Dariana H. v. OMalley

Background

Dariana H. sought Supplemental Security Income benefits under the Social Security Act. An administrative law judge denied the claim after a hearing, and the Social Security Appeals Council declined review. Dariana H. asked the district court to reverse that decision and remand the matter under sentence four of 42 U.S.C. § 405(g). Martin O’Malley, Commissioner of Social Security, asked the court to affirm the administrative decision.

The administrative law judge found that Dariana H. had not engaged in substantial gainful activity since January 29, 2021. The judge found severe impairments including cyclic vomiting syndrome, depressive disorder, anxiety disorder, panic disorder, adjustment disorder, obsessive-compulsive disorder, post-traumatic stress disorder, learning disorder, and cannabis use disorder. The judge found that her impairments did not meet or equal a listed impairment, assessed a residual functional capacity for a limited range of light work, and found that she could perform jobs including cleaner in housekeeping, inspector, or garment sorter.

Court’s analysis

The court reviews a Social Security decision to determine whether it is supported by substantial evidence and whether the agency applied the correct legal standards.

Subjective symptoms. The administrative law judge found that Dariana H.’s medically determinable impairments could cause her symptoms but that her statements about their intensity, persistence, and limiting effects were not entirely consistent with the record. The court held that the judge did not meaningfully identify which portions of her testimony were rejected or explain the evidence undermining them. The decision did not cite the hearing transcript. The court also rejected the Commissioner’s effort to identify reasons in the record that could have supported discounting the testimony, because the judge had not stated those reasons. The court therefore found that the judge failed to provide the required clear and convincing reasons for discounting Dariana H.’s symptom statements.

Back pain. The administrative law judge classified Dariana H.’s degenerative disc disease and back pain as not severe. The court found that conclusion was not clearly established by the medical evidence. Although imaging showed mild degenerative disc disease and no significant narrowing or other listed abnormalities, the record also included reports of difficulty sitting and standing for long periods, treatment for low back and tailbone pain, and a pain-clinic assessment. The court held that Dariana H. satisfied the low threshold for showing that her back condition had more than a minimal effect on her ability to work.

Medical opinions. The court found errors in the evaluation of opinions from Dr. Katherine Wiebe, four State agency consultants, and Dr. Aparna Dixit.

The administrative law judge rejected Dr. Wiebe’s opinion as too restrictive, insufficiently supported by treatment notes, based heavily on self-reporting, conducted by telephone, and obtained through a referral from Dariana H.’s attorney. The court held that these reasons were not supported by substantial evidence. Dr. Wiebe’s report included objective testing and detailed explanations, and the fact that an opinion was requested by counsel was not, by itself, a valid reason to find it unpersuasive.

The court also held that the judge failed to adequately address the required supportability and consistency factors when evaluating the opinions of State agency consultants Dr. H. Samplay, Dr. K. Rudito, Dr. D. Lucila, and Dr. M. Morando. The judge described some opinions as persuasive or well-reasoned but did not sufficiently connect those conclusions to objective evidence or the record as a whole.

As to Dr. Dixit, whose opinion the judge relied on primarily for the mental residual functional capacity assessment, the court found that the judge asserted consistency with the State agency consultants’ opinions but then described material differences between those opinions. The judge did not adequately explain the opinion’s supportability or consistency.

Residual functional capacity. The court remanded the residual functional capacity issue because that assessment depended on the flawed evaluation of Dariana H.’s impairments, symptoms, and medical opinions. On remand, the administrative law judge must reassess the residual functional capacity based on the medical opinions and all medically determinable impairments.

Disposition

The court concluded that outstanding issues remained and that the record did not clearly require a finding that Dariana H. was disabled. It therefore determined that further administrative proceedings, rather than an immediate award of benefits, were appropriate. Judge Thomas S. Hixson granted Dariana H.’s motion for summary judgment and denied the Commissioner’s cross-motion. The court ordered a remand consistent with the order and stated that a separate judgment would follow, after which the Clerk of Court would terminate the case.