Cristina H. v. Kijakazi

Background

Cristina H. applied for Social Security Disability Insurance benefits in October 2019. She initially alleged that her disabilities began on February 14, 2018, but amended the alleged onset date to August 11, 2021 at the administrative hearing. The Social Security Administration denied the application initially and on reconsideration. After a hearing at which Cristina H. was represented by counsel, Administrative Law Judge Kevin Plunkett denied the claim on October 17, 2022. The Appeals Council declined review, making the administrative law judge’s decision the Commissioner’s final decision.

The administrative law judge found severe impairments including degenerative disc disease, left-shoulder degenerative joint disease and tendonitis or tendinosis, bilateral carpal tunnel syndrome, Chiari I malformation, left Bell’s Palsy, and obesity. He found that Cristina H. could perform light work with specified limits, including frequent overhead reaching, handling, and fingering with both hands. Relying on vocational-expert testimony, he found that she could perform her past relevant work as a cleaner and was not disabled.

Cristina H. moved for summary judgment, asking the court to reverse the Commissioner’s decision. The defendant cross-moved for summary judgment, asking the court to affirm it. Cristina H. argued that the administrative law judge improperly evaluated her symptom testimony and Dr. Martinovsky’s medical opinion.

Symptom Testimony

The court held that the administrative law judge failed to provide specific, clear, and convincing reasons for rejecting Cristina H.’s symptom testimony. The administrative law judge found that her impairments could reasonably be expected to cause the alleged symptoms and cited no evidence of malingering. Under the applicable standard, the administrative law judge therefore had to identify specific reasons supported by the record for rejecting testimony about symptom severity.

The court found that the statement that Cristina H.’s testimony was persuasive only to the extent it was consistent with the residual functional capacity was a generic, circular statement. The administrative law judge focused on her reported ability to lift and walk but did not address her testimony that she could not raise her arms and that pain extended from her neck through her shoulder and hands. The record included medical opinions and examinations describing restrictions or limitations involving overhead reaching and the left shoulder. By assigning an ability to reach overhead frequently with both arms, the administrative law judge implicitly rejected that testimony without explaining why.

The court also rejected the administrative law judge’s reliance on Cristina H.’s supposedly conservative treatment. The record showed approximately twelve physical-therapy sessions, five or six acupuncture sessions, carpal-tunnel injections, medication, and a request for additional chiropractic treatment that workers’ compensation denied. The court stated that the record showed Cristina H. pursued recommended treatment, could not pursue some treatment because of insurance coverage, and was not considered a candidate for surgery. The court concluded that the administrative law judge’s treatment rationale was not adequately linked to the record and was not supported by substantial evidence. The court also declined to consider “normal activities” as a reason for rejecting the testimony because the administrative law judge had discussed those activities in another part of the decision and had not identified them as a reason for rejecting the symptom testimony.

Dr. Martinovsky’s Medical Opinion

The court also held that the administrative law judge erred by failing to address Dr. Martinovsky’s detailed May 31, 2019 medical-legal evaluation report. Under the revised Social Security regulations, the administrative law judge must explain how persuasive each medical opinion is, particularly considering supportability and consistency, and must support the explanation with substantial evidence.

The administrative law judge labeled a May 29, 2019 treatment note as Dr. Martinovsky’s opinion, even though the note appeared to have been prepared during a visit with Nurse Practitioner Natalya Golovanov, a member of Dr. Martinovsky’s treatment team. The administrative law judge did not discuss the other visits with that treatment team or the twelve-page report Dr. Martinovsky authored on May 31, 2019. That report diagnosed rotator cuff syndrome, chronic pain syndrome, and cervicalgia; attributed injuries involving the neck, left shoulder, and both hands to Cristina H.’s employment; and recommended work restrictions including no lifting, pushing, or pulling over 20 pounds and no repetitive bending, crawling, or stooping.

The court noted that the report’s recommended limits on repetitive bending and stooping were consistent with a consultative examiner’s opinion that Cristina H. could bend or stoop only occasionally. Although the administrative law judge found that consultative examiner’s opinion persuasive, he did not explain why he rejected its limitation on bending and stooping while assigning an ability to stoop, kneel, crouch, and crawl frequently. The court found that the failure to consider Dr. Martinovsky’s report could have affected the residual-functional-capacity finding and therefore was not harmless.

Disposition

The court granted Cristina H.’s motion for summary judgment and denied the defendant’s cross-motion for summary judgment. It remanded the action under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with the order, including a new decision.