David D. v. Saul

Background

David D. sought Title II Social Security disability benefits based on physical impairments including back pain, neck pain, and numbness and weakness in his extremities. He applied for benefits on April 12, 2016, alleging a disability onset date of March 8, 2013. The agency denied the application initially and again on reconsideration.

After a hearing on September 11, 2018, Administrative Law Judge Mary Parnow decided that David D. was not disabled. The administrative law judge found degenerative disc disease of the cervical and lumbar spine with lumbar radiculopathy to be a severe impairment, but found that the impairments did not meet or medically equal a listed impairment. She determined that David D. could perform less than the full range of sedentary work and could perform jobs existing in significant numbers in the national economy. The Appeals Council denied review, and David D. filed this action under 42 U.S.C. § 405(g).

The parties filed cross-motions for summary judgment. The court considered whether the administrative law judge properly evaluated medical equivalence, David D.’s symptom testimony, the medical opinions, and his residual functional capacity, which is the most work a person can still do despite limitations.

Medical Equivalence

The court held that the administrative law judge did not adequately evaluate whether David D.’s impairments met or medically equaled Listing 1.04(A), which concerns certain spinal disorders. The administrative law judge made only a general statement that the impairments did not meet or equal a listing. Her decision did not specifically analyze Listing 1.04(A), even though the record contained unclear findings concerning motor loss and straight-leg-raising tests. The court concluded that the administrative law judge needed to resolve those ambiguities and explain whether the listing was satisfied.

Symptom Testimony

The administrative law judge rejected David D.’s testimony about the severity and effects of his symptoms for two stated reasons: alleged gradual improvement with treatment and the conservative nature of his treatment.

The court found that the record did not support the claimed gradual improvement. It showed repeated reports of severe neck and lower-back pain over several years, along with evidence of both temporary improvement and worsening. The court concluded that the administrative law judge had relied selectively on some evidence and had not provided a specific, clear, and convincing reason to discount the testimony.

The court also found that the administrative law judge did not adequately consider David D.’s explanations for not pursuing certain treatments. David D. testified that doctors told him he was not a surgical candidate because of his age, and the records stated that he declined epidural steroid injections because he feared permanent neurological damage. Because the administrative law judge did not address those explanations, the court held that the conservative-treatment rationale was inadequate.

Medical Opinions

The court upheld the administrative law judge’s decision to give limited weight to workers’ compensation evaluations because many were temporary, addressed the ability to perform a particular job at a particular time, and contained changing limitations rather than a consistent long-term assessment.

The court held, however, that the administrative law judge did not properly address parts of consultative examiner Dr. Pon’s opinion. The administrative law judge gave the opinion substantial weight but did not include, or explain why she rejected, Dr. Pon’s finding that David D. could walk and climb steps only at a slow pace. The court held that this pace limitation was meaningful and had to be included in the residual functional capacity assessment or rejected with an explanation.

The court also held that the administrative law judge lacked adequate reasons for giving greater weight to the opinion of non-examining medical expert Dr. Urbaniak than to Dr. Pon, who examined David D. The reasons given—consistency with the record and review of much of the medical evidence—did not explain why Dr. Urbaniak’s opinion deserved more weight than Dr. Pon’s opinion.

Regarding treating physician Dr. Yoshida, the court agreed that the administrative law judge could discount opinions about David D.’s walking ability and need to walk because those statements were internally inconsistent and inconsistent with the record. The court also agreed that the date Dr. Yoshida selected as the beginning of the limitations did not establish a significant change in symptoms. But the court held that the administrative law judge did not give sufficiently specific and legitimate reasons for discounting other parts of Dr. Yoshida’s opinion, including limitations involving sitting, standing, walking, neck position, and medication side effects.

Disposition

Because the medical-equivalence finding, symptom evaluation, and consideration of medical opinions were not supported by substantial evidence, the court held that the administrative law judge’s decision could not stand. The court did not decide David D.’s additional challenge to the residual functional capacity finding.

David D. requested either an award of benefits or a remand for further proceedings. The court chose further proceedings because the record was not fully developed, unresolved questions remained concerning the listing and the effects of the improperly evaluated evidence, and the vocational expert had not been asked questions addressing several of the relevant limitations. The court therefore granted Plaintiff’s motion, denied Defendant’s cross-motion, and remanded for further proceedings. It did not award benefits.