J.L. v. Commissioner of Social Security, et al.

Background

J.L. sought review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s decision denying her application for disability insurance benefits. She protectively filed the application on August 31, 2021. After the application was denied initially and on reconsideration, an administrative law judge (ALJ) held a hearing involving testimony from J.L. and a vocational expert. The ALJ denied benefits on July 26, 2024, and the Appeals Council denied review, making the ALJ’s decision the Commissioner’s final decision.

The ALJ found that J.L. had not engaged in substantial gainful activity since her alleged onset date of March 21, 2019. The ALJ identified severe impairments including right lateral epicondylitis, right wrist tendinitis, cervical-spine degenerative disc disease, a history of left-breast cancer treated with surgery and radiation, anxiety, and depression. The ALJ found that these impairments did not meet or medically equal a listed impairment, determined that J.L. could perform light work with restrictions, and concluded that she could not return to her past work but could perform other jobs existing in significant numbers in the national economy.

Court’s analysis

The court upheld the ALJ’s step-three finding. Although the ALJ did not expressly discuss the listing for breast cancer, the ALJ considered evidence relevant to J.L.’s alleged continuing treatment complications, including pain, shoulder restrictions, anxiety, depression, and fatigue. The record also contained evidence of full strength, intact sensation and reflexes, full right-arm and shoulder range of motion, generally normal mental-status findings, and imaging suggesting that the cancer treatment had been effective and the cancer was not persisting or recurring. The court concluded that substantial evidence supported the finding that J.L. did not meet the breast-cancer listing.

The court also rejected J.L.’s arguments concerning Dr. Herman Sandhu and Dr. Lawrence Enweze. The court concluded that the ALJ’s residual functional capacity assessment reflected or exceeded Dr. Sandhu’s limitations. It also concluded that substantial evidence supported the ALJ’s decision to find Dr. Enweze’s opinions unpersuasive because they were based on one examination rather than the full record and were inconsistent with other evidence, including evidence about the side of J.L.’s limitations and her conservative treatment.

The court agreed, however, that the ALJ failed to explain the treatment of conflicting opinions from Dr. S. Amon and Dr. E. Trias. Both opinions were characterized as among the most persuasive, but Dr. Amon found that J.L. had limitations reaching forward and laterally with her left arm, while Dr. Trias did not identify those limitations. The ALJ’s residual functional capacity assessment adopted Dr. Trias’s view without explaining why. The court found this error was not harmless because accepting Dr. Amon’s limitations could affect J.L.’s ability to perform the jobs identified at step five, each of which required frequent reaching.

The court also found that the ALJ did not provide the specific, clear, and convincing reasons required for rejecting J.L.’s testimony about the severity and effects of her symptoms. The ALJ relied on general references to conservative treatment and objective evidence without identifying which symptoms would have required more aggressive treatment. The ALJ also inaccurately characterized J.L.’s testimony about working part time and failed to account adequately for her testimony that full-time work would overwhelm her. In addition, the ALJ relied on the absence of treatment after 2023 when evaluating symptoms alleged to have begun in 2019, and did not explore possible reasons for limited mental-health treatment. A general reference to positive clinical and diagnostic findings was also insufficiently specific.

The court rejected J.L.’s argument that the ALJ inadequately handled her mother’s lay testimony. The ALJ acknowledged and summarized the testimony and stated that it had been considered in relation to J.L.’s statements and the objective evidence. Under the regulations applicable to claims filed on or after March 27, 2017, the ALJ was not required to explain how the nonmedical-source evidence was evaluated in the same manner as medical opinions.

The court did not decide whether the ALJ’s existing step-five analysis or hypothetical question to the vocational expert was adequate. Because the ALJ must reconsider the medical evidence and determine a new residual functional capacity, the step-five analysis may also need to be reconsidered.

Disposition

J.L. requested either an immediate award of benefits or further administrative proceedings. The court held that an immediate award was not appropriate because unresolved issues remained, including the evaluation of the medical opinions, J.L.’s symptom testimony, and her ability to perform jobs in the national economy. Judge Casey ordered that the Commissioner’s decision be reversed and the matter remanded for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).