K.A. v. O'malley

Background

K.A. sought judicial review of the Commissioner of Social Security’s final decision denying his application for Supplemental Security Income under Title XVI of the Social Security Act. K.A. alleged disability based on back pain, hypertension, diabetes, arthritis, and pain. After an administrative hearing, Administrative Law Judge Kevin Gill found that K.A. had not been disabled since October 31, 2018. The judge found several severe impairments and determined that K.A. could perform medium work with some restrictions. Based on that residual functional capacity, age, education, and work experience, the judge found that K.A. could perform jobs such as floor waxer, linen clerk, and automobile detailer.

K.A. argued that the administrative law judge failed to adequately develop the record, improperly evaluated the opinions of examining consultant Thein Win, M.D., and treatment provider Jennifer Tsang, NP, and improperly discounted K.A.’s statements about the severity of his symptoms. The Commissioner maintained that the administrative law judge properly evaluated the evidence and that substantial evidence supported the finding that K.A. was not disabled.

Development of the Medical Record

The administrative record contained LifeLong Medical Care records through August 2019, but did not contain the 2021 and 2022 treatment records referenced in Nurse Tsang’s May 2023 note. Those records allegedly included 2021 lumbar x-rays showing moderate degenerative disc disease and osteoarthritis. At step two of the disability analysis, the administrative law judge accepted Nurse Tsang’s summary of the missing records and found lumbar degenerative disc disease, even though the records themselves were not in the file.

The court did not find that the administrative law judge breached the independent duty to fully and fairly develop the record. Instead, the court found that the administrative law judge made an internally inconsistent use of the evidence: he purported to credit Nurse Tsang’s summary to fill the gap in the treatment records, but then relied on the absence of those same records to discount Nurse Tsang’s opinion and K.A.’s symptom statements. The court concluded that this error was not harmless because the treatment gap appeared to influence the finding that K.A. had not experienced a change in his physical residual functional capacity since an earlier decision.

Medical Opinions

The administrative law judge found Dr. Win’s opinion persuasive. Dr. Win reported largely normal physical findings and opined that K.A. could perform activities within a range of medium work. The court found that substantial evidence supported the administrative law judge’s findings about the supportability and consistency of Dr. Win’s opinion, including Dr. Win’s examination findings, largely normal examinations in the treatment records, and the opinions of state agency consultants.

The court nevertheless required reconsideration of Dr. Win’s opinion because it was unclear how the administrative law judge’s acceptance of Nurse Tsang’s summary and the diagnosis of lumbar degenerative disc disease affected the evaluation of the medical evidence.

The administrative law judge found Nurse Tsang’s opinion very unpersuasive, citing the largely unremarkable physical examinations, including her own observations, and the fact that she had seen K.A. only once. The court found no error in those reasons as far as they went. But the court held that the administrative law judge erred by accepting the summary of the missing records and then rejecting Nurse Tsang’s opinion partly because the treatment records were absent.

K.A.’s Statements and Residual Functional Capacity

K.A. reported substantial back and leg pain, difficulty walking and standing, trouble gripping and holding objects, and episodes when he could not get out of bed. The court found that substantial evidence supported some of the administrative law judge’s reasons for discounting these statements, including largely normal physical examinations and the lack of objective observations of back spasms or right-sided tenderness. The court also noted that the administrative law judge properly considered a 2019 report that K.A.’s pain was managed with Naproxen at that time.

However, the court held that the same improper reliance on the treatment gap affected the evaluation of K.A.’s subjective statements. The court also held that, after identifying lumbar degenerative disc disease as a severe impairment, the administrative law judge needed to consider that impairment in the later stages of the disability analysis, including when evaluating the medical opinions, K.A.’s statements, and residual functional capacity. The court found it unclear whether the administrative law judge had done so.

Disposition

The court reversed the Commissioner’s decision and remanded the case for further administrative proceedings consistent with the order. On remand, the administrative law judge must reassess the opinions of Dr. Win and Nurse Tsang, K.A.’s subjective statements, and K.A.’s residual functional capacity while considering all impairments identified at step two, including those reflected in the summary of records that the administrative law judge accepted. The court stated that it did not intend to limit the scope of the remand. The Clerk was directed to enter judgment and close the file.