M.T. v. Bisignano

Background

M.T. sought judicial review of the Commissioner of Social Security’s final decision denying her claim for Supplemental Security Income under Title XVI of the Social Security Act. The administrative law judge found severe physical impairments involving M.T.’s knees, pelvis, and spine, but found that her opioid-use and stimulant-use disorders were non-severe. The administrative law judge assessed a residual functional capacity for a reduced range of light work, without mental limitations, and found at the fifth step of the disability evaluation that M.T. could perform other work in the national economy.

The parties filed cross-motions for summary judgment. The disputed issues included the evaluation of psychologist Ruth Gallo’s and internist Robert Tang’s opinions, the finding that M.T.’s mental impairments were non-severe, the adequacy of the step-three analysis, and whether the residual functional capacity was supported by substantial evidence.

Dr. Gallo’s Opinion

The court held that the administrative law judge’s rejection of Dr. Gallo’s opinion was not supported by substantial evidence. Dr. Gallo performed a psychological examination and standardized testing. M.T. scored at the second percentile for processing speed, between the 0.2 and second percentiles on several memory measures, and below the performance thresholds Dr. Gallo identified on Trail Making testing. Dr. Gallo assessed limitations involving complex instructions, concentration and pace, workplace interactions, adaptation to work pressures, and completing a normal workday or workweek.

The administrative law judge relied on several findings from Dr. Gallo’s report, including a notation that M.T.’s recent and remote memory seemed intact, her low-average full-scale intelligence score, her acceptable mood and affect, and her logical thought process. The court found that these reasons did not address the objective test results or explain how those results conflicted with the limitations Dr. Gallo assessed. The court also found that a cooperative presentation during a structured, one-on-one examination did not, without more explanation, resolve the question of how M.T. could interact with supervisors, co-workers, and the public under ordinary work pressures.

The court further found that the administrative law judge had not adequately addressed treatment records documenting drowsy or distracted attention, slowed or mumbled speech, a distractible thought process, limited insight, difficulty remembering and organizing appointments, and difficulty identifying the month during an appointment. The court said that ordinary treatment notes showing alertness and orientation were weak evidence against specific deficits in processing speed, delayed memory, and sustained attention.

The administrative law judge relied in part on testimony from medical expert Betty Borden, Ph.D. The court found that Dr. Borden’s reasons largely repeated the same deficient rationales. Although Dr. Borden noted that the reported psychiatric hospitalizations were not documented in the record, that issue did not address the standardized testing. The court also noted that Dr. Borden acknowledged that the processing-speed and memory scores could reflect severe limitations, but discounted them because she found no cognitive diagnosis or corroboration in routine treatment records.

The court rejected the Commissioner’s argument that any error was harmless. The vocational expert had been asked about some limitations involving simple instructions and production-rate pace, but not about the marked limitation in adapting to ordinary work stresses and changes, workplace interaction limitations, off-task time, absenteeism, or social restrictions. The court therefore could not conclude that the step-five finding would remain valid if the rejected limitations were credited in whole or in part.

Step Two and Residual Functional Capacity

The court held that the step-two finding—that M.T.’s mental impairments were non-severe—rested on the same flawed evaluation of the evidence. The administrative law judge adopted Dr. Borden’s view that references to depression and post-traumatic stress symptoms did not establish those impairments, without reconciling Dr. Gallo’s diagnosis of unspecified depressive disorder or treating clinicians’ repeated diagnoses of moderate recurrent major depressive disorder.

The court also found that the administrative law judge relied on selected daily activities and cooperative presentations while failing to address contrary evidence, including M.T.’s testimony that she forgot appointments and lost her train of thought. The court did not decide that the evidence required a finding that the mental impairments were severe; instead, it held that the administrative law judge must reevaluate the issue.

Because the residual functional capacity excluded mental limitations based on the unsupported findings about Dr. Gallo’s opinion and the severity of M.T.’s mental impairments, the court required the administrative law judge to reassess the residual functional capacity as well. The court did not resolve the parties’ separate dispute about whether the administrative law judge adequately explained the relationship between mild paragraph-B ratings and the residual functional capacity.

Dr. Tang’s Opinion

The administrative law judge found Dr. Tang’s opinion persuasive overall but concluded that regular breaks were sufficient for M.T. to vary her sitting, standing, and walking positions. The court found that this explanation did not address the specifics of Dr. Tang’s statement. According to M.T.’s reading of the medical-source statement, it limited sitting to two hours at a time and standing and walking to one hour each at a time.

The court did not decide whether the treatment of Dr. Tang’s opinion alone required remand because it was already remanding on other grounds. It directed the administrative law judge on remand to address the alternation and duration components of Dr. Tang’s opinion, either incorporating supported limitations into the residual functional capacity or explaining with record support why they should not be adopted. The administrative law judge must also obtain vocational testimony about any positional limitation included in the revised residual functional capacity.

Remedy and Disposition

M.T. requested that the court credit the rejected evidence as true and remand for an award of benefits. The court declined to do so because the record contained unresolved conflicts, ambiguities, and gaps, including the conflict between Dr. Gallo’s opinion and Dr. Borden’s testimony, the lack of corroboration for the reported psychiatric hospitalizations, and uncertainty about the extent of any mental or positional limitations. The court concluded that further proceedings could be useful and that a supported finding of no disability remained possible.

The court granted M.T.’s motion in part, including by denying her request for a remand for an award of benefits, denied the Commissioner’s cross-motion, reversed the Commissioner’s final decision, and remanded the case under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with the order. On remand, the administrative law judge must reevaluate Dr. Gallo’s opinion, reconsider the medically determinable mental impairments and their severity, reassess the residual functional capacity and any necessary later steps, address Dr. Tang’s position-related findings, obtain appropriate vocational evidence, and further develop the record as appropriate.