Stephanie E. v. Commissioner

Background

Stephanie E. appealed the Commissioner of Social Security’s decision denying her applications for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. The administrative law judge (ALJ) found that she had several severe impairments, including major depressive disorder, generalized anxiety disorder, obesity, hyperparathyroidism, hypertension, osteoarthritis of the hips, and stage 3 chronic kidney disease. The ALJ determined that she could perform a restricted range of medium work and that jobs existed in significant numbers in the national economy. The ALJ therefore found her not disabled from the alleged onset date through the date of the decision.

This was the second federal-court review of Stephanie E.’s benefits application. In a prior related proceeding, the court had remanded after finding errors in the ALJ’s treatment of her subjective testimony. On remand, a different ALJ again denied benefits.

Medical Opinions

The court rejected Stephanie E.’s challenge to the ALJ’s treatment of Dr. Jacklyn Chandler’s opinion. The ALJ found that opinion largely persuasive and incorporated its workplace limitations into the residual functional capacity (RFC), meaning the most work a claimant can do despite her limitations. The court concluded that any additional error in analyzing that opinion would have been harmless because the relevant limitations were included in the RFC.

The court found harmful errors in the treatment of Dr. Tiadora Kim’s opinion. Dr. Kim identified moderate limitations in Stephanie E.’s ability to sustain concentration, attention, consistency, and persistence at a reasonable pace and to adapt to typical workplace stressors and pressures. Dr. Kim stated that Stephanie E. would likely need assistance and support in those areas.

The ALJ described Dr. Kim’s opinion as largely persuasive but did not include the assistance-and-support limitation in the RFC. The court held that the ALJ failed to explain why the limitation was omitted and failed to analyze whether it was consistent with the medical record. The court rejected the Commissioner’s argument that Dr. Kim’s statements were merely suggestions rather than medical opinions. The court held that the statements were opinions about Stephanie E.’s functional limitations and that the ALJ had to incorporate them, in full or in part, or explain why they were excluded.

Subjective Testimony

The court also held that the ALJ improperly rejected Stephanie E.’s testimony about absenteeism and her ability to maintain regular attendance. The ALJ did not identify the specific portions of that testimony being rejected, except for testimony about leaving home. The court also found that the ALJ failed to distinguish among different periods of alleged disability and relied heavily on records from late 2022 through 2024 to discount testimony concerning earlier periods.

The court concluded that the ALJ improperly relied on generally unremarkable mental-status examinations without considering the broader diagnostic record, including treatment notes describing depression and anxiety that interfered with employment and a 2022 hospitalization. The court also found that the ALJ’s characterization of Stephanie E.’s mental-health treatment as routine and conservative was not supported by substantial evidence, noting her psychiatric medications and the absence of identified more-aggressive treatment that she declined. Finally, the court found that the ALJ mischaracterized Stephanie E.’s testimony about leaving home.

These errors were harmful. Vocational-expert testimony indicated that missing more than one day of work per month, or two or more days per month, would make a claimant unemployable. The court concluded that properly crediting Stephanie E.’s testimony required a finding of disability at least through 2021.

Remand and Disposition

Stephanie E. requested an immediate award of benefits. The court held that the requirements for crediting her testimony as true and awarding benefits were satisfied from the alleged onset date through at least 2021. However, the court could not determine whether she remained disabled afterward or whether a closed period of disability was appropriate because the record did not establish when any disability ended.

The court therefore reversed and remanded rather than ordering benefits for the entire claimed period. On remand, the ALJ must credit Stephanie E.’s testimony as true and find her disabled from the alleged onset date through at least 2021. The ALJ must then determine whether the disability continued or whether a closed period is appropriate, including the end date if necessary. The ALJ must credit testimony from both the 2021 and 2025 hearings, incorporate Dr. Kim’s finding regarding assistance and support, revisit the analysis of Listings 12.04 and 12.06, and reformulate the RFC to include any required additional limitations. Judgment will be entered.