D.S. v. O'Malley

Background

D.S. brought this second appeal from a decision denying her applications for disability insurance benefits under Title II and supplemental security income under Title XVI of the Social Security Act. She alleged disability beginning May 1, 2015, based on physical and mental conditions. Her last-insured date for Title II benefits was December 31, 2016.

In an earlier round of this case, the court remanded for further development of the evidence about D.S.’s mental and physical impairments. That order specifically directed the administrative law judge to obtain a psychiatric consultative examination and a medical opinion about D.S.’s mental impairments before her last-insured date. D.S. was later found disabled as of April 13, 2021 on a separate Title XVI claim. The Appeals Council did not reopen that determination, and the administrative law judge considered the period before February 11, 2021 in the post-remand decision.

After a hearing at which a vocational expert and a medical expert testified, the administrative law judge found that D.S. became disabled on February 11, 2021, but was not disabled before that date and was not disabled through December 31, 2016. Before February 11, 2021, the judge found that D.S. could perform work at all physical exertion levels with limits to simple, routine tasks and occasional interaction with the public, coworkers, and supervisors. The judge found that she could not return to her past work but could perform other jobs, including floor waxer and hand packager.

Issues and analysis

D.S. argued that the administrative law judge failed to comply with the earlier remand order, used broad record citations, improperly evaluated her spinal impairments and right ankle bone spur at step two, rejected her symptom testimony without adequate reasons, and improperly evaluated medical opinions. The Commissioner argued that the administrative law judge reasonably developed and evaluated the evidence and that substantial evidence supported the finding that D.S. was not disabled before February 11, 2021.

Failure to develop the record

The court held that the administrative law judge failed to comply with the earlier order. For D.S.’s physical impairments, the administrative law judge again rejected the medical opinions about her physical functioning and independently assessed the severity and work-related limits from the evidence. The court found that this repeated the earlier error and that the Commissioner did not adequately address D.S.’s argument about the physical record.

For D.S.’s mental impairments, the administrative law judge obtained testimony from a medical expert but did not order the psychiatric consultative examination required by the earlier order. The court concluded that the earlier order required both the examination and a medical opinion concerning D.S.’s mental impairments before her last-insured date. The failure to comply required a remand.

Step-two findings

At step two, the administrative law judge determines whether an impairment significantly limits a claimant’s ability to perform basic work activities. The court found no error in the finding that D.S.’s plantar bone spur was not severe, based on the records cited by the administrative law judge. Those records showed the bone spur but, in the court’s view, tended to show that it did not significantly limit D.S.’s basic work abilities.

The court found the administrative law judge’s findings about D.S.’s cervical and lumbar spine impairments unclear. D.S. identified records documenting cervical and lumbar issues dating from 2015, making it unclear why the administrative law judge stated that there were no medical signs or laboratory findings establishing a medically determinable impairment before February 11, 2021. The court directed the administrative law judge to consider these issues on remand.

Symptom testimony

The court held that the administrative law judge did not adequately explain the rejection of D.S.’s testimony about the intensity, persistence, and effects of her symptoms. The decision summarized D.S.’s allegations and medical records but did not identify which portions of her testimony were rejected or explain why particular evidence contradicted that testimony. The court concluded that this prevented meaningful review of whether her testimony had been rejected arbitrarily.

Medical opinions

The court found that the administrative law judge did not meaningfully address the opinions of psychologists Phaedra Caruso-Rudin and Heather Abrahimi concerning D.S.’s mental impairments. The court also found that the reasons given for rejecting their opinions about the Title II period were not adequately supported by the cited records. In addition, broad citations covering hundreds of pages were not specific enough to allow the court to evaluate the administrative law judge’s reasoning.

The court reached similar conclusions about the opinion of medical expert Linda Miller, M.D. The administrative law judge cited broad portions of the record to find that Dr. Miller viewed D.S. as less limited than the evidence showed, but did not meaningfully explain the assessment.

As to orthopedic consultant Soheila Benrazavi, M.D., the court was not persuaded that reversal was required based on the administrative law judge’s discussion of the duration of D.S.’s lumbosacral condition. However, the court found that clarification was needed because the administrative law judge did not identify which records supported the conclusion that Dr. Benrazavi’s opinion was inconsistent with the rest of the evidence.

The court also found that the administrative law judge’s reasons for rejecting the physical-function assessments of state-agency consultants Steven Kao, M.D., and Patty Rowley, M.D., were not supported by substantial evidence. The record showed that those consultants reviewed records beyond Dr. Benrazavi’s report, contrary to the administrative law judge’s explanation.

Disposition

The court reversed the Commissioner’s decision and remanded the case for further administrative proceedings. On remand, the administrative law judge must order a psychiatric consultative examination, obtain a medical opinion about D.S.’s mental impairments before her last-insured date, and further develop the record about her physical impairments. The administrative law judge must then reassess the step-two findings, D.S.’s symptom testimony, the medical opinions, and her residual functional capacity. The clerk was directed to enter judgment and close the file.