S.M. v. Commissioner of Social Security

Background

S.M. appealed the June 20, 2024 decision of an Administrative Law Judge denying disability benefits for the period beginning September 7, 2018. The ALJ found severe impairments including lumbar degenerative disc disease, anxiety, obesity, and depressive disorders. The ALJ found anemia and migraine headaches nonsevere, concluded that S.M.’s impairments did not meet or equal a listed impairment, and determined that S.M. could perform light work with limits to simple, routine, and repetitive tasks. The ALJ found that S.M. could not perform past relevant work but could perform other work available in significant numbers.

S.M. argued that the ALJ improperly evaluated the severity of her small fiber neuropathy and migraine headaches, rejected her testimony, and weighed medical opinions and other medical evidence improperly. S.M. sought reversal and remand, including an argument for an immediate award of benefits. The Commissioner opposed the request and sought affirmance of the ALJ’s decision.

Medical Opinions

The court held that the ALJ harmfully erred in evaluating the medical opinions. The ALJ found every opinion concerning S.M.’s physical impairments unpersuasive or not persuasive, effectively assigning them no weight. The court concluded that the ALJ improperly substituted his own interpretation of the medical evidence for the medical opinions when determining S.M.’s residual functional capacity, meaning the most work-related activity S.M. could still perform despite her limitations.

The ALJ also failed to address opinions from Dr. Angeles, Dr. Olivares, and Dr. Carstens. The Commissioner conceded that these opinions were not addressed but argued that the omissions were harmless. The court rejected that argument. It explained that Dr. Angeles’s in-home assistance form could not be disregarded without considering the records and treatment relationship supporting it. Dr. Olivares’s opinion was not the same as Dr. Staley’s because Olivares assessed sedentary work and reviewed additional medical evidence, while Staley assessed light work. Dr. Carstens’s opinion also reached conclusions different from Dr. Morgan’s, even though both relied on the same objective medical evidence.

The court further held that the ALJ did not adequately explain the supportability and consistency of certain opinions, including those of PA-C Ahern and Dr. Staley. The ALJ also relied on later medical evidence when evaluating some earlier opinions without adequately considering the evidence during the period when those opinions were made. In addition, the court found that the ALJ’s reasons for entirely rejecting PA-C Ahern’s opinion were not supported by substantial evidence. The ALJ relied on selected normal findings, unrelated medical visits, and a later magnetic resonance imaging scan while failing to address other abnormal findings, spinal injections and nerve blocks, and earlier imaging showing additional spinal abnormalities.

Small Fiber Neuropathy

The Commissioner conceded that the ALJ did not specifically decide at step two whether S.M.’s small fiber neuropathy was severe or nonsevere. The court held that this omission at step two was not harmful because the ALJ found other severe impairments and continued with the sequential evaluation.

The court reached a different conclusion about step three. The ALJ failed to consider whether S.M.’s small fiber neuropathy met or equaled Listing 11.14 for peripheral neuropathy. The court declined to make that initial disability determination itself or rely on reasoning that the ALJ had not provided. It held that the failure to address the condition at step three was harmful error.

Disposition

The court held that the errors were not harmless because they prevented meaningful review of the ALJ’s reasoning and could affect the residual-functional-capacity determination and the disability analysis. The court did not reach the remaining arguments, including whether the ALJ improperly evaluated the severity of S.M.’s headaches or rejected her testimony.

Judge Nathanael M. Cousins ruled that this was not the exceptional case requiring an immediate award of benefits. The court therefore REVERSED the ALJ’s decision and REMANDED the matter for further consideration and proceedings. On remand, the ALJ must reevaluate all steps of the sequential process, S.M.’s physical and mental impairments, and whether S.M. was disabled for any qualifying period since the alleged onset date.