Debra Rowe v. Andrew Saul

Background

Debra Rowe sought judicial review of the Commissioner of Social Security’s final decision denying her applications for disability insurance benefits and supplemental security income. The administrative law judge found that Rowe had not been disabled from March 24, 2015, through the date of the decision. The judge determined that Rowe could perform light work with certain limits and could perform her past work as a waitress, bartender, and cashier. Alternatively, the judge found that she could perform other jobs identified by a vocational expert.

The parties filed cross-motions for summary judgment. Rowe argued that the administrative law judge improperly evaluated medical opinions, her own testimony, and testimony from her friend and roommate. The Commissioner sought affirmance of the benefits denial or, alternatively, a remand for further proceedings.

Court’s analysis

The court reviewed whether the administrative law judge’s decision was supported by substantial evidence, meaning relevant evidence that a reasonable person could accept as adequate, and whether the judge applied the correct legal standards.

The court upheld the administrative law judge’s decision to give no weight to the opinion of examining physician assistant Chris Buschar because the assessment cited no objective findings, was prepared without treatment records, and followed an examination with normal findings.

The court found that the administrative law judge had evaluated an opinion that non-examining physician Dr. Trula Thompson did not actually make. Dr. Thompson stated that Rowe did not appear likely to meet the severity criteria for supplemental security income and disability benefits but did not affirmatively determine Rowe’s physical residual functional capacity, meaning what she could still do despite her limitations.

The court also found problems with the evaluation of treating physician Dr. Tatiana Antoci’s opinions. For the February 2017 assessment, the administrative law judge incorrectly characterized the opinion as unsupported by examination findings and self-reports, even though it cited examination findings, diagnostic testing, magnetic-resonance imaging, spinal injections, and a range-of-motion chart. Regarding Dr. Antoci’s March 2018 assessment, the court found that some reasons for discounting the opinion were improper, including the judge’s focus on normal neurological findings while ignoring repeated findings of decreased and stiff lumbar range of motion, the alleged lack of observations of Rowe in distress, and activities that did not show her current work capacity. The court nevertheless found that the administrative law judge could discount the assessment because its extreme limitations lacked adequate explanation and because Dr. Antoci had noted that Rowe was malingering multiple symptoms.

The decisive error involved non-examining agency medical consultant Dr. Guillermo Rubio. The administrative law judge gave Dr. Rubio’s February 2017 assessment the most weight, but that assessment predated substantial later evidence, including an April 2017 cervical-spine magnetic-resonance image, a March 2018 lumbar-spine magnetic-resonance image, much of Dr. Antoci’s treatment history, five emergency-room visits, and later neurosurgical reports. The court held that Dr. Rubio’s opinion therefore did not provide substantial evidence supporting the administrative law judge’s residual-functional-capacity finding. Because the administrative law judge relied exclusively on that assessment for the light-work finding and related limits, the error was harmful.

Disposition

The court held that it could not determine from the record whether Rowe was actually disabled. It therefore chose further proceedings rather than ordering an immediate award of benefits. The court directed the administrative law judge to obtain additional medical opinion evidence about Rowe’s physical functioning from a consultative examiner or medical expert and to further develop the record as necessary. The court also stated that, on remand, the administrative law judge should reevaluate the assessment of testimony from Rowe and Sandra Russell.

Judge Yvonne Gonzalez Rogers granted Rowe’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further administrative proceedings. The court directed entry of judgment for Rowe and closed the case.