Alexander H. v. Kijakazi

Background

Alexander H. applied for Supplemental Security Income under Title XVI of the Social Security Act. After the application was denied initially and on reconsideration, an administrative law judge held a hearing at which Alexander H. was represented by counsel. The administrative law judge found him not disabled, and the Appeals Council denied review. Alexander H. then sought judicial review under 42 U.S.C. § 405(g).

The administrative law judge found severe impairments involving depression, post-traumatic stress disorder, and borderline intellectual functioning. The judge found Alexander H.’s gastrointestinal impairments and asthma non-severe, determined that his impairments did not meet the listed-disability criteria, and assessed a residual functional capacity allowing a full range of work at all exertional levels with substantial non-exertional restrictions. Based on vocational-expert testimony, the administrative law judge found that Alexander H. could perform jobs including dishwasher, hospital cleaner, and industrial cleaner.

The Court’s Analysis

The court held that the administrative law judge erred at step two by finding that Alexander H.’s irritable bowel syndrome and other gastrointestinal problems had resolved, were controlled by medication, or did not meet the required duration. The record showed repeated diagnoses, treatment, and medical visits for constipation, abdominal pain, irritable bowel syndrome, gastroesophageal reflux disease, and related complaints. Even if the gastrointestinal impairment was non-severe, the administrative law judge was required to consider it when determining the residual functional capacity. Because the impairment could have affected that determination, the error was not harmless.

The court also held that the administrative law judge did not adequately explain the rejection of Alexander H.’s statements about the severity and effects of his symptoms. The decision did not clearly identify which statements were being rejected or connect those statements to specific evidence. The court further found that the administrative law judge could not rely on the lack of ongoing mental-health treatment without considering possible reasons for that lack of treatment, including circumstances discussed in the record and an examining psychologist’s opinion that Alexander H.’s symptoms could interfere with attending appointments and consistently engaging in treatment.

The court concluded that these errors could have affected the evaluation of the medical opinions and the residual functional capacity. It did not decide whether the medical opinions were otherwise properly evaluated. The court also declined to order an immediate award of benefits because further proceedings could be useful concerning the gastrointestinal impairment and the reasons for the lack of ongoing mental-health treatment.

Disposition

Judge Susan Illston granted Alexander H.’s motion for summary judgment and denied the defendant’s cross-motion for summary judgment. The court remanded the case under sentence four of 42 U.S.C. § 405(g) for further proceedings and a new decision. The administrative law judge must reevaluate Alexander H.’s symptom testimony under the correct standard, consider the effect of the gastrointestinal impairments at step two and/or when determining the residual functional capacity, and reweigh the medical opinions as appropriate.