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A woman with chronic back pain failed to convince the 7th Circuit Court of Appeals that she is entitled to disability benefits.
The case involves Angel Combs, who filed for disability benefits in August 2019.
According to the administrative record, Combs suffers from several physical and mental impairments including lumbar spondylosis, diabetes and migraines. She received an epidural steroid injection for her lower back pain in March 2018 at the PPG Pain Management Clinic but didn’t go back until May 2019 because she lost insurance.
During the May 2019 visit, Dr. Kenneth Austin determined Combs was positive for radicular pain on the right side and pain with flexion at her hips, tenderness in her lower back and an antalgic gait. Austin also noted she had normal range of motion, normal sensation, normal reflexes and full strength.
The doctor replaced Combs’ muscle relaxant with nerve pain medication and refilled her anti-inflammatory medication. He also scheduled her for a right medial branch block, encouraged daily low-impact exercise, and referred her to physical therapy and nutrition services.
Combs returned to the clinic the next month and reported improvement with the new medicine and no side effects. She had also stopped going to physical therapy.
Combs was negative for radicular pain but still had an antalgic gait and tenderness to the touch in the lower back. Austin’s notes said his “professional judgment (is) that this patient’s diagnosis requires narcotic therapy for their management of pain for greater than seven days,” but she was not prescribed narcotic pain medication.
Combs received a right medial branch block at the L3 level of her lumbar spine that same month. A few weeks later, she returned to the clinic reporting that the branch block provided her with 100% pain relief for three days.
Combs received a second branch block in July 2019 and reported 95% pain relief for four days. Nurse practitioner Sheila Barlow noted that Combs was tender to the touch on her lower back but had a normal range of motion without pain reproduction, as well as normal strength, sensation and gait.
Combs continued to receive procedures like branch blocks and others for her back pain, and she continued taking medication for months.
Then in August 2019, Combs applied for disability benefits, alleging an onset of disability in December 2015. The claim was denied both initially and upon reconsideration.
Combs filed for a hearing, so a telephonic hearing was held before an administrative law judge in March 2021. She testified that her back pain prevented her from standing for longer than 10 minutes and that there were times when injections and nerve blocks didn’t provide any relief.
The ALJ concluded Combs had the residual function to perform light work and was not disabled from December 2015 to December 2020.
Combs then turned to the Indiana Northern District Court, arguing that the ALJ failed to find a closed period of disability from at least February 2018 to July 2020. The district court disagreed, noting the ALJ’s detailed discussion of Combs’ treatment history and physical examination findings.
Combs then brought her case to the 7th Circuit and argued that the ALJ should have concluded she suffered a close period of disability from June 2019 to July 2020.
“Specifically, Ms. Combs faults to ALJ for failing to acknowledge that her back pain was at its worst during this period as evidenced by the numerous procedures that she underwent,” Senior Judge Kenneth Ripple wrote. “Second the ALJ’s decision was deficient because it failed to discuss the medial branch blocks in December 2019 and March 2020. Finally, Ms. Combs submits, the ALJ did not consider the excessive number of absences Ms. Combs would have incurred during the relevant period.”
Turning to her first contention — that her back pain was worse from June 2019 to July 2020, when she underwent multiple procedures — the 7th Circuit held, “This treatment regimen, without further clinical elaboration, does not establish that the treatments were of increasing severity or indicate a disabling condition.”
As for her second contention — that the ALJ failed to mention, and therefore ignored, relevant evidence — Ripple noted the ALJ was not required to mention every piece of evidence.
“The evidence recited by the ALJ shows an understanding that Ms. Combs was undergoing multiple and different procedures for pain relief on both the left and right side of her back,” he wrote. “Thus, the ALJ did not ignore an entire line of evidence that would have supported a finding of disability.”
Lastly, the 7th Circuit rejected Combs’ argument that the ALJ should have considered the amount of work she would have missed between June 2019 and July 2020: an estimated 14½ days.
“There is no evidence in the record to support the time estimates that Ms. Combs employs,” Ripple wrote. “By way of example, Ms. Combs assigns one day off work for each of the medial branch blocks. However, the record shows that each of these lasted only ten minutes. Given that one of these procedures took place at 3:30 p.m., it is difficult to see how this would have necessitated a full day off work.”
Even if she is not found disabled during the relevant time period, Combs argued her case should be remanded because it was incumbent upon the ALJ to address explicitly whether she endured a closed period of disability. She relied on Reed v. Colvin, 656 F. App’x 781 (7th Cir. 2016), and Jackson v. Astrue, No. 09 C 50028, 2010 WL 4793309 (N.D. Ill. Nov. 18, 2010), but the appellate court found neither case was helpful to her.
“Here, as in Reed, the ALJ discussed the medical records from the proposed period of disability. Those records reveal largely normal physical evaluations, no prescriptions for narcotics, and minor procedures to relieve back pain,” Ripple wrote. “The ALJ’s recitation makes it evident that the ALJ did not believe that Ms. Combs was disabled during this time.”
Further, “Here, unlike in Jackson, there was no clear evidence of serious, repeated medical interventions over a defined period of time that should have alerted the ALJ to consider a closed period of disability,” Ripple wrote. “There were no falls, trips to the emergency room, surgeries, or hospitalizations that would have apprised the ALJ that Ms. Combs’s back pain was becoming more serious.”
The case is Angel Combs v. Kilolo Kijakazi, Acting Commissioner of Social Security, 22-2381.
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