Anne B. v. O'Malley

Background

Anne B. applied for Social Security Disability Insurance and Supplemental Security Income benefits, alleging disability beginning June 1, 2015. After the applications were denied initially and on reconsideration, an Administrative Law Judge (ALJ) held a hearing and issued an unfavorable decision. The Appeals Council denied review. Anne B. sought judicial review under 42 U.S.C. § 405(g).

The ALJ found that Anne B. had epilepsy as a severe impairment, but found her adjustment disorder with anxiety and depression non-severe. The ALJ determined that she could perform medium work with restrictions involving ladders, ropes, scaffolds, dangerous machinery, unprotected heights, sharp objects, and driving. The ALJ concluded that she could perform jobs existing in significant numbers in the national economy, including cleaner, dining room attendant, and laundry worker.

Anne B. moved for summary judgment, asking the court to reverse the denial of benefits. The Commissioner cross-moved for summary judgment, asking the court to affirm the decision.

Mental limitations

The court held that the ALJ’s finding that Anne B. had only mild limitations in interacting with others was not supported by substantial evidence. The ALJ relied on a consultative examination but did not address the examiner’s finding that Anne B. had mild to moderate difficulty interacting with the public. The ALJ also relied on supposed evidence that Anne B. could interact with friends and family, although the cited report did not make that finding. The ALJ further relied on public shopping and the absence of social difficulties during medical visits without accounting for the fact that Anne B. shopped only when accompanied and that many appointments occurred by telehealth.

Although step two is a threshold screening step, the error mattered because the ALJ did not include any mental limitations in Anne B.’s residual functional capacity (RFC), meaning the most she could still do despite her impairments. The court therefore found that the error was not harmless.

Evaluation of Anne B.’s symptoms

The court also found that the ALJ failed to give clear and convincing reasons for discounting Anne B.’s statements about her symptoms. The ALJ relied on objective findings, alleged failures to follow medication instructions, conservative treatment, and Anne B.’s driving in 2017.

The court found that the ALJ’s description of the objective evidence was incomplete because a 2021 magnetic resonance imaging scan suggested left mesial temporal sclerosis and a January 2022 electroencephalogram showed positive findings. The court also found that the ALJ did not adequately address Anne B.’s stated reasons for changing or missing medication, including fatigue and the fact that seizures continued despite medication. It rejected the characterization of her treatment as conservative in light of repeated medication changes, testing, and hospital visits. Finally, the court found that the ALJ did not adequately explain why the 2017 vehicle accident undermined Anne B.’s testimony about being unable to work beginning in 2015.

Medical opinions

The court found that the ALJ’s treatment of the medical opinions also contained errors. Regarding Dr. Katherine Werbaneth, the court held that the ALJ was not required to further develop the record because her opinion was not ambiguous. The court nevertheless found harmless the ALJ’s failure to discuss the opinion’s supportability, meaning the medical evidence the doctor used to support it.

The court found non-harmless errors concerning the state agency psychological consultants and Dr. Aparna Dixit. The ALJ discussed the consistency of the state consultants’ opinions with other evidence but did not address supportability, which the applicable regulations required. As to Dr. Dixit, the ALJ relied on portions of her opinion but did not address her finding that Anne B. might have mild to moderate difficulty dealing with the public. The ALJ was not required to accept that limitation, but had to include it in the RFC or explain why it was rejected. The court also found that the ALJ failed to consider the supportability of Dr. Dixit’s opinion.

Disposition and remedy

The court held that the errors involving mental limitations, symptom testimony, and medical opinions were not harmless because they affected the RFC and the ultimate disability determination. It concluded that the record did not clearly require a finding that Anne B. was disabled, so an immediate award of benefits was not appropriate. Instead, the court ordered a remand, sending the matter back for further administrative proceedings.

The court granted Anne B.’s motion for summary judgment, denied the Commissioner’s cross-motion, reversed the ALJ’s decision, and remanded the matter for further administrative proceedings consistent with the order. The court stated that the Clerk would terminate the case after entry of a separate judgment.