Deborah M. v. Berryhill

Background

Deborah M. applied for Social Security Disability Insurance benefits. The Social Security Administration denied her application, and an administrative law judge (ALJ) later found that she was not disabled. The ALJ determined that she had severe impairments including degenerative disc disease, osteoarthritis of the left hip, morbid obesity, and complex regional pain syndrome (CRPS). The ALJ assessed a residual functional capacity (RFC)—an estimate of the work a person can still perform—and concluded, based on vocational-expert testimony, that Deborah M. could perform her past work as a personnel clerk.

Deborah M. represented herself and moved for summary judgment, asking the court to reverse the administrative decision. The Commissioner cross-moved to affirm it.

Medical-opinion evidence

The court held that the ALJ improperly discounted the opinions of Deborah M.’s treating neurologist, Dr. Steven Schadendorf, who had treated her since 2011. Dr. Schadendorf described significant limitations caused by pain, numbness, weakness, and CRPS, including limits on sitting, standing, walking, lifting, concentration, and attendance.

The court found that the ALJ incorrectly treated parts of Dr. Schadendorf’s 2013 opinion as internally inconsistent. For example, the fact that Deborah M. did not need a cane did not contradict an opinion that pain limited how long she could walk. The court also found that the ALJ mischaracterized Dr. Schadendorf’s statements about lifting and upper-extremity use.

The ALJ also relied on generally normal strength, reflexes, coordination, imaging, and testing to discount the 2017 opinion. The court ruled that this analysis did not properly account for Social Security Ruling 03-2p, which provides guidance for evaluating CRPS. The ruling recognizes that CRPS can produce severe pain even when objective findings are limited or temporary and emphasizes the importance of the longitudinal medical record, including treatment, response to treatment, and functional limitations over time. The court concluded that the ALJ had not provided the required specific and legitimate reasons, supported by substantial evidence, for rejecting Dr. Schadendorf’s opinions about Deborah M.’s limitations.

The court agreed that one part of the 2017 statement appeared contradictory: Dr. Schadendorf answered that Deborah M. did not have significant limitations in reaching, handling, or fingering but also indicated that she could rarely or never reach with her arms. However, the court said it was unclear whether this inconsistency was material to the ALJ’s decision and directed the ALJ to reconsider the issue on remand. The court also held that the ALJ properly disregarded Dr. Schadendorf’s opinion that Deborah M. could not perform full-time competitive work because that ultimate disability determination is reserved to the Commissioner.

Deborah M.’s symptom testimony

The court also held that the ALJ did not provide adequate reasons for partially rejecting Deborah M.’s testimony about the severity and effects of her symptoms. The ALJ relied on medical evidence and daily activities, but the court rejected the medical-evidence reasoning for the same reasons it rejected the analysis of Dr. Schadendorf’s opinions.

The court further found that the ALJ mischaracterized Deborah M.’s testimony about driving and using her arms. She did not testify that she was completely unable to drive or use her arms; she testified that those activities increased her pain and could not be sustained for long periods. The court found that this testimony was consistent with her reports of driving her son to activities and experiencing pain while doing computer work and washing dishes. The ALJ therefore did not provide clear and convincing reasons for discrediting her testimony.

Disposition

The court did not reach Deborah M.’s arguments about the RFC assessment or the vocational expert’s testimony because the errors concerning the medical opinions and her symptom testimony could affect later steps of the disability analysis. The court granted Deborah M.’s motion for summary judgment, denied the Commissioner’s cross-motion, directed the clerk to enter judgment for Deborah M. and against the defendant, closed the case, and remanded the matter for further proceedings consistent with the order.