Yvonne M. v. Kijakazi

Background

Yvonne M. applied for Social Security disability benefits on February 14, 2019, alleging that her disability began on December 1, 2011. The application was denied initially and on reconsideration. After a hearing, an Administrative Law Judge (ALJ) issued an unfavorable decision on January 14, 2021. The Appeals Council denied review, and Yvonne M. sought judicial review under 42 U.S.C. § 405(g).

The ALJ found that Yvonne M. had not engaged in substantial paid work since the alleged onset date. The ALJ identified trace lumbar scoliosis, thoracic spondylosis, chronic pain syndrome, and obstructive sleep apnea as severe impairments, but found that her impairments did not meet or equal a listed impairment. The ALJ determined that she had the residual functional capacity (RFC)—the most she could still do despite her impairments—to perform light work. Based on that RFC, the ALJ found that she could perform her past work as an ad taker/receptionist and telephone solicitor, and therefore found her not disabled.

Issues

Yvonne M. raised three challenges: whether the ALJ properly assessed the medical evidence, whether the ALJ’s evaluation of her reported symptoms was supported by substantial evidence, and whether the ALJ properly considered statements from lay witnesses.

Medical Evidence and Fibromyalgia

The court rejected the argument that the ALJ improperly ignored records from Harris Pain Clinic. Those records consisted of treatment notes from a chiropractor and did not state what Yvonne M. could still do or identify work-related restrictions. The court held that they were not medical opinions that the ALJ was required to evaluate under the applicable regulations.

The court also upheld the ALJ’s treatment of the alleged fibromyalgia. Social Security Ruling 12-2p requires appropriate medical evidence, including findings satisfying either the 1990 or 2010 American College of Rheumatology criteria. The court found that the record contained references to self-reported fibromyalgia, trigger points, and symptoms, but did not show the required tender points, widespread pain findings, or exclusion of other possible causes. No physician made findings sufficient to satisfy either set of criteria.

The court added that, even if the ALJ had erred by not treating fibromyalgia as a medically determinable impairment at the second step of the disability analysis, any error would have been harmless because the ALJ considered the condition when assessing the RFC. The court also found that the cited records did not identify additional restrictions that should have been included in the RFC.

Reported Symptoms

The court held that the ALJ gave sufficiently clear reasons for discounting the extent of Yvonne M.’s reported fatigue, exhaustion, pain, mental-health symptoms, and physical limitations. The court pointed to evidence that pain was generally controlled with treatment, that fatigue was not consistently reported, and that treatment for fatigue was limited and conservative. The ALJ also considered Yvonne M.’s inconsistent use of a recommended continuous positive airway pressure (CPAP) device for sleep apnea.

The court further found that the medical records did not support the alleged severity of her depression, anxiety, cognitive problems, back and neck symptoms, or hand and wrist pain. The records included generally normal mental-status findings, improved later cognitive testing, mild spinal imaging findings, and no corresponding treatment or workup for some claimed limitations. The court concluded that the ALJ’s finding that Yvonne M. could perform light work was supported by substantial evidence and that the court could not replace the ALJ’s reasonable interpretation of the evidence with its own.

Lay Witness Statements

A friend and a former co-worker provided statements describing deterioration, isolation, fatigue, aches, resting during work, and difficulty performing tasks. The court did not decide whether the ALJ was required to give specific reasons for rejecting each lay witness’s statement under the newer regulations. Instead, it assumed that requirement applied and held that any failure to give separate reasons was harmless because the statements described symptoms and limitations similar to those Yvonne M. reported herself. The reasons supporting the ALJ’s evaluation of her testimony therefore also adequately addressed the lay statements.

Disposition

The court denied Yvonne M.’s motion for summary judgment and granted the Commissioner’s cross-motion for summary judgment. The court ordered entry of a separate judgment and termination of the case.