Robert B. v. Kijakazi

Background

Robert B. sought judicial review of an administrative law judge’s decision finding that he was not disabled under Title II of the Social Security Act. The Social Security Administration’s Appeals Council declined to review that decision, making it the agency’s final decision for purposes of review in the district court.

The record described swelling, skin problems, cellulitis, pain, mobility limits, and Stage 3 lymphedema in Robert B.’s legs and feet. Robert B. reported that he had difficulty standing and walking, needed to elevate his legs frequently, and used a cane for balance. A consulting examiner, Dr. Tang, observed markedly thickened chronic lower legs that appeared to have hard edema and chronic vascular disease, but also found that Robert B. could walk normally without an assistive device and had full strength.

At the administrative hearing, a vocational expert testified that elevating the legs twice daily for 15 minutes could fit within normal work breaks, but four such breaks or two 30-minute breaks would not. The expert also testified that using a cane for balance would preclude all competitive work.

Administrative Decision

The administrative law judge found that Robert B. was not disabled. At step three of the disability analysis, the judge discussed Listings 3.02 and 8.09, but did not analyze whether Robert B.’s lymphedema medically equaled Listing 4.11A. That listing concerns chronic venous insufficiency involving a lower extremity, incompetence or obstruction of the deep venous system, and extensive firm swelling over at least two-thirds of the leg between the ankle and knee.

The administrative law judge also concluded, without further explanation, that Robert B.’s cellulitis did not meet the severity required by Listing 8.09. The judge cited two exhibits containing 257 pages of medical records. The judge determined that Robert B. could perform light work with environmental limits, a 10-minute break away from his workstation after every two hours of standing, and permission to elevate his legs twice daily for 15 minutes.

Court’s Analysis

The court held that the Commissioner erred at step three by failing to consider whether Robert B.’s lymphedema symptoms equaled Listing 4.11A. The court found that the record was a close fit for that listing. Evidence of venous reflux supported possible venous insufficiency and incompetence, while descriptions of hard or thickened edema and Stage 3 lymphedema supported possible firm or dense swelling.

The court rejected the Administration’s argument that Robert B. had not adequately raised the listing-equivalence issue. The court found that Robert B. cited Dr. Tang’s report before the Appeals Council and that the report provided medical evidence—not merely Robert B.’s personal interpretation—supporting the possibility that his lymphedema equaled Listing 4.11A. Because the administrative law judge did not analyze that issue and the error could not be considered harmless, remand was required.

The court also found that the administrative law judge improperly discounted Robert B.’s testimony. Because there was no finding of malingering, the administrative law judge was required to provide specific, clear, and convincing reasons for rejecting testimony about symptom severity. The judge gave no reason for discounting Robert B.’s testimony.

The court declined to remand for an immediate award of benefits. It found that the record was not fully developed, including because another leg scan was being completed around the time of the hearing. The record also contained conflicting evidence about Robert B.’s need for a cane and how often he needed to elevate his legs. Those issues required further administrative proceedings rather than a court-ordered benefits award.

The court further found that the administrative law judge had not adequately explained the Listing 8.09 analysis. If Robert B. was not found disabled under Listing 4.11A, the administrative law judge was directed to reevaluate the conditions under Listing 8.09 and consider whether Robert B.’s lymphedema, rather than only his cellulitis, caused lesions meeting that listing’s severity requirement.

Disposition

Judge Robert M. Illman denied the defendant’s motion for summary judgment and remanded the case to the administrative law judge for further proceedings consistent with the order. On remand, the administrative law judge must reconsider the Listing 4.11A issue, apply the proper standard to Robert B.’s testimony, allow clarifying statements from treatment providers about leg elevation, and further evaluate Listing 8.09 if necessary.