R.S. v. Kijakazi

Background

R.S. applied for supplemental security income under Title XVI of the Social Security Act, alleging disability beginning January 7, 2016. He identified paranoid schizophrenia, bipolar disorder, depression, insomnia, a right-arm gunshot wound, breathing difficulty, lack of equilibrium, a neck injury, and attention deficit hyperactivity disorder. The Social Security Administration denied the application initially and on reconsideration. After a hearing at which R.S. did not appear but his attorney did, the administrative law judge denied the claim. The Appeals Council denied review, making the administrative law judge’s decision the Commissioner’s final decision.

The administrative law judge found at step one that R.S. had not engaged in substantial gainful activity since he filed his application. At step two, the judge found medically determinable schizophrenia-spectrum disorder and polysubstance abuse, but concluded that neither impairment was severe and that R.S. had no severe impairment or combination of impairments. The judge found no limitations in the four broad areas used to evaluate mental impairments and denied the claim at step two without addressing the later steps.

R.S.’s Arguments

R.S. argued that the administrative law judge failed to consider treatment providers’ observations and diagnoses, failed to consider possible reasons for his limited treatment and missed consultative examinations, failed to evaluate his impairments in combination, and failed to discuss his alleged brain disorder and post-traumatic stress disorder. He also argued that he met or equaled listed impairments and that any residual functional capacity assessment was unsupported. He requested reversal and an award of benefits, or alternatively a remand for further proceedings.

Court’s Analysis

The court held that the administrative law judge properly found no medically determinable physical impairment. Although R.S. had received treatment for gunshot wounds and a dirt-bike accident, the records did not document resulting functional impairment. The court also held that the evidence did not establish bipolar disorder or attention deficit hyperactivity disorder because those diagnoses appeared only in R.S.’s reports of prior diagnoses. The record did not establish post-traumatic stress disorder; the court noted that the only reference to it indicated that R.S. denied having it.

The court concluded that the administrative law judge erred by failing to recognize depression and insomnia as medically determinable impairments. Treatment records documented observations of depression, repeated complaints of insomnia, and a prescription for insomnia. The court found the error harmless, however, because the record did not show that either condition significantly affected R.S.’s ability to perform work-related functions.

The court upheld the finding that R.S.’s impairments were not severe. It found substantial evidence supporting the administrative law judge’s reliance on the limited treatment records, reports of medication noncompliance, refusals of mental-health services, denials of mental-health problems, generally normal mental-status examinations apart from reported auditory hallucinations, and R.S.’s failure to attend scheduled consultative examinations. The court also found that counsel’s statements linking the missed examinations to schizophrenia and paranoid delusions did not provide specific facts establishing good cause.

The court rejected R.S.’s argument that the administrative law judge improperly disregarded treatment providers’ medical opinions. It explained that the providers had not addressed R.S.’s functional limitations or restrictions, so they had not provided medical opinions that the administrative law judge was required to evaluate for persuasiveness. The court also found that the administrative law judge reasonably treated the state-agency consultants’ and medical expert’s conclusions as opinions that the record did not establish functional limitations severe enough to support a severe impairment.

Disposition

The court denied R.S.’s motion for summary judgment, granted the Commissioner’s motion for summary judgment, and affirmed the Commissioner’s decision denying supplemental security income.