Jose S. v. Commissioner of Social Security

Background

Jose S. brought this action under Section 205(g) of the Social Security Act seeking review of the Commissioner of Social Security’s denial of his application for Title II Disability Insurance Benefits. After a leg fracture during an altercation on March 11, 2021, Jose S. underwent multiple surgeries and continued to report leg or knee pain. The administrative law judge held a telephonic hearing on May 9, 2023, and issued an unfavorable decision on May 22, 2023. The Appeals Council denied review.

The administrative law judge ended the five-step disability analysis at step two. The judge found that Jose S. had medically determinable impairments, including a right tibial plateau fracture, osteoarthritis, and bilateral sacroiliitis, but concluded that these impairments did not significantly limit his ability to perform basic work activities for 12 consecutive months. The decision relied on the judge’s assessment of Jose S.’s statements, the medical evidence, and reports by Drs. Perotti and Chen, who reviewed records without personally examining him.

Court’s analysis

The court held that the administrative law judge’s credibility assessment was not supported by substantial evidence. Although the judge cited facts such as Jose S.’s ability to walk for exercise, medical advice concerning cane use, and a statement that he could lift up to 20 pounds, the decision did not explain how those facts supported the adverse assessment or address the factors required for evaluating reported pain and limitations. The court also found that the judge had selectively relied on portions of the record.

The court further held that the administrative law judge did not adequately explain the treatment of Dr. Perotti’s and Dr. Chen’s reports. Dr. Perotti recommended a consultative examination because additional evidence was needed, but no examination was performed. Dr. Chen’s report stated that there was insufficient evidence to evaluate the claim and did not evaluate the severity of Jose S.’s symptoms. The reports also did not cover the full 12-month period considered by the administrative law judge. The administrative law judge nevertheless characterized the reports as generally persuasive and treated Dr. Perotti’s prediction of likely improvement as evidence that improvement had occurred, without addressing the conflict between that conclusion and Dr. Perotti’s statement that objective evidence supported the limiting effects of Jose S.’s symptoms.

The court also found that the administrative law judge failed to develop a comprehensive record. The judge did not order the recommended consultative examination and did not adequately consider the severity of Jose S.’s arthritis and sacroiliitis or the combined effects of those conditions and the leg fracture. The court noted that, on remand, the administrative law judge must either obtain an updated assessment from another consulting physician or, ideally, order a consultative examination. If the impairments are found not severe individually, the judge must explain why they are not severe in combination.

Ruling

The court granted Jose S.’s motion for judgment on the pleadings and remanded the case for further proceedings consistent with the opinion and order. The court declined to decide whether Jose S.’s symptoms were severe, whether any residual functional capacity determination was correct, or whether he is entitled to benefits. Judge Ona T. Wang directed the Clerk to enter final judgment and close the file.