Chad S. v. Berryhill

Background

Chad S. applied for Social Security Disability Insurance benefits and Supplemental Security Income, alleging that he became unable to work because of a right-foot injury. The applications were denied initially and on reconsideration. After hearings, Administrative Law Judge T. Patrick Hannon found that Chad S. was not disabled. The administrative law judge identified a history of fractures of the right tarsal bones and obesity as severe impairments. The Appeals Council declined review, making the administrative law judge’s decision the Commissioner’s final decision.

Chad S. filed this federal action under 42 U.S.C. § 405(g). He moved for summary judgment, asking the court to reverse the Commissioner’s decision. The Commissioner cross-moved for summary judgment, asking the court to affirm it.

Issues

Chad S. argued that the administrative law judge improperly evaluated the opinions of treating physician Dr. Elizabeth McCraven and consultative examiner Dr. Ralph Wood. He also argued that the administrative law judge improperly rejected his testimony about the severity of his symptoms. He contended that these errors affected the assessment of his residual functional capacity—the most he could still do despite his impairments—and the finding at the fifth step of the disability analysis that he could perform other work.

Medical opinions

Dr. McCraven, Chad S.’s primary care physician since August 2015, opined that pain from a nonhealing metatarsal fracture limited his ability to stand and walk. She stated that he could stand or walk for about 15 minutes at a time and for less than two hours total in an eight-hour workday. She also opined that he would likely be off task for at least 25 percent of a typical workday, absent more than four days per month, and unable to perform even low-stress work because of pain-medication side effects.

The administrative law judge gave Dr. McCraven’s opinion only partial weight. The judge described the treatment as conservative, characterized imaging as showing stable and healing fractures, and found that some limitations were based on Chad S.’s subjective reports. Judge Ryu concluded that these reasons were inadequate. The record showed that Chad S. took prescription opioids, received periodic intravenous antibiotics for a chronic staph infection, and had been advised against surgery because of increased risk from diminished vascular status. The imaging cited by the administrative law judge also described a new fracture, new bone formation, swelling, and progressive demineralization rather than improvement. Judge Ryu held that the administrative law judge did not provide specific and legitimate reasons supported by substantial evidence for rejecting Dr. McCraven’s opinion.

Dr. Wood performed a consultative examination and gave limitations indicating that Chad S. could not stand for more than 15 minutes, walk for more than 10 minutes, or sit for more than two hours total in an eight-hour workday. The administrative law judge gave Dr. Wood’s opinion great weight and treated it as supporting sedentary work. Judge Ryu found the opinion ambiguous because Dr. Wood also stated that standing or walking for up to two hours might be possible but “might be stretching it.” The administrative law judge did not reconcile these statements or further develop the record. Judge Ryu concluded that Dr. Wood’s opinion did not support a finding that Chad S. could perform the full range of sedentary work.

Symptom testimony

Chad S. testified that he could walk only about four to ten yards at a time, needed a cane, and had to rest for 10 to 15 minutes. He also testified that he could sit for about 40 minutes before losing feeling in his feet and then needed to lie down for 10 to 15 minutes.

The administrative law judge rejected this testimony based on the same characterization of the medical evidence as conservative treatment and stable imaging. Judge Ryu found those characterizations inaccurate and concluded that the administrative law judge failed to provide specific, clear, and convincing reasons for rejecting Chad S.’s testimony.

Disposition

Judge Ryu held that the errors were not harmless because different evaluations of the medical opinions and testimony could result in a more restrictive residual functional capacity and affect the ultimate disability determination. The court granted Chad S.’s motion for summary judgment and denied the Commissioner’s cross-motion. On remand, the administrative law judge was to revisit the identified issues and make findings consistent with the order and applicable regulations.