Contreras v. Berryhill

Background

Christopher Contreras sought judicial review under 42 U.S.C. § 405(g) of the Commissioner’s final decision denying his application for Title II disability benefits. Contreras had alleged that his disability began on June 7, 2013. After the Social Security Administration denied his application initially and on reconsideration, an administrative law judge held a hearing and denied the application. Contreras then brought this action and requested payment of benefits or, alternatively, further proceedings.

Both sides moved for summary judgment. Summary judgment is a procedure for deciding a case when the material facts do not require a trial. In reviewing the disability decision, the court considered whether the administrative law judge made a legal error or reached findings unsupported by substantial evidence, meaning relevant evidence that a reasonable person could accept as adequate.

Issues and Analysis

Contreras raised three issues: whether the administrative law judge failed to consider his chronic pain syndrome when determining his residual functional capacity; whether the judge improperly evaluated medical opinions; and whether the judge failed to address Contreras’s concentration problems.

Chronic pain syndrome. The administrative law judge identified degenerative disc disease of the lumbar spine as a severe impairment but did not specifically address chronic pain syndrome. The decision summarized medical findings, medical opinions, third-party statements, and Contreras’s testimony concerning his pain and the effect of pain on his ability to work. The court held that the failure to specifically consider chronic pain syndrome was an error. The court rejected the Commissioner’s argument that the error was harmless, noting that Contreras identified additional limitations, including concentration problems, and that many of the limitations discussed in the record were directly attributed to pain.

Medical opinions. The court held that the administrative law judge did not provide legally sufficient reasons for giving little weight to the opinions of Contreras’s treating physician, John Massey, M.D. Dr. Massey had opined that Contreras could sit, stand, and walk for limited periods, needed a sit-stand option, faced lifting and postural restrictions, and would miss more than four days of work per month. The administrative law judge relied partly on the absence of observations about muscle weakness. The court found that rationale unpersuasive because Dr. Massey’s limitations were based on pain, not muscle weakness.

The administrative law judge also relied on an apparent discrepancy concerning whether the limitations began in February 1995, even though Contreras continued working until 2013. The court said that discrepancy might justify rejecting Dr. Massey’s opinion about when the limitations began, but it was not by itself a reason to reject the rest of his opinion. Finally, the administrative law judge characterized Contreras’s treatment as generally conservative. The court disagreed, pointing to treatment that included intradiscal electrothermal therapy, stem cell therapy, and multiple series of trigger-point injections. The court concluded that the administrative law judge had not identified specific, legitimate reasons supported by substantial evidence for discounting Dr. Massey’s opinions.

The court reached a similar conclusion regarding the state-agency doctors. Those doctors had found that Contreras could stand or walk for three hours in an eight-hour workday and had various restrictions on balancing, stooping, kneeling, crouching, crawling, and climbing. The administrative law judge discounted their opinions based on the allegedly conservative nature of Contreras’s impairments and records describing his gait as stable, coordinated, and smooth. The court found that these reasons did not adequately address the doctors’ opinions, which considered pain and the ability to sustain activities over an eight-hour workday.

Concentration. The court rejected Contreras’s challenge to the administrative law judge’s treatment of concentration. The administrative law judge found only a mild limitation and relied on Contreras’s ability to manage financial tasks, participate in a weekly podcast, research its subject, work on patents, and care for his son. The court held that Contreras had not shown that this interpretation of the evidence was irrational. It therefore found no error in excluding concentration limitations from the residual functional capacity assessment.

Disposition

Judge Westmore granted Contreras’s motion for summary judgment and denied the Commissioner’s cross-motion for summary judgment. The court remanded the case for further proceedings because it was not clear that properly evaluating all the evidence would necessarily require a finding that Contreras was disabled. On remand, the administrative law judge must properly evaluate the medical evidence under applicable law and consistently with the opinion.