Stephanie R. v. Kijakazi

Background

Stephanie R. sought judicial review of an administrative law judge’s decision denying her applications for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. She alleged that her disability began on January 1, 2004. The Social Security Appeals Council denied review, making the administrative law judge’s decision the final agency decision subject to review by the district court.

The administrative law judge found at the second step of the required five-step disability process that Stephanie R. had somatic disorder, adjustment disorder, and substance abuse, but that none of those impairments was severe. The administrative law judge ended the analysis at that point and found that Stephanie R. was not disabled.

The record included evidence of chronic pain and fibromyalgia, arthritis, shoulder and spinal conditions, scoliosis, a degenerative cyst, bipolar or schizoaffective disorder, insomnia, anxiety, depression, panic attacks, impaired cognitive functioning, somatic symptom disorder, and syncope. The opinion also describes testimony and reports concerning pain, limited movement, use of braces, a cane, and a walker, difficulty with personal care, and reduced social activity.

Issues and Positions

Stephanie R. argued that the administrative law judge failed to adequately develop the record and improperly ended the evaluation at step two. She specifically argued that the administrative law judge failed to assess numerous diagnosed impairments, improperly rejected treating physicians’ opinions while relying on a state examining physician, and concluded without substantial evidence that all her impairments were non-severe.

Kijakazi argued that the administrative law judge committed no reversible error. Kijakazi also argued that the administrative law judge had no further duty to develop the record because Stephanie R. had the burden of proving disability, was represented at the administrative hearing, the Social Security Administration had searched for medical records, and three consultative examinations were already in the record.

Court’s Analysis

A district court may set aside a denial of Social Security benefits if it is not supported by substantial evidence or is based on legal error. “Substantial evidence” means relevant evidence that a reasonable person could accept as adequate to support a conclusion. At step two, an impairment is not severe only when the evidence clearly establishes that it has no more than a minimal effect on the claimant’s ability to perform basic work activities. The court described step two as a limited screening step for groundless claims.

The court held that the administrative law judge failed to fully and fairly develop the record. The record lacked information concerning treatment by a rheumatologist for fibromyalgia and treatment for somatic symptom disorder. The administrative law judge did not seek additional records or opinions, did not contact the rheumatologist, did not refer Stephanie R. to a rheumatology specialist for a consultative examination, and relied on incomplete consultative evaluations.

The court also held that the administrative law judge improperly omitted or inadequately evaluated multiple diagnosed conditions. The administrative law judge did not mention or evaluate arthritis, supraspinatus tendinosis, a herniated disc, scoliosis, a degenerative cyst, insomnia, panic attacks, depression, anxiety, and syncope. The court found that the evidence of chronic pain, fibromyalgia, physical conditions, and mental-health conditions was enough to pass step two’s limited screening threshold.

The court further concluded that the administrative law judge’s reasons for rejecting Stephanie R.’s complaints did not meet the required clear-and-convincing standard. The administrative law judge relied on activities such as grocery shopping, driving, personal care, limited work activity, participation in the hearing, cooperation during examinations, and improvement with depression medication. The court explained that these activities did not establish that Stephanie R.’s claims were groundless, particularly because medical records documented physical abnormalities and fluctuating psychological symptoms.

Disposition

The court granted Stephanie R.’s motion for summary judgment and denied Kijakazi’s cross-motion. It remanded the case for further proceedings so that the administrative law judge could fully develop the record and conduct a proper step-two analysis. The court stated that it was unclear whether Stephanie R. would ultimately prove that she was disabled and entitled to benefits.