J.S. v. Commissioner of Social Security

Background

J.S. sought review under 42 U.S.C. § 405(g) of the Commissioner’s final decision denying an application for disability insurance benefits. The application alleged disability beginning August 16, 2018, through December 31, 2023, the date J.S. was last insured. Administrative Law Judge Davis Yee held a telephonic hearing and issued a written decision on November 27, 2024.

The administrative law judge found that J.S. had not engaged in substantial gainful activity, had severe degenerative disc disease of the cervical spine with radiculopathy to both upper extremities and major depressive disorder, and did not have an impairment meeting or equaling a listed impairment. The judge found that J.S. had no past relevant work but retained the residual functional capacity—the most the person can still do despite physical and mental limitations—to perform jobs existing in significant numbers in the national economy.

J.S. argued that the administrative law judge improperly discounted testimony about cervical-spine-related physical limitations, improperly evaluated the opinion of consulting psychological examiner Dr. Salvador-Moses, and wrongly found that lumbar degenerative disc disease was not severe at the second step of the disability analysis. The Commissioner argued that the decision should be affirmed and that, if an error existed, the proper remedy was a remand for further proceedings.

Analysis

Symptom testimony

The court held that the administrative law judge failed to provide specific, clear, and convincing reasons for discounting J.S.’s testimony about pain, limited neck positioning, limited standing, radiating pain, shaking, and dropping objects. The administrative law judge cited imaging, examinations showing normal gait and generally intact sensation and strength, physical therapy records, and activities such as driving J.S.’s mother and occasionally reaching overhead.

The court found that the written decision did not specifically identify which statements were inconsistent with which evidence or explain the connection between normal gait and allegations involving shaking hands and dropping objects. The court also found that the administrative law judge improperly relied on isolated periods of improvement and some daily activities without adequately addressing the longitudinal record.

Medical-source opinion

Dr. Salvador-Moses gave opinions that included marked limitations in dealing with changes in a routine work environment and maintaining persistence, as well as moderate limitations in attending to usual work situations, maintaining pace, and interacting with supervisors and coworkers. The administrative law judge found the opinion unpersuasive because it allegedly lacked explanations and was inconsistent with the record.

The court held that this explanation was inadequate. The administrative law judge did not sufficiently address the opinion’s supportability—how the source’s evidence and explanations supported the opinion—or its consistency with the other record evidence. The decision also overlooked the underlying seven-page assessment, including the review of other medical records and objective testing, and selectively relied on portions of records while not addressing consistent findings in those same records.

Lumbar impairment at step two

The administrative law judge classified lumbar degenerative disc disease with lower-extremity radiculopathy as non-severe. The court stated that the explanation appeared inadequate because the decision acknowledged a history of back pain, imaging showing degenerative changes, injections, and other evidence of lumbar limitations while relying on normal gait and range-of-motion findings.

The court nevertheless found no harmful error in the step-two classification. Because the administrative law judge found at least one severe impairment and continued the disability analysis, any error in classifying the other impairment did not legally prejudice J.S. The court’s remand therefore rested on the inadequate evaluation of symptom testimony and Dr. Salvador-Moses’s opinion, not on harmful step-two error.

Disposition and remedy

The court declined to remand for an immediate award of benefits. It found that further proceedings were needed to evaluate J.S.’s testimony and medical opinions, formulate a revised residual functional capacity, and determine whether work existed for a person with that capacity. The court therefore reversed the Commissioner’s final decision and remanded the case to the Commissioner for further administrative proceedings consistent with the order. The order resolved Docket Nos. 1, 9, 10, 12, and 15.