J.B. v. Saul

Background

J.B. sought judicial review of the Commissioner of Social Security’s decision denying his application for supplemental security income under Title XVI of the Social Security Act. He alleged disability based on diabetes, low back pain or sciatica, neuropathy, and later-reported mental-health conditions. The administrative law judge found severe impairments consisting of lumbar degenerative disc disease with neuropathy and low back pain.

The administrative law judge found that J.B. could not perform his past work, but could perform other jobs existing in significant numbers in the national economy, including cashier, ticket seller, and information clerk. The Appeals Council declined review, and J.B. filed this case. The parties filed cross-motions for summary judgment, which asks the court to decide whether the administrative decision was legally and factually supported.

Medical opinions

The court held that the administrative law judge’s decision to find the state-agency consultants’ opinions only “somewhat persuasive” was narrowly supported by substantial evidence. Those opinions predated later evidence, including a May 2019 magnetic-resonance imaging scan showing severe facet arthritis and severe central spinal stenosis, and a June 2019 examination showing an antalgic gait, a positive right-sided straight-leg raise, and diagnoses of lumbar stenosis with neurogenic claudication and lumbar facet arthropathy.

The court reached a different conclusion about Sharonne Rogers’s October 2019 opinion. Ms. Rogers opined that J.B. had substantial limits on standing, walking, sitting, changing positions, lying down during the workday, performing postural activities, tolerating environmental conditions, and attending work. The administrative law judge discounted the opinion for several reasons, including an inconsistency about lifting 20 pounds occasionally and 25 pounds frequently, purportedly excessive restrictions, and insufficient support for limitations involving pushing, pulling, and absences.

The court found that most of those reasons were not supported by substantial evidence. The treatment records were not “sparse,” and they included repeated reports of severe or worsening back and leg pain, instructions to avoid extended sitting or standing and lifting or pulling, physical-therapy records describing excruciating pain, and imaging showing severe spinal stenosis. The court acknowledged the lifting inconsistency but concluded that the rest of the opinion was generally consistent with the medical record. The administrative law judge therefore erred in finding Ms. Rogers’s opinion only “somewhat persuasive.”

J.B.’s testimony

The court also found that the administrative law judge did not give sufficiently clear and convincing reasons for rejecting J.B.’s testimony about his symptoms and limitations. The administrative law judge relied on some records showing improvement with medication, a normal-appearing December 2018 x-ray, full motor strength at one examination, a reported pain level of zero at one visit, and J.B.’s decision not to receive steroid injections.

The court found that this reasoning selectively relied on evidence and did not account for contrary evidence. The records also described worsening and radiating pain, restrictions on lifting and prolonged sitting or standing, positive examination findings, severe abnormalities on the May 2019 magnetic-resonance imaging scan, and high pain levels. The court further found that declining injections because of their inherent risks did not establish that J.B.’s testimony conflicted with the medical evidence.

Listed impairment

The court found the administrative law judge’s brief explanation for concluding that J.B.’s impairments did not meet or medically equal a listed impairment was unsupported by substantial evidence. The court stated that the administrative law judge needed to adequately explain the evaluation of alternative tests and the combined effects of the impairments.

The court also noted evidence relevant to Listing 1.04(C), as it existed when the administrative law judge issued the decision: the magnetic-resonance imaging scan showed severe central spinal stenosis and bilateral lateral recess stenoses; physicians diagnosed lumbar stenosis with neurogenic claudication; and J.B. testified that he used a cane and needed to rest while walking. On remand, the administrative law judge must reconsider whether J.B. meets a listed impairment. The court did not find that J.B. was disabled under the listing.

Residual functional capacity

Residual functional capacity is the most a person can still do despite medically supported limitations. The court rejected J.B.’s argument that the administrative law judge was required to give one medical opinion controlling weight, because the applicable regulations do not require deference or a specific evidentiary weight for medical opinions.

Nevertheless, the court required a new residual-functional-capacity assessment. The existing assessment did not fully incorporate Ms. Rogers’s limitations or J.B.’s testimony because the administrative law judge had discounted both. Since those discounting decisions were not supported by substantial evidence, the resulting residual functional capacity was also unsupported.

Disposition

The court held that the standard for ordering immediate payment of benefits was not satisfied because unresolved issues remained. It therefore granted J.B.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further administrative proceedings. The administrative law judge must reconsider Ms. Rogers’s opinion, J.B.’s testimony, whether J.B. meets a listed impairment, and J.B.’s residual functional capacity. The court did not order immediate payment of benefits.