjective statements in conjunction with her
mental status findings, including her “largely normal” consultative mental status
examination. (Id. at 26; R. 25).
The ALJ properly addressed Claimant’s subjective statements and considered
them alongside the treatment record and a consultative psychological examiner’s
opinion. Therefore, the ALJ did not err.
IV. 	C ONCLUSION
For the foregoing reasons, the Magistrate Judge RECOMMENDS the ALJ’s
decision be AFFIRMED.
You are hereby notified that the District Judge may reconsider any pretrial
matter assigned to a United States Magistrate Judge pursuant to 28 U.S.C. §
636(b)(1)(B). Any party shall have fourteen (14) days from the date of service to file
written objections to this Report and Recommendation.
SO RECOMMENDED this 3 rd day of December 2025.
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Distributed electronically to all ECF-registered counsel of record.
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