Bass v. Berryhill

Background

Demetta Bass applied for Supplemental Security Income under Title XVI of the Social Security Act. The Social Security Administration denied her application, and an administrative law judge later found that she was not disabled. The administrative law judge found severe impairments of obesity, asthma, an affective disorder, an anxiety disorder, and a substance-abuse disorder. He determined that Bass could perform medium work with certain limitations and, relying on vocational-expert testimony, found that she could perform jobs including assembler, hand packager, and machine feeder. The Appeals Council denied review, making the administrative law judge’s decision the Commissioner’s final decision.

Bass sought judicial review and argued that the administrative law judge erred in evaluating the severity of her impairments, medical opinions, lay testimony, her statements about her symptoms, her residual functional capacity, and the vocational-expert testimony. The court reviewed whether the decision was based on legal error or supported by substantial evidence, meaning evidence that could lead a reasonable person to accept the conclusion.

Step-Two Findings and Residual Functional Capacity

At the second step of the disability analysis, the administrative law judge must identify impairments that significantly limit basic work activities. Bass argued that post-traumatic stress disorder, diabetes, back pain, obstructive sleep apnea, and migraines should also have been classified as severe impairments.

The court held that the administrative law judge erred by finding that Bass’s back pain and diabetes were not severe impairments. The record included reports of back pain, spinal abnormalities shown by magnetic-resonance imaging, a referral for physical therapy, and a medical opinion that assessed physical limitations partly based on back pain. The record also included reports of tingling, numbness, and swelling related to diabetes, including symptoms while Bass was taking medication. The administrative law judge did not account for these conditions when assessing Bass’s residual functional capacity, or RFC—the most a claimant can still do despite her impairments.

The court found harmless the administrative law judge’s failure to separately classify post-traumatic stress disorder, sleep apnea, and migraines as severe impairments. The administrative law judge considered Bass’s mental symptoms generally, the record contained little evidence that sleep apnea affected her ability to work, and the record did not show how migraines limited her work-related functioning. The court directed the administrative law judge to revisit the step-two analysis and the RFC assessment on remand.

Medical Opinions

The court rejected Bass’s argument that the administrative law judge was required to weigh ordinary treatment notes as medical opinions concerning physical limitations. The treating sources identified by Bass had not offered opinions about her work-related functional limitations. The court also found that the administrative law judge was not required to assign specific weight to treatment notes from Meilin Mehri, Psy.D., because those notes recorded observations and diagnoses rather than functional limitations.

The court held, however, that the administrative law judge did not give adequate reasons for discounting the mental-health assessment prepared by Kari Jennings-Parriott, LCSW, and co-signed by Ted Aames, Ph.D. The court found no record basis to treat Dr. Aames as a treating source, but concluded that Jennings-Parriott’s assessment was from an “other source” and therefore required germane, meaning relevant and specific, reasons for rejection. The administrative law judge’s characterization of the records as showing stable mental states, few interaction problems, and generally normal cognition was not supported by the record. The treatment notes instead documented depression, anxiety, impaired judgment and insight, abnormal thought processes, mood instability, and interpersonal problems.

The court also found that the administrative law judge erred in giving great weight to the opinion of consultative examiner Philip Sack, M.D. The reasons given for crediting that opinion relied on the same unsupported characterization of Bass’s mental-health records. The court directed the administrative law judge to reconsider all medical opinions.

The court rejected Bass’s argument that the administrative law judge erred merely by failing to address a later assessment from Van Nguyen, M.D., because that assessment was submitted to the Appeals Council after the administrative law judge’s decision. The court nevertheless considered the assessment as part of the administrative record and found that it might materially affect the disability determination, particularly because it addressed which symptoms improved with medication and which continued.

Other Arguments and Disposition

The court did not resolve Bass’s arguments about the testimony of Cassandra Attaway, Bass’s statements about her symptoms, or the vocational-expert testimony. Those issues could change after the administrative law judge reassesses the impairments, medical opinions, and RFC.

The court granted in part Bass’s motion for summary judgment, denied the Commissioner’s cross-motion, and remanded the case for further proceedings. The remand required the administrative law judge to reconsider the identified issues consistently with the order and applicable regulations.