Webb v. Acting Commissioner of Social Security

Background

Stella Webb sought disability insurance benefits under Titles II and XVI of the Social Security Act for the period from April 10, 2010, through March 31, 2014. After a hearing at which Webb and a vocational expert testified, an Administrative Law Judge (ALJ) issued an unfavorable decision. The ALJ found that Webb had severe impairments including congestive heart failure, obesity, substance addiction disorder, depressive disorder, and a left ankle fracture. The ALJ determined that Webb could perform less than the full range of light work with limitations and concluded that she was not disabled. The Appeals Council denied review, and Webb sought review in the district court.

The parties filed cross-motions for summary judgment, which ask the court to decide whether the agency’s decision was legally valid and supported by the record.

Issues

The court identified an issue concerning the ALJ’s description of Webb’s severe ankle impairment. Webb’s covered period ended March 31, 2014, but the opinion stated that her left ankle fracture occurred later. The ALJ did not explain whether he meant a specific fracture or more general chronic left ankle pain during the covered period. The ALJ also relied on ankle-related evidence when discounting the opinion attributed to treating physician Dr. Jenny Cohen. The court therefore found it unclear what ankle impairment the ALJ considered.

Webb separately argued that the ALJ improperly gave more weight to the opinions of two non-examining state medical consultants and examining physician Dr. Jenna Brimmer than to Dr. Cohen’s opinion. The opinion’s footnote states that the medical source statement at issue appears to have been written by FNP Heather Rowley.

Analysis

The court held that the ALJ’s observation that Webb sat for longer than ten minutes at the hearing was not a specific and legitimate reason to reject the sitting limitation in the treating source’s opinion. The court compared this reasoning to the prohibition on relying solely on a claimant’s behavior at a hearing to reject alleged symptoms. But the court also held that this error alone did not require remand.

The court upheld the ALJ’s reliance on later imaging to discount the treating source’s standing and walking limitations. The ALJ reasonably inferred that the treating source had relied on a June 2015 ankle x-ray. The court found that an April 2016 radiology report and other records provided an adequate basis for the ALJ’s conclusion that later x-rays showed no fracture or significant degeneration. The court also found that the ALJ’s detailed review of the medical records satisfied the requirement to give specific and legitimate reasons for discounting a contradicted treating medical opinion.

The court further held that the ALJ did not err by giving great weight to the two non-examining state medical consultants. Their opinions were consistent with the clinical findings and opinion of Dr. Brimmer, so the court concluded that they constituted substantial evidence. Overall, the court concluded that the ALJ did not err in evaluating the medical evidence.

Disposition

The court determined that the unresolved ambiguity about the ankle impairment required remand. On remand, the ALJ must re-examine the Step Two finding that listed a left ankle fracture as a severe impairment and determine what ankle-related impairment existed during the covered period. If the ALJ finds a different severe ankle-related impairment during that period, the ALJ may need to reconsider the treating source’s opinion in light of that finding and the court’s analysis.

The court granted Webb’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further administrative proceedings. Because the court remanded on the ankle-impairment issue, it did not direct an immediate award of benefits.