Justia U.S. 7th Circuit Court of Appeals Opinion Summaries

Prosser, a 37-year-old Medicare recipient, suffers from glioblastoma, which causes brain tumors. The five-year survival rate hovers around 5%. Though not curative, Prosser benefits from tumor treating fields therapy (TTF), approved by the FDA in 2011. For most of the day, patients use a device that attaches to the head via adhesive patches that connect to a mobile power supply. The device emits electrical fields to the tumor, which disrupt the division of cancer cells. Early studies show that the device holds promise in prolonging life. TTF therapy is available through a single supplier, Novocure, which rents the device on a monthly basis. The therapy is expensive. Prosser must file a Medicare benefits claim for each period she uses the device. Medicare denied coverage for the treatment period January-April 2018. Though Prosser received the therapy and owed nothing, the denial left Novocure with the bill. Prosser challenged this denial through Medicare’s appeals process before filing suit.The Seventh Circuit affirmed the dismissal of Prosser’s claim for Medicare Part B coverage, holding that she has suffered no injury-in-fact sufficient to satisfy Article III’s standing requirement. Prosser received—and continues to receive—the TTF therapy. She faces no financial liability for the treatment period Medicare denied coverage. Any future financial risk is too attenuated from the denial of the past coverage and far too speculative to establish standing. View "Prosser v. Becerra" on Justia Law

Gedatus, born in 1976, sought social security disability benefits, alleging many medical conditions, including lumbar degenerative disc disease, sciatica, leg pain, knee pain, wrist difficulties, tremors, and residual effects from a head hemorrhage. She graduated from high school. By 2003, she worked at a bar. Over the years, she underwent multiple surgeries and other treatments.After a hearing, the Administrative Law Judge agreed with Gedatus about several issues, but concluded she could perform light work with some limits, so she was not disabled. No doctor opined she needed more limits than the ALJ determined. The district judge affirmed. The Seventh Circuit affirmed the denial as supported by substantial evidence, rejecting claims that errors permeated the ALJ’s symptom evaluation and that the ALJ erred by not setting forth an assessment of her limited sitting tolerance or tremors. View "Gedatus v. Saul" on Justia Law

MAO-MSO acquired rights to collect conditional payments that Medicare Advantage Organizations (MAOs) made if a primary insurer (such as automobile insurance carriers) has not promptly paid medical expenses. MAO-MSO sued those primary payers. The district court proof of required actual injury. Specifically, MAO-MSO needed to identify an “illustrative beneficiary”— a concrete example of a conditional payment that State Farm, the relevant primary payer, failed to reimburse to the pertinent MAO. MAO-MSO alleged that “O.D.” suffered injuries in a car accident and that State Farm “failed to adequately pay or reimburse” the appropriate MAO. The district court determined that these allegations sufficed for pleading purposes to establish standing.As limited discovery progressed, MAO-MSO struggled to identify evidence supporting the complaint. One dispute centered on whether O.D.’s MAO made payments related to medical care stemming from a car accident before State Farm reached its limit under O.D.’s auto policy so that State Farm should have reimbursed the MAO. The payment in question was to a physical therapist. State Farm argued that the physical therapy services had no connection to O.D.’s car accident and related only to her prior knee surgery.The district court determined no reasonable jury could find that the payment related to O.D.’s car accident, meaning that MAO-MSO lacked standing. The Seventh Circuit affirmed the dismissal. The Medicare Act may authorize the lawsuit but MAO-MSO fail to establish subject matter jurisdiction by establishing an injury in fact. View "MAO-MSO Recovery II, LLC v. State Farm Mutual Automobile Ins. Co." on Justia Law

The Seventh Circuit affirmed the ALJ's determination that plaintiff has the capacity to perform light work and is therefore not entitled to disability benefits. Plaintiff claimed that the ALJ committed reversible error when determining her residual functional capacity (RFC) by selectively reviewing evidence of cervical and lumbar degenerative disc disease (back problems); incorrectly discounting plaintiff's credibility regarding her description of the intensity, persistence, and limiting effects of her symptoms; and not including any manipulative limitations in the RFC assessment.The court found plaintiff's arguments unpersuasive and concluded that substantial evidence supports the ALJ's denial of benefits where the ALJ did not ignore a line of evidence contradicting her decision; the ALJ's assessment of plaintiff's symptoms was not patently wrong; and the ALJ did not fail to note any supported manipulative limitations. View "Deborah M. v. Saul" on Justia Law

Pavlicek, age 49. applied for Disability and Supplemental Security Income benefits. He suffers from anxiety, depression, severe tremors, and pseudoseizures that resemble epileptic seizures but stem from psychological causes. A truck driver, he has a high-school education. Two non-examining agency consultants determined that he could function with some limitations. Pavlicek testified that he had constant tremors and had seven pseudoseizures in the past 16 months when he lost consciousness; in seven other episodes, he remained conscious. A vocational expert testified about employers’ tolerance for absenteeism and about a hypothetical employee with various restrictions. The treating psychiatrist reported that Pavlicek could not work.The ALJ determined that Pavlicek retained the residual functional capacity to perform medium work with exceptions and could perform work that existed in significant numbers in the national economy. The ALJ largely dismissed the report by the treating psychiatrist, who had not justified how his findings could apply “as far back as 2013,” having not treated Pavlicek until 2015 and who relied heavily on Pavlicek’s subjective reporting. The ALJ noted the “infrequent” nature of the treatment relationship and that the report’s assessment of severe functional limitations was unsupported by the clinical records. The Seventh Circuit affirmed. The decision was supported by substantial evidence. The court rejected claims that the ALJ gave inadequate reasons for rejecting the treating psychiatrist's opinion, afforded too much weight to the opinions of non-examining agency physicians, and posed hypothetical questions to the vocational expert that failed to account for his limitations. View "Pavlicek v. Saul" on Justia Law

Bailey became partially disabled by pneumoconiosis, caused by the inhalation of coal dust. In 2002, he entered into an agreement with his employer to settle his state workers’ compensation claim; $27,677.50 was designated as Bailey’s take-home amount, representing payments of $135.67 per month, for 17 months beginning in July 2002. In November 2011, Bailey filed a claim under the Black Lung Benefits Act. The Office of Workers’ Compensation Programs (OWCP) granted Bailey’s claim in October 2013, but his benefits entitlement began the month he filed his claim and continued through May 2016—the month preceding the month that he died. At the time of his death, he had received benefits totaling $30,507.70 but was still owed benefits for the months from November 2011 through September 2013, $21,508.90. Bailey’s employer went bankrupt. He sought the remaining benefits from the federal Black Lung Disability Trust Fund. While the OWCP approved that claim, a District Director reevaluated the original award, finding that Bailey’s state workers’ compensation award represented monthly state benefits, some of which ran concurrently with his federal benefits eligibility period, so that the federal benefits must be offset by the state benefits received for that time—$135.67 per month over 55 months ($7,461.85). The OWCP subtracted this amount from the $21,508.90. The Seventh Circuit affirmed. The offset is required by the Act; that Bailey received his state benefits years before he became eligible for federal benefits does not alter the conclusion. View "Bailey v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

Arnold applied for Social Security disability benefits based on ailments related to her back, heart, and joints, and chronic pain syndrome. Following the initial denial of her claim, Arnold requested a hearing before an ALJ. Arnold testified at the hearing, as did a vocational expert. The ALJ concluded that Arnold was not disabled, finding Arnold had several severe impairments, but that she retained the ability, with certain movement restrictions, to perform her past relevant work as a daycare center director. The district court and Seventh Circuit affirmed the ALJ’s decision, rejecting an argument that the ALJ failed to analyze whether the side effects of her medications impacted Arnold’s ability to work. While there is some evidence of side effects in the record, there is no evidence that the side effects impacted Arnold’s ability to work. On this record, the ALJ was not required to make findings about Arnold’s side effects. View "Arnold v. Saul" on Justia Law

Karr applied for Social Security disability benefits based on her complaints of chronic lower back pain and other ailments. Karr traces the source of her back pain to a car accident in the late 1990s. She has tried multiple forms of treatment for her pain, numbness, and weakness in her lower back and legs.An ALJ concluded that Karr was not disabled because she still could perform sedentary work with some restrictions. The district court and Seventh Circuit affirmed, rejecting Karr’s claim that the ALJ improperly discounted a statement from her treating neurosurgeon that she could not sit, stand, or walk for sustained periods. The ALJ’s decision was supported by substantial evidence Although acknowledging that the neurosurgeon was a treating provider who had examined Karr, the ALJ found “extreme” his notation that Karr could not “sit, stand or walk for any sustained period of time” because the record contained reports of multiple physical examinations showing that Karr had full strength and could walk normally. View "Karr v. Saul" on Justia Law

Zellweger applied for disability benefits in 2013, claiming a per se disabling spinal condition equivalent to Listing 1.04. His amended onset date was August 28, 2013. His last-insured status expired on September 30, 2013, so the application presented a narrow question: whether he was disabled during the one-month period from August 28 to September 30 (42 U.S.C. 416(i)(3)(B)). The primary medical basis for his application was cervical and lumbar degenerative disc disease.An ALJ denied his claim, concluding that the medical evidence did not meet the criteria for Listing 1.04 and that Zellweger could perform light work. A magistrate reversed, ruling that the ALJ’s discussion was too cursory at step three of the sequential analysis prescribed in the agency regulations: assessing whether the claimant has an impairment that meets or medically equals one of the Listings. Although the ALJ explained his reasoning more thoroughly later in his decision, the magistrate refused to consider that discussion.The Seventh Circuit reversed and remanded. The sequential process is not so rigidly compartmentalized. Nothing prohibits a reviewing court from reading an ALJ’s decision holistically. The ALJ thoroughly analyzed the medical evidence at the step in the sequential analysis that addresses the claimant’s residual functional capacity. That analysis elaborated on the more cursory discussion at step three and was easily adequate to support the ALJ’s rejection of a per se disability under Listing 1.04. View "Zellweger v. Saul" on Justia Law

Lothridge applied for disability insurance benefits and supplemental security income in 2013 when she was 33 years old. She asserted that she was disabled by fibromyalgia, COPD, asthma, and hypertension. She was diagnosed with bipolar disorder, learning disabilities, significant problems with decision-making, moderate problems with social functioning, and problems with remote memory. She had worked as a CNA, a daycare worker, a cashier, and a telemarketer. She had tried, unsuccessfully. to earn her GED. Hip and back pain caused her to stop working in 2009.After an ALJ denied her application, a district judge remanded for further explanation of how the ALJ considered Lothridge’s periodic non-compliance with treatments. The ALJ again denied the application, finding that Lothridge could still perform light work with certain limitations. A district judge affirmed.The Seventh Circuit vacated. In assessing Lothridge’s impairments using the five-step disability analysis, the ALJ found moderate limitations in concentration, persistence, and pace. In determining her residual functional capacity, the ALJ failed to take those limitations into account. The jobs that the ALJ determined that Lothridge could still perform would require the ability to stay on-task for at least 90% of the workday and would have little tolerance for tardiness or absences. The ALJ made no determination of whether Lothridge is capable of meeting these requirements. View "Lothridge v. Saul" on Justia Law