Angel Combs v. KILOLO KIJAKAZI , Acting Commissioner of Social Security

In the
United States Court of Appeals
For the Seventh Circuit
____________________
No. 22-2381
A NGEL C OMBS ,
Plaintiff-Appellant,
v.
K ILOLO K IJAKAZI ,
Acting Commissioner of Social Security,
Defendant-Appellee.
____________________
Appeal from the United States District Court for the
Northern District of Indiana, Fort Wayne Division.
No. 1:21-cv-00328 — William C. Lee, Judge.
____________________
A RGUED M ARCH 31, 2023 — DECIDED M AY 30, 2023
____________________
Before EASTERBROOK, R IPPLE, and WOOD, Circuit Judges.
R IPPLE, Circuit Judge. Angel Combs filed for disability ben-
efits on August 2, 2019. An Administrative Law Judge (“ALJ”)
considered her claim and determined that Ms. Combs was not
disabled at any time since the alleged onset of disability. On
review, the district court concluded the ALJ’s determination
was supported by substantial evidence.

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2 No. 22-2381
In this court, Ms. Combs maintains that the ALJ should
have concluded that she suffered a closed period of disability
from June 2019 to July 2020. Nevertheless, the record amply
supports the ALJ’s conclusion that Ms. Combs was not disa-
bled at any time, including during this period. We therefore
affirm the judgment of the district court.
I.
BACKGROUND
A.
The evidence in the administrative record reveals that
Ms. Combs suffers from several physical and mental impair-
ments including lumbar spondylosis, diabetes, and mi-
graines. She sought treatment for lower back pain in March
2018 at PPG Pain Management Clinic (“PPG”), where she re-
ceived an epidural steroid injection. Due to a loss of insur-
ance, she did not return to PPG until May 2019, when she
sought treatment for radiating lower back pain. She reported
that her pain was aggravated by standing in one spot and mit-
igated by lying down. The pain did not disturb her sleep.
Dr. Kenneth Austin’s notes of that visit indicate that
Ms. Combs’s straight-leg test was positive for radicular pain
on the right side; she also had pain with flexion at her hips,
tenderness in her lower back, and an antalgic gait. He also
noted that Ms. Combs had normal ranges of motion, normal
sensation, normal reflexes, and full strength. He replaced her
Tizanidine (a muscle relaxant) with Gabapentin (for nerve
pain) and refilled her Diclofenac (an anti-inflammatory). He
scheduled her for a right medial branch block, encouraged
daily low-impact exercise, and referred her to physical ther-
apy and nutrition services.

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No. 22-2381 3
Ms. Combs returned to PPG on June 19, 2019. She reported
improvement with Gabapentin and Diclofenac without side
effects. She was no longer going to physical therapy. Dr. Aus-
tin observed that Ms. Combs had an antalgic gait and tender-
ness to the touch in the lower back, but her straight-leg test
was negative for radicular pain. Although Dr. Austin’s treat-
ment notes from that visit state the “professional judgement
that this patient’s diagnosis requires narcotic therapy for their
management of pain for greater than 7 days,” Ms. Combs was
not prescribed narcotic pain medication.1 She was scheduled
for a medial branch block later that month.
On June 28, 2019, Ms. Combs received a right medial
branch block at the L3 level of her lumbar spine. The admin-
istration of the branch block took ten minutes with no compli-
cations. Two weeks later, Ms. Combs returned to PPG and re-
ported that the branch block provided one hundred percent
relief for three days.2 She stated that she was not experiencing
any side effects from her medications, Gabapentin and Diclo-
fenac. Her physical exam revealed a normal range of motion
without pain. Her treatment plan included a second medial
branch block and a follow-up appointment in three months.
Her medications were not changed.
Ms. Combs received a second right medial branch block
on July 26, 2019. The administration of the branch block took
ten minutes with no complications. At her follow-up appoint-
ment, Ms. Combs indicated that the branch block gave her
ninety-five percent pain relief for four days. Nurse
1 A.R. 367.
2 Id. at 347.

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4 No. 22-2381
Practitioner Sheila Barlow observed that Ms. Combs was
again 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. Ms. Combs was continued on
the same dosage of Gabapentin and Diclofenac; she also was
counseled about the importance of activity modification, die-
tary changes, and tobacco cessation.3
On November 5, 2019, Ms. Combs saw Dr. Gianna Casini
at PPG. Dr. Casini observed that Ms. Combs was again tender
to the touch on her lower back, but otherwise had a normal
examination. She performed a right L3-sacral radiofrequency
ablation, a procedure in which radio waves are sent through
a needle to heat an area of the nerve and prevent it from send-
ing pain signals to the brain. The procedure took twenty
minutes.
On December 4, 2019, Ms. Combs returned to PPG for a
follow-up appointment. Ms. Combs indicated that the radio-
frequency ablation performed one month earlier had given
her eighty percent pain relief to date. Ms. Combs’s examina-
tion was the same as it had been at the last appointment, and
her medications remained the same.4
On December 31, 2019, Dr. Casini administered a left L3-
sacral medial branch block. The procedure took nine minutes.
At her follow-up appointment, Ms. Combs reported that the
3 The notes from an October 2019 appointment addressing Ms. Combs’s
diabetes state that Ms. Combs was negative for “arthralgias, back pain and
joint swelling.” Id. at 646.
4 In December 2019, Ms. Combs’s counseling notes stated that Ms. Combs
had a normal gait and normal strength.

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No. 22-2381 5
branch block gave her eighty percent relief lasting two days.
Ms. Combs’s medications remained the same, and she again
was counseled on the importance of activity modification and
dietary changes.5
On March 10, 2020, Ms. Combs saw Dr. Casini, who ad-
ministered a left medial branch block. The procedure lasted
ten minutes. At a follow-up appointment a week later,
Ms. Combs reported that the branch block had given her
ninety percent relief for four days. Ms. Combs’s examination
revealed a “[n]ormal range of motion without pain reproduc-
tion,” and she was continued on the same medications and
dosages.6
In June 2020, Ms. Combs saw Nurse Practitioner Barlow.
Ms. Combs’s physical exam was unchanged, and she was
continued on the same medications and dosages. The treat-
ment notes indicate that Ms. Combs would be scheduled for
a left radiofrequency ablation as soon as COVID protocols
were eased.
On July 14, 2020, Dr. Casini performed a left sacral radio-
frequency neurotomy (another name for radiofrequency abla-
tion) on Ms. Combs; the procedure took twenty minutes.7
Two months later, Ms. Combs reported to Nurse Practitioner
5 On January 20, 2020, Ms. Combs attended a counseling session in which
she reported that she “cleans and keeps the inside of the house main-
tained.” Id. at 914.
6 Id. at 729–30.
7 At a counseling session on August 17, 2020, Ms. Combs related that she
was still having “quite a bit of pain” in her back that was making it diffi-
cult to do chores like vacuuming and sweeping. Id. at 894.

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6 No. 22-2381
Barlow that the procedure had provided ten percent relief to
date. Her physical exam revealed a normal gait and “[n]ormal
range of motion with minimal pain reproduction,” but she
was experiencing some “[p]ain radiation down right hip to
feet.”8 Nurse Practitioner Barlow recommended that she get
an x-ray of her lower back before her next appointment. Re-
garding her medications, Ms. Combs stayed on the same dos-
ages of Diclofenac and Gabapentin; she had not been taking
her Gabapentin for a month because she thought she was out
of refills. Ms. Combs was not prescribed any narcotic pain
medication.9
On December 10, 2020, Ms. Combs had an appointment
with Nurse Practitioner Barlow in which she reported that her
pain was approximately a four out of ten. Her straight leg test
was “negative to radicular pain,” and she had a normal range
of motion and gait.10 Her medications were unchanged, and a
follow-up appointment was scheduled in eight weeks.
B.
Ms. Combs applied for Disability Insurance Benefits on
August 2, 2019, alleging an onset of disability of December 24,
2015. The claim was denied initially and upon reconsidera-
tion.
8 Id. at 707.
9 On October 12, 2020, Ms. Combs had a telephonic counseling session in
which she reported that she was watching her granddaughter while her
daughter attended college.
10 Id. at 700.

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No. 22-2381 7
Ms. Combs filed a request for a hearing, and a telephonic
hearing was held before an ALJ on March 26, 2021. At the
hearing, Ms. Combs testified that her back pain prevented her
from standing in one spot for more than ten minutes at a time
before she had to sit down. The various interventions—injec-
tions and nerve blocks—had not brought her any relief. She
further testified that there were days that her back was
“worse,” to the point that she could “barely move” and had
to have someone “help [her] physically out of [her] bed” be-
cause she felt “paralyzed.”11
The ALJ issued an unfavorable decision. The ALJ found
that Ms. Combs had the following severe impairments:
lumbar spondylosis, asthma, migraines/head-
aches, chronic pain syndrome, diabetes with di-
abetic polyneuropathy, obesity, attention deficit
hyperactivity disorder, schizoaffective disor-
der, bipolar type, posttraumatic stress disorder,
social anxiety disorder, generalized anxiety dis-
order, and borderline personality disorder.12
However, the ALJ continued, Ms. Combs’s statements related
to “the intensity, persistence and limiting effects of the[]
symptoms” of these impairments were “not entirely con-
sistent with the medical evidence and other evidence in the
record.”13 Thus, the ALJ concluded that Ms. Combs had the
residual function to
11 Id. at 44.
12 Id. at 17.
13 Id. at 21.

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8 No. 22-2381
perform light work … except that the claimant
can occasionally climb ramps and stairs, she can
never climb ladders, ropes, scaffolds, she can
occasionally balance, stoop, kneel, crouch, and
crawl, and she should avoid concentrated expo-
sure to fumes, odors, dusts, gases, poor ventila-
tion, wet, slippery or uneven surfaces, and un-
guarded moving machinery. In addition, the
claimant can understand, remember, and carry
out simple instructions and tasks, … make judg-
ments related to simple decisions, … respond
appropriately to brief interactions with cowork-
ers and supervisors[.] [S]he should avoid work
activity performed in tandem with others, she
should avoid work activity requiring interac-
tions with the general public, she can respond
appropriately to usual work situations, and she
can deal with routine changes in a routine work
setting.14
The ALJ also determined that, even with these limitations,
there were jobs in the national economy, in significant num-
bers, that Ms. Combs could perform. The ALJ thus found that
Ms. Combs “was not under a disability, … at any time from
14 Id. at 20 (emphasis removed).

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No. 22-2381 9
December 24, 2015, [15] the alleged onset date, through Decem-
ber 31, 2020, the date last insured.”16
C.
Ms. Combs brought this action in district court. She main-
tained that the ALJ “erred in not finding a closed period of
disability from at least February 21, 2018 to a reasonable time
of healing after July 14, 2020 due to her back impairment, her
pain, and her multiple invasive procedures that would have
rendered her off task or absent beyond employer toler-
ances.”17 The district court disagreed. It noted that the ALJ’s
determination included a detailed discussion of Ms. Combs’s
treatment history and physical examination findings
throughout the relevant period. These revealed that, during
the relevant period, Ms. Combs underwent several injections
and procedures for back pain, which provided her with some
relief. Moreover, her physical exams during this time re-
vealed normal strength and range of motion. In short, the ALJ
had considered all of the evidence and had reasonably
15 Although the ALJ references Ms. Combs’s onset date, the ALJ only con-
sidered evidence from October 2018 forward. This is because Ms. Combs
had pursued other disability claims through the administrative process,
and those claims had ended in adverse administrative findings that were
not appealed. Thus, at the outset of Ms. Combs’s hearing in this action, the
ALJ clarified that the earliest date that Ms. Combs could be found to be
disabled was “the date following the prior hearing decision,” which was
sometime in October 2018. Id. at 36.
16 Id. at 26 (emphasis removed).
17 R.25 at 4–5.

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10 No. 22-2381
concluded that Ms. Combs was capable of light work that ac-
commodated her documented limitations.
Ms. Combs timely appealed.
II.
DISCUSSION
“We review de novo the district court’s affirmance of the
ALJ’s decision and review directly the decision of the ALJ.”
Butler v. Kijakazi, 4 F.4th 498, 501 (7th Cir. 2021). We will affirm
the ALJ’s decision if it is supported by substantial evidence.
See 42 U.S.C. § 405(g); Biestek v. Berryhill, 139 S. Ct. 1148, 1152
(2019). “[S]ubstantial evidence” is “such relevant evidence as
a reasonable mind might accept as adequate to support a con-
clusion.” Simila v. Astrue, 573 F.3d 503, 513 (7th Cir. 2009)
(quoting Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008)). If
reasonable minds could disagree on whether a claimant is dis-
abled based on the evidence, a reviewing court must affirm
the agency’s decision to deny benefits. Elder v. Astrue, 529 F.3d
408, 413 (7th Cir. 2008).
An individual is entitled to disability benefits if the person
is unable “to do any substantial gainful activity by reason of
any medically determinable physical or mental impairment
which … has lasted or can be expected to last for a continuous
period of not less than 12 months.” 20 C.F.R. § 404.1505(a).
Thus, a disability for a continuous period of twelve or more
months entitles a person to benefits for that period of time.
The burden is on the claimant to establish disability. See
Bowen v. Yuckert, 482 U.S. 137, 146 (1987).

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No. 22-2381 11
A.
Ms. Combs now maintains that the ALJ’s determination is
not supported by substantial evidence because it failed to rec-
ognize a closed period of disability between June 2019 and
July 2020. Specifically, Ms. Combs faults the ALJ for failing to
acknowledge that her back pain was at its worst during this
period as evidenced by the numerous procedures that she un-
derwent. 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. We consider each
of these.
Turning to Ms. Combs’s first contention, she maintains
that the record establishes a closed period of disability from
June 2019 to July 2020 because, “[d]uring this fourteen-month
period, [she] had six spinal procedures done, of increasing se-
verity.”18 Ms. Combs’s characterization of her spinal proce-
dures is not supported by the record. Ms. Combs received the
same procedure—a medial branch block—on four occasions:
June 2019 (right side), July 2019 (right side), December 2019
(left side), and March 2020 (left side). None of these proce-
dures took longer than ten minutes. She also had two ablation
procedures: November 2019 (right side) and July 2020 (left
side). Neither of these procedures took more than twenty
minutes. This treatment regimen, without further clinical
elaboration, does not establish that the treatments were of in-
creasing severity or indicate a disabling condition.
18 Appellant’s Br. 15.

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12 No. 22-2381
Additionally, although Ms. Combs maintains that the fre-
quency of her treatments is evidence that her back condition
“was at its worse [sic] from June 2019 through July 2020,”19
her hearing testimony did not distinguish the pain she en-
dured before, during, or after the relevant period. Ms. Combs
stated that she had been suffering debilitating back pain at
least since 2018, and that the “injections” and procedures that
“burnt the nerves” did not bring her relief.20 According to
Ms. Combs, at the time of the hearing, she still was experienc-
ing days where her back was “awful,” she could “barely
move,” and it felt as if she were “paralyzed almost.”21 Thus,
Ms. Combs’s testimony undermines her argument that her
back condition clearly was worse during the proposed closed
period.
Ms. Combs’s second contention—that the ALJ failed to
mention, and therefore must have ignored, relevant evi-
dence—is also unpersuasive. Although the ALJ may not ig-
nore “an entire line of evidence that supports a finding of dis-
ability,” Jones v. Astrue, 623 F.3d 1155, 1162 (7th Cir. 2010), the
19 Id.
20 See A.R. 38–40. This testimony is in tension with the contemporaneous
statements that Ms. Combs made to her medical providers. At the time
she underwent these procedures, she reported experiencing between ten
and one hundred percent pain relief that lasted between a few days and a
few months. See, e.g., id. at 347, 702, 724, 748, 775. The ALJ’s decision took
note of these discrepancies, stating that “the claimant’s statements con-
cerning the intensity, persistence and limiting effects of these symptoms
are not entirely consistent with the medical evidence and other evidence
in the record for the reasons explained in this decision.” Id. at 21.
21 Id. at 44.

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No. 22-2381 13
ALJ is not required to mention every piece of evidence, Geda-
tus v. Saul, 994 F.3d 893, 901 (7th Cir. 2021). Here, the ALJ did
not mention the medial branch blocks that took place in De-
cember 2019 and March 2020. However, the ALJ mentioned
the two other medial blocks as well as the ablation proce-
dures. The evidence recited by the ALJ shows an understand-
ing that Ms. Combs was undergoing multiple and different
procedures for pain relief on both the left and right side of her
back. Thus, the ALJ did not ignore an entire line of evidence
that would have supported a finding of disability.
Ms. Combs lastly submits that the ALJ should have con-
sidered the amount of time that she would have missed work
between June 2019 and July 2020. Ms. Combs estimates that
she would have missed fourteen and one-half days of work
during this period due to her multiple procedures and ap-
pointments. Ms. Combs submits that this number of absences
would have been unacceptable to any employer and therefore
rendered her unemployable during this period.22
There is no evidence in the record to support the time es-
timates that Ms. Combs employs. 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. See Barnett v. Apfel, 231
22 The Commissioner maintains that this argument was forfeited because
it was not made before the district court. See Appellee’s Br. 24. Although
the argument before the district court was paltry, the district court never-
theless recognized the argument and addressed it. See R.25 at 5. Therefore,
it has not been forfeited.

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14 No. 22-2381
F.3d 687, 691 (10th Cir. 2000) (rejecting argument that the ALJ
should have “consider[ed] plaintiff’s absenteeism” when
“plaintiff’s … extrapolation of how many days she [would]
have missed from work … assume[d] she was required to
miss entire days of work for each appointment”). Therefore,
Ms. Combs has not met her burden of showing that the addi-
tional appointments would have resulted in a level of absen-
teeism that employers would have found unacceptable.
B.
Ms. Combs submits that, even if the record does not com-
pel a finding that she was disabled between June 2019 and
July 2020, her case should be remanded because it was incum-
bent upon the ALJ to address explicitly whether she endured
a closed period of disability. Ms. Combs relies upon two cases
in support of this contention: 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). Neither case is helpful to
Ms. Combs.
In Reed, the claimant was injured in a car accident and un-
derwent surgery. Her application for disability benefits was
denied, and she maintained that the ALJ had not “adequately
explain[ed] why she did not satisfy the standard for disability
for at least the 12 months following the accident.” Id. at 788.
We upheld the ALJ’s determination even though the ALJ had
“not separately explain[ed] the basis for concluding that Reed
was not disabled for at least the 12 months after the accident.”
Id. We noted that “[t]he ALJ’s discussion of the medical evi-
dence from that period makes evident her conclusion that
Reed’s injuries had healed and ceased to prevent a return to
work long before the one-year anniversary of the accident.”
Id.

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No. 22-2381 15
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 nar-
cotics,23 and minor procedures to relieve back pain. The ALJ’s
recitation makes it evident that the ALJ did not believe that
Ms. Combs was disabled during this time.
Jackson presents a scenario different from that in Reed and
the present case. Jackson involved a claimant who slipped and
fell in July 2004, necessitating ankle surgery. In February 2005,
while still healing from the ankle surgery, she developed “a
large disc herniation,” and a microdiskectomy was performed
in May 2005. Jackson, 2010 WL 4793309, at *14. The following
month, while recovering from her back surgery, the claimant
was hospitalized for deep vein thrombosis. Despite these re-
peated, serious incidents over a twelve-month period, the ALJ
had “not ma[d]e clear during Claimant’s hearing or in his de-
cision that he considered the possibility of a closed period of
disability around the times Claimant underwent her surger-
ies.” Id. Consequently, the district court remanded the case to
the ALJ.
Here, unlike in Jackson, there was no clear evidence of se-
rious, repeated medical interventions over a defined period
of time that should have alerted the ALJ to consider a closed
period of disability. There were no falls, trips to the emer-
gency room, surgeries, or hospitalizations that would have
23 The notes from several of Ms. Combs’s appointments contain the fol-
lowing statement: “It is our professional judgment that this patient’s diag-
nosis requires narcotic therapy for their management of pain for greater
than 7 days.” See, e.g., A.R. 367. Nevertheless, Ms. Combs was not pre-
scribed narcotics for pain.

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16 No. 22-2381
apprised the ALJ that Ms. Combs’s back pain was becoming
more serious.
Moreover, Ms. Combs has struggled to identify consistent
dates to bookend the proposed closed period. In the district
court, Ms. Combs argued that the ALJ “erred in not finding a
closed period of disability from at least February 21, 2018 to a
reasonable time of healing after July 14, 2020.”24 In this court,
however, the proposed closed period is June 2019 to July
2020.25 We cannot fault the ALJ for failing to consider a closed
period that Ms. Combs herself has had difficulty identifying.
Conclusion
The record supports the ALJ’s determination that
Ms. Combs was not disabled during a closed period between
June 2019 and July 2020. We therefore affirm the judgment of
the district court.
AFFIRMED
24 R.21 at 10.
25 See Appellant’s Br. 15.

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