T.S. v. Commissioner

Background

T.S. applied for Social Security disability-insurance benefits and supplemental security income. She amended her alleged disability onset date to June 1, 2022, claiming disability based on congestive heart failure, degenerative joint disease in both knees, obesity, and chronic headaches related to a 2012 gunshot wound to the head. The administrative law judge, or ALJ, found several impairments severe but concluded that T.S. retained the residual functional capacity (RFC)—her ability to perform work-related activities—for a reduced range of light work. The ALJ found that she could perform other jobs in the national economy and was not disabled.

Three physicians who assessed T.S.’s physical functioning limited her to sedentary work or less. The vocational expert testified that T.S. had no skills transferable to sedentary work. The court noted that, given T.S.’s age, education, and work history, a sedentary RFC would direct a finding of disability under Medical-Vocational Rule 201.14.

Medical-opinion analysis

The court held that the ALJ did not properly evaluate the opinions of Dr. Rose Lewis, Dr. B. Morgan, and Dr. Nancy Simpkins under 20 C.F.R. § 404.1520c. That regulation requires the ALJ to explain the opinions’ supportability—whether the opinions are backed by medical evidence and explanations—and consistency with the other evidence.

As to Dr. Lewis, the ALJ relied on normal strength and sensation findings and the absence of knee tenderness. The court found that this reasoning overlooked abnormal findings from the same examination, including obesity, an antalgic gait while using a cane, difficulty with tandem and toe-heel walking, knee swelling, ankle edema, and limited knee movement. The court also found that Dr. Lewis had explained the restrictions by referring to fatigue, heart failure, shortness of breath, knee osteoarthritis, balance problems, obesity, and effects of the gunshot wound.

The court also rejected the ALJ’s characterization of T.S.’s gait as often normal and the ALJ’s reliance on treatment gaps, missed follow-up, and medication noncompliance without considering documented reasons for those lapses. In addition, the ALJ failed to consider that Drs. Morgan and Simpkins independently reached materially similar sedentary-work assessments. The court held that the error was not harmless because crediting any of the opinions could change the disability determination.

Symptom testimony

The court held that the ALJ did not give sufficiently clear and convincing reasons for discounting T.S.’s testimony about the severity and effects of her symptoms. The ALJ relied principally on medication noncompliance, missed follow-up, gaps in treatment, and alleged improvement.

The court found that the ALJ did not address evidence that Lasix caused excessive urination associated with a genital rash, that T.S. had reported limited benefit from some knee treatments, or that providers referred her to complex-care management because of factors including her brain injury, posttraumatic stress disorder, ongoing substance use, and memory complaints. The court also found that the identified improvement concerned the heart condition and did not establish comparable improvement in the knee condition, headaches, or obesity. The ALJ must reassess the symptom testimony on remand.

Substance-use evidence

The ALJ’s decision did not mention T.S.’s substance use. The court found the evidence significant and potentially relevant because cardiologists identified stimulant use as the likely cause of her heart failure, therapy notes documented continuing use into late 2024, and substance use was included among the reasons for the complex-care referral.

On remand, the ALJ must determine whether the substance use is a medically determinable impairment and must consider it with T.S.’s posttraumatic stress disorder and brain injury at the relevant evaluation steps and when formulating the RFC. If the ALJ finds T.S. disabled after considering all impairments, the ALJ must then determine whether substance use is a contributing factor material to the disability determination. The court did not decide whether the substance-use issue alone required remand.

Disposition and remedy

The court did not reach T.S.’s separate argument that the RFC was legally deficient because it was based on the ALJ’s interpretation of raw medical data. The court said the RFC must be reconsidered after the medical opinions and symptom testimony are reevaluated.

The court found unresolved factual issues concerning the treatment lapses, cardiac improvement, medical opinions, and substance-use evidence. It therefore concluded that further administrative proceedings were appropriate rather than an immediate award of benefits.

The court granted T.S.’s motion, denied the Commissioner’s cross-motion, reversed the Commissioner’s final decision, and remanded under sentence four of 42 U.S.C. § 405(g). The ALJ must reevaluate the medical opinions, reassess T.S.’s symptom testimony, address the substance-use evidence, reassess the RFC, and reconsider the findings about past and other work, including obtaining additional vocational-expert evidence if warranted.