Steven M. v. Andrew M. Saul

Background

Steven M. sought judicial review of an administrative law judge’s decision denying his application for Social Security disability insurance benefits under Title II of the Social Security Act. The Appeals Council denied review, making the administrative law judge’s decision the Commissioner’s final decision for purposes of district-court review. Both parties filed motions for summary judgment, which ask the court to decide the case based on the administrative record and applicable law.

The record described poorly controlled diabetes, vision problems, heart disease, two heart attacks, coronary stent procedures, chronic dizziness, fatigue, shortness of breath, and balance problems. Steven M.’s treating physician, Dr. Ton Hoang, directed that he be placed off work from October 2015 through August 2016. Steven M. and his mother also submitted reports describing significant limits caused by his dizziness and shortness of breath.

Parties’ arguments and administrative decision

Steven M. argued that the administrative law judge failed to properly develop the record concerning his persistent dizziness, fatigue, and shortness of breath and Dr. Hoang’s work restriction. He also argued that the administrative law judge improperly rejected medical opinions and testimony and that the finding at the final step of the disability analysis was not supported by substantial evidence. Saul argued that Dr. Hoang’s statement was clear, that further development was unnecessary, and that the administrative law judge’s evaluation of the evidence, residual functional capacity, and final-step finding was supported by substantial evidence.

The administrative law judge found severe impairments including coronary artery disease, diabetes with high blood sugar, chronic renal insufficiency, and diabetic neuropathy. The judge assessed a capacity for sedentary work with additional restrictions, found that Steven M. could not perform his past relevant work, and concluded at the fifth step that he could perform jobs such as document preparer or bench hand.

Court’s analysis

The court held that the record was inadequately developed. It found unclear why Dr. Hoang concluded that Steven M. could not work during 2015 and 2016, whether that inability continued after August 2016, and how Steven M.’s continuing dizziness, fatigue, and shortness of breath affected his ability to work, including in sedentary employment. The court noted that the administrative law judge had not substantially explored these issues with Steven M. or the testifying medical expert.

Because the record was insufficient for the court to determine whether the residual functional capacity and fifth-step determination were supported by substantial evidence, the court ordered further proceedings. On remand, the administrative law judge must hold a second hearing, contact Dr. Hoang by subpoena or other means to resolve the work-restriction issues, seek an opinion from Dr. Hoang or another treating physician about the functional effects of Steven M.’s symptoms, and obtain more substantial testimony from Steven M. about those symptoms. The court declined to decide Steven M.’s remaining issues because they could be addressed on remand and might be affected by the further proceedings.

Disposition

Judge Robert M. Illman granted Steven M.’s motion for summary judgment, denied Saul’s cross-motion, and remanded the case for further proceedings under the stated instructions. The court did not add a with-prejudice or without-prejudice designation.