Lia L. v. Bisignano

Background

Lia L. sought judicial review of the Social Security Commissioner’s denial of her application for supplemental security income. She alleged disability based on fibromyalgia, post-traumatic stress disorder, osteoarthritis, and related conditions. The Administrative Law Judge (ALJ) found several severe impairments but determined that Lia L. retained the residual functional capacity (RFC)—the ability to work despite her limitations—to perform a limited range of light work.

The RFC finding included the expectation that Lia L. could stand or walk, off and on, for about six hours during an eight-hour workday. The ALJ acknowledged Lia L.’s use of a cane or walker, shuffling and antalgic gait, and receipt of home health care. The ALJ nevertheless concluded that the medical findings did not show an ongoing need for an assistive device, relying on physical-therapy discharge notes, normal strength findings, and conservative treatment.

Issue and analysis

Lia L. argued that the ALJ did not adequately explain the RFC finding, particularly in light of her reported pain and numbness and the documented use of a cane and walker. The court focused on Social Security Ruling 96-9p, which requires medical documentation establishing that a hand-held assistive device is necessary for walking and describing when it is needed. The court explained that a formal prescription is not required; clinical notes, treatment observations, or a consistent documented pattern of assistive-device use linked to functional limitations must be considered.

The court held that merely acknowledging cane or walker use was not enough. Records described cane and walker use connected to pain and mobility limitations, an antalgic and shuffling gait that improved with assistive support, and assistance with daily activities. The ALJ’s statement that the examination findings did not document an ongoing need for an ambulatory aid was conclusory and did not explain whether the devices were medically necessary or whether their use required a limitation in the RFC.

The court also found that the omission mattered because the difference between light and sedentary work could affect the result, particularly given Lia L.’s age category. The ALJ had not reconciled the evidence with the physical demands of light work and had not asked the vocational expert about cane use at Step Four. The court therefore required further proceedings so the ALJ could assess medical necessity, decide whether any resulting limitation must be included in the RFC, and then make proper conclusions at Steps Four and Five.

Ruling

The court adopted the Report and Recommendation to the extent it accurately described the procedural history, review standard, and general legal framework, but rejected its conclusion that substantial evidence supported the ALJ’s RFC finding. Judge Jerry W. Blackwell ordered:

- Lia L.’s objection was sustained in part. - The Report and Recommendation was accepted in part and rejected in part. - Lia L.’s request for relief was granted in part. - The defendant’s request to affirm the Commissioner’s decision was denied. - The matter was remanded under sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with the Order.

The court did not itself determine whether Lia L. was disabled. It required the Social Security Administration to address the assistive-device issue and reevaluate the matter in further proceedings.