I. v. Kijakazi

Background

K. I. sought supplemental security income under Title XVI of the Social Security Act. He alleged disability based on physical and mental impairments, including a gunshot injury to the spine, depression, anxiety, and bipolar disorder. After a hearing, the administrative law judge (ALJ) found that K. I. had severe depression with psychotic features and an anxiety disorder, but retained the capacity to perform work at all exertional levels with restrictions on contact with the public, coworkers, and supervisors and with a low-stress work environment. Relying on vocational-expert testimony, the ALJ found that jobs existed in significant numbers that K. I. could perform and concluded that he was not disabled. The Appeals Council declined review.

The parties filed cross-motions for summary judgment, asking the court to decide whether the Commissioner’s denial was supported by the record.

Medical-opinion evidence

The court held that the ALJ did not adequately evaluate the opinions of examining psychologist Nicole Kirsch, treating psychiatrist Said Shefayee, and treating therapist Jonathan Oakes.

As to Dr. Kirsch, the ALJ discounted her opinions that K. I. had extreme limitations in interacting with others, completing a normal workday, and maintaining regular attendance. The court found that the ALJ failed to discuss evidence supporting those opinions, including K. I.’s reported anxiety symptoms, difficulty getting along with others, inconsistent cooperation during the examination, history of psychiatric treatment, and reported difficulty maintaining employment. The court directed the ALJ to reconsider Dr. Kirsch’s opinions and revise the residual functional capacity as necessary.

The ALJ also gave little weight to the opinions of Dr. Shefayee and Mr. Oakes. The court agreed that substantial evidence supported rejecting their opinions that K. I. had marked limitations in understanding, remembering, and carrying out simple instructions. Treatment notes described K. I. as cooperative, able to communicate properly, and a reliable historian, and Dr. Kirsch found no limitation in understanding, remembering, or carrying out instructions.

But the court found inadequate support for rejecting Dr. Shefayee’s and Mr. Oakes’s opinions about K. I.’s marked limitations in maintaining attendance, completing a normal workday, working with or near others, and dealing with normal work stress, as well as his extreme limitations in sustaining ordinary routines without special supervision and accepting supervision. The court stated that the ALJ had not addressed medical evidence supporting those limitations. The court also directed the ALJ to reconsider whether the record supported the providers’ opinion that K. I. would miss more than four days of work per month.

The court further held that the ALJ erred by treating the opinions of state-agency psychological consultants as persuasive without adequately considering that they lacked a treatment relationship with K. I. and reviewed the claim before much of the later behavioral-health evidence was available.

Subjective-symptom testimony

The court also found that the ALJ improperly rejected K. I.’s testimony about the severity of his symptoms. The ALJ used a general statement that K. I.’s symptoms were not entirely consistent with the evidence, but did not specifically identify the testimony that was being rejected or link it to particular evidence. The court held that this did not satisfy the requirement for specific, clear, and convincing reasons.

The court also said that any improvement during treatment had to be considered in context. The ALJ needed to consider whether K. I.’s improvement resulted from a stable institutional setting with consistent access to treatment and medication, and whether his functioning might differ outside that setting.

Other issues and disposition

Because the errors involving the medical evidence and symptom testimony required remand, the court did not decide K. I.’s additional arguments concerning the ALJ’s step-two and step-three findings or the residual functional capacity. The court found the errors were not harmless because a properly conducted evaluation could lead to a different disability determination.

K. I. requested either an immediate award of benefits or further proceedings. The court concluded that the record was not fully developed, unresolved issues remained, and it was not clear that properly crediting the disputed evidence would require a finding of disability. The court therefore granted K. I.’s motion, denied the Commissioner’s cross-motion, and remanded for further proceedings consistent with the order.