Susan W. v. Kijakazi

Background

Susan W. sought review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s decision that she was not disabled during the period from January 1, 2017, through May 26, 2019. She had previously been found disabled because of end-stage liver disease. After a continuing disability review, the agency found that she was no longer disabled as of January 1, 2017. An administrative law judge later found that her disability ended on that date but that she became disabled again on May 26, 2019, when she reached an age category described in the regulations as “advanced age.”

The administrative law judge found that Susan W. had several severe impairments, including liver cirrhosis, portal hypertensive gastropathy, gastric antral vascular ectasias, type 2 diabetes, hepatic encephalopathy, and a right-wrist condition following surgery. The judge found that she could perform light work with limitations from January 1, 2017, until May 26, 2019, but could not perform her past relevant work. The judge concluded that she could perform other jobs existing in significant numbers in the national economy during that period.

Susan W. and the Commissioner filed cross-motions for summary judgment. Summary judgment is a decision based on the written record when there is no legally significant dispute requiring a trial.

Court’s Analysis

Medical opinions. The administrative law judge gave the greatest weight to the opinion of Dr. Tanaka, a physician who did not examine or treat Susan W.; partial weight to Dr. Dipsia’s opinion; and little weight to Dr. Cataldo’s opinion. Dr. Cataldo, a treating physician, had opined that Susan W. could not work because of fatigue, medication-related bathroom breaks, naps, and possible episodes of confusion or delirium.

The court held that the administrative law judge properly discounted Dr. Cataldo’s opinion. The judge reasonably found that the opinion was inconsistent with Dr. Cataldo’s treatment notes, which described Susan W.’s liver disease as stable, noted generally normal examinations, and described her as doing well with a healthy lifestyle and conservative treatment. The court therefore concluded that the medical-opinion analysis was supported by substantial evidence, meaning relevant evidence that a reasonable decision-maker could accept.

Susan W.’s symptom testimony. The administrative law judge found that Susan W.’s impairments could reasonably cause the symptoms she described, including weakness, confusion, nausea, fatigue, right-arm pain, stress, headaches, and stomach pain. Because the judge identified no evidence of malingering, the judge could reject Susan W.’s testimony about the severity of those symptoms only by giving specific, clear, and convincing reasons.

The court found that the administrative law judge did not meet that requirement. The judge stated only that Susan W.’s statements were not fully supported “for the reasons explained in this decision.” The court held that this boilerplate explanation was not specific enough. The medical evidence cited elsewhere in the decision also did not provide a sufficient reason to reject the testimony because it substantially corroborated the symptoms Susan W. described. The court further found that arguments about conservative treatment were unpersuasive because many of the symptoms were documented side effects of treatment for her liver disease and diabetes.

Third-party statement. Susan W. argued that the administrative law judge should have considered a function report submitted by her husband in 2008. The court held that the judge was not required to consider that report because it had already been considered in the earlier disability determination and the current review concerned Susan W.’s impairments at the later time.

Remedy. The court held that the error concerning Susan W.’s symptom testimony was not harmless because it affected the heart of the disability determination. The court declined to order immediate payment of benefits. The record was not fully developed, and it was not clear that properly crediting Susan W.’s testimony would require a finding that she was disabled. The administrative law judge therefore had to reconsider the residual functional capacity—the most a person can still do despite her limitations—in light of that testimony.

Disposition

The court GRANTED Susan W.’s motion for summary judgment, DENIED the Commissioner’s cross-motion, and REMANDED the case to the Commissioner for further proceedings consistent with the order. The order disposed of Docket Nos. 27 and 30.