M.A.L. v. Kijakazi

Background

M.A.L. sought judicial review of the Commissioner of Social Security’s decision denying her applications for disability insurance benefits and supplemental security income. She alleged disability beginning June 3, 2019, after a car accident. The administrative law judge (ALJ) found severe impairments involving degenerative disc disease of the cervical and lumbar spine with radiculopathy, costochondritis, and myofascial pain syndrome of the thoracic spine. The ALJ determined that M.A.L. could perform light work with restrictions, could not perform her past relevant work, but could perform other jobs existing in significant numbers. The Appeals Council denied review.

The parties filed cross-motions for summary judgment. M.A.L. argued that the ALJ improperly discounted her allegations of pain and physical dysfunction, improperly evaluated the opinion of consulting physician Vasantha Natarajan, M.D., failed to develop the record, and should have remanded the matter for consideration of additional evidence submitted to the Appeals Council.

M.A.L.’s Pain and Physical-Dysfunction Allegations

The court held that the ALJ did not provide sufficiently clear or specific reasons, supported by substantial evidence, for discounting M.A.L.’s allegations based on objective medical evidence. The ALJ relied on largely normal or mildly abnormal imaging and examination findings, including normal gait, strength, sensation, and reflexes. But the court found that the ALJ did not clearly explain why those findings were inconsistent with M.A.L.’s allegations of pain and physical dysfunction. The ALJ also discussed improvement in some symptoms without adequately addressing records showing continuing pain and worsening of other symptoms.

The court found that the ALJ properly considered the gap in treatment between March 2021 and early 2022. The court concluded, however, that the ALJ improperly focused on the supposedly conservative nature of M.A.L.’s treatment without assessing her treatment history as a whole, which included injections and epidural steroid injections as well as medications, physical therapy, and other measures. Because the RFC did not include all limitations associated with M.A.L.’s alleged symptoms, the court could not conclude that these errors were harmless. On this issue, the court granted M.A.L.’s summary-judgment motion and denied the Commissioner’s cross-motion.

Dr. Natarajan’s Opinion

The ALJ found Dr. Natarajan’s opinion unpersuasive. The court upheld that determination. Dr. Natarajan’s functional limitations were based largely on M.A.L.’s reported symptoms and were not supported by explanations tied to objective medical evidence. The court also found that several limitations were unsupported by Dr. Natarajan’s own findings, including normal strength, sensation, reflexes, and a negative Romberg balance test. The court further found substantial evidence supporting the ALJ’s conclusion that the opinion was inconsistent with the record’s generally minimally abnormal examinations, treatment gaps, and symptom improvement after some epidural injections.

On this issue, the court denied M.A.L.’s summary-judgment motion and granted the Commissioner’s cross-motion.

Additional Evidence Submitted to the Appeals Council

The court considered the additional evidence submitted to the Appeals Council. It found that a June 2022 colonoscopy pathology report did not undermine the ALJ’s decision. It also found that an August 2022 chiropractic record and treatment records from September, November, and December 2022 generally did not show a reasonable probability of changing the decision or did not relate to the relevant period.

The court reached a different conclusion about September 20, 2022 MRI results concerning M.A.L.’s cervical and lumbar spine. Although the MRIs were taken after the ALJ’s decision, they concerned the same conditions identified as severe impairments and suggested a significant increase in severity shortly afterward. The court found that the MRI evidence undermined the ALJ’s reliance on largely normal or mildly abnormal objective findings and was directly relevant to the evaluation of M.A.L.’s allegations. On this issue, the court granted M.A.L.’s summary-judgment motion and denied the Commissioner’s cross-motion.

Disposition

Judge Virginia K. DeMarchi granted in part and denied in part M.A.L.’s motion for summary judgment, granted in part and denied in part the Commissioner’s cross-motion for summary judgment, and remanded the matter for further administrative proceedings consistent with the order. The court did not award benefits or decide that M.A.L. is disabled.