John S. v. O'Malley

Background

John S. 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 final decision subject to review by the district court under 42 U.S.C. § 405(g). The parties consented to a magistrate judge’s jurisdiction and filed briefs addressing the decision.

John S. alleged disability beginning September 1, 2018. The record described a heart attack, unsuccessful stent procedures, joint and back pain, shoulder and knee problems, dizziness and vertigo, and mental-health symptoms. A consultative physical examiner, Dr. Katherine Kenny, found pain and other examination findings and opined that John S. could lift or carry 20 pounds occasionally and 10 pounds frequently. A consultative psychological examiner, Dr. Tiadora Kim, found impaired attention and concentration and opined that John S. would have moderate difficulty maintaining concentration, attention, persistence, and consistency during a normal workday.

The administrative law judge found heart disease and right-knee arthritis to be severe impairments, but found several other conditions not severe or not medically determinable. The judge determined that John S. could perform medium work with limitations and could understand, remember, and carry out simple instructions. Although the judge found that he could not perform his past work, the judge concluded that he could perform hand-packer and agricultural produce-packer jobs and therefore was not disabled.

Legal standard

The court could set aside the denial of benefits only if it was unsupported by substantial evidence or based on legal error. Substantial evidence means relevant evidence that a reasonable person could accept as adequate to support a conclusion. The court had to review the administrative record as a whole and could not affirm the administrative law judge on a reason that the judge did not provide.

Analysis

Step 2: medically determinable impairments

The court found that the administrative law judge appeared to have applied the wrong standard when determining that some conditions were not medically determinable. The judge treated John S.’s back pain as only a symptom and found no medically determinable impairment related to his left-foot injury. But the record included an X-ray showing posterior calcaneal enthesopathy in the left foot, as well as Dr. Kenny’s findings of low-back trigger points and a palpable lumbar-muscle spasm.

The court explained that an error at Step 2 can be harmless if the administrative law judge later considers the affected conditions. Here, however, the court could not determine that the back and foot conditions had been incorporated into the later analysis. The court therefore concluded that the Step 2 error required remand.

Pain and lifting capacity

The administrative law judge found that John S. could perform medium work, which includes lifting up to 50 pounds at a time and frequently lifting or carrying objects weighing up to 25 pounds. Dr. Kenny instead gave lifting restrictions consistent with light work, which involves lifting no more than 20 pounds at a time. The court noted that Dr. Kenny appeared to base those restrictions on pain rather than on a lack of muscle strength, and John S. gave similar testimony about his lifting limitations.

The court held that the administrative law judge improperly discounted the pain-related limitations based in part on normal strength findings. The judge also failed to provide specific, clear, and convincing reasons for rejecting John S.’s testimony about the severity of his pain. The judge stated only that the testimony was not entirely consistent with the medical and other evidence, without identifying the testimony being rejected or the evidence undermining it. The court found this explanation legally insufficient and not harmless because the pain allegations could prevent John S. from performing medium work.

The court directed the administrative law judge on remand to properly consider and evaluate John S.’s subjective pain symptoms and, if necessary, revise his residual functional capacity, meaning the most he can still do despite his impairments.

Concentration, persistence, and pace

The administrative law judge found that John S. had a moderate limitation in concentrating, persisting, or maintaining pace. But the judge did not determine whether he could perform simple tasks despite that limitation and did not identify medical evidence supporting that conclusion. The court held that the judge should have included the concentration, persistence, and pace limitation in the hypothetical questions posed to the vocational expert, or made a finding that John S. could perform simple, repetitive work regardless of that limitation.

Disposition

The court REVERSED the administrative law judge’s decision and REMANDED the case FOR FURTHER PROCEEDINGS consistent with the order. The provided opinion text ends during the discussion of the required mental-impairment analysis, so the full wording of the final remand instruction is not available in the supplied text.