S.L. v. Kijakazi

Background

S.L. appealed the Commissioner of Social Security’s denial of her application for Disability Insurance Benefits. She alleged that fibromyalgia, migraines, degenerative disc disease, obesity, depression, and anxiety prevented her from working. The administrative law judge found four severe impairments—fibromyalgia, migraine headaches, obesity, and degenerative disc disease of the cervical and lumbar spine—but found her depression and anxiety non-severe. The administrative law judge determined that S.L. had the residual functional capacity (RFC), meaning the most she could still do despite her limitations, to perform light work. Based on vocational-expert testimony, the administrative law judge found that she could return to her past work as a general office clerk or perform other jobs, including parking lot attendant and mailroom clerk.

This was the second administrative law judge decision in the matter. After an earlier remand for further proceedings, a new hearing was held and a new decision again found S.L. not disabled. S.L. then sought judicial review under 42 U.S.C. § 405(g).

Court’s Analysis

The court reviewed whether the Commissioner’s decision was supported by substantial evidence—relevant evidence that a reasonable person could accept as adequate—and was free of legal error.

The court held that the administrative law judge improperly discounted the opinion of S.L.’s treating physician, Dr. Washington. Dr. Washington stated that S.L.’s pain and other symptoms would substantially limit sitting, standing, walking, lifting, hand use, and her ability to maintain a regular work schedule. He also opined that she would need two to four additional breaks each day. The administrative law judge gave this opinion little weight, citing incomplete or illegible treatment notes, unclear diagrams, uncertainty about who wrote some notes, and other records showing normal gait, strength, reflexes, and range of motion.

The court held that these reasons were not legally sufficient. Fibromyalgia is diagnosed largely through a patient’s reports of pain and related symptoms, and normal strength, reflexes, gait, and range of motion can be consistent with disabling fibromyalgia. The court also found that Dr. Washington’s records repeatedly documented pain and that his medical source statement identified 15 positive tender points. The administrative law judge therefore failed to provide the required clear and convincing or specific and legitimate reasons for rejecting Dr. Washington’s opinion.

The court separately held that the administrative law judge improperly evaluated S.L.’s testimony about her symptoms. Although the administrative law judge summarized medical evidence and concluded that S.L.’s symptoms were less limiting than she alleged, the judge did not identify which specific testimony was not credible or explain which evidence contradicted it. That failure was legal error.

The court found no error in the administrative law judge’s treatment of the mental-health evidence. The administrative law judge could find anxiety non-severe because the mental-health sources identified only mild limitations, and the judge was not required to add a specific work restriction based on those mild limitations. The court also upheld the decision to give S.L.’s brother’s report less weight because he saw her only once a week. However, the court stated that the alleged conflict between his report and evidence of normal physical functioning was not a valid reason because it rested on the same misunderstanding of fibromyalgia.

Relief and Disposition

The court applied the “credit-as-true” rule, under which a court may award benefits rather than order more administrative proceedings when the record is fully developed, the administrative law judge gave legally insufficient reasons for rejecting evidence, and accepting that evidence would require a finding of disability. The court found all three conditions satisfied. The record included extensive treatment records, medical opinions, S.L.’s reports and testimony, and her brother’s report. The court also concluded that Dr. Washington’s opinion, if credited, established disability, and the vocational expert had testified that the stated limitations would prevent S.L. from returning to past work or performing other available jobs.

The court granted S.L.’s motion for summary judgment, denied the Commissioner’s motion for summary judgment, and remanded the matter for calculation and award of benefits.