Rosalinda M. v. Commissioner of Social Security

Background

Rosalinda M. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s final decision denying her disability-benefits application. She alleged disability beginning July 30, 2015, based primarily on osteoarthritis and fibromyalgia, along with other physical and mental impairments.

The Administrative Law Judge (ALJ) found that Rosalinda M. had severe impairments consisting of osteoarthritis in her hands, feet, knees, and back; obesity; and fibromyalgia. The ALJ found that high blood pressure and high cholesterol were not severe impairments and that the record did not establish a medically determinable mental impairment based on depression. The ALJ determined that Rosalinda M. could perform a limited range of light work, could not perform her past relevant work, but had transferable skills that allowed her to perform other jobs existing in significant numbers. The ALJ therefore found that she was not disabled.

The medical opinions included an assessment from Dr. Zuzana U. Foster, Rosalinda M.’s treating rheumatologist, that she had substantially greater limitations. Dr. Foster opined that Rosalinda M. could stand or walk for less than two hours in an eight-hour workday, would need frequent unscheduled breaks, had significant limitations in reaching, handling, and fingering, could not tolerate even low-stress work, and would miss more than four workdays per month. Consultative examining physician Dr. Satish K. Sharma gave a less restrictive assessment, and state-agency physicians concluded that Rosalinda M. could perform light work.

Court’s Analysis

The court held that the ALJ committed reversible error in evaluating the medical-opinion evidence concerning fibromyalgia and osteoarthritis. The ALJ gave Dr. Foster’s opinion limited weight because contemporaneous treatment records allegedly did not support the opinion’s extreme limitations and because the opinion appeared to rely heavily on Rosalinda M.’s reported symptoms.

The court found that the ALJ failed to address clinical findings from several physicians, including findings involving osteoarthritis, knee problems, knee instability, and severe osteoarthritis shown by imaging. The court also emphasized that fibromyalgia is diagnosed based on patients’ reports of pain and other symptoms and that the ALJ could not reject Dr. Foster’s opinion merely because the treatment course was periodic or conservative. The ALJ did not identify a viable, more invasive treatment that Dr. Foster could have pursued for fibromyalgia.

The court further held that the ALJ failed to give adequate reasons for crediting Dr. Sharma’s opinion over Dr. Foster’s. Although the two physicians’ examinations occurred during the same month, they recorded different findings. The ALJ relied on the consistency of Dr. Sharma’s opinion with his own examination but did not adequately explain how she resolved the conflict or account for Dr. Foster’s specialized rheumatology relationship with Rosalinda M. The court concluded that the ALJ did not identify substantial evidence supporting the choice to give Dr. Sharma’s opinion greater weight.

Because the medical-opinion error affected the assessment of Rosalinda M.’s reported symptoms and the step-four and step-five work findings, the court determined that the error was not harmless. The court did not reach Rosalinda M.’s other arguments concerning depression, pain evaluation, or the use of medical-vocational profiles because the medical-opinion error required remand.

Disposition

Rosalinda M. requested reversal and a remand for payment of benefits, or alternatively a remand for additional administrative proceedings. The court found that unresolved issues remained regarding the severity of her impairments and her functional limitations. Because the record did not establish that the ALJ would be required to find her disabled if the improperly discounted evidence were accepted, the court declined to order payment of benefits.

Judge Jacqueline Scott Corley granted Rosalinda M.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded for further proceedings. On remand, the ALJ must reassess the medical opinions and appropriately analyze the limitations caused by Rosalinda M.’s fibromyalgia and osteoarthritis at the later steps of the disability evaluation.