Rosemarie V. v. Kijakazi

Background

Rosemarie V. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner’s decision denying her disability benefits. She alleged disability beginning September 4, 2014. After an earlier administrative decision was vacated and the case was sent back for further proceedings, an administrative law judge held additional hearings and again found her not disabled.

The administrative law judge found severe impairments including major depressive disorder, anxiety, mood disorder, unspecified bipolar disorder, insomnia, left atrial enlargement, and asthma. The judge determined that Rosemarie V. could perform medium work with modifications and relied on vocational-expert testimony identifying jobs such as hand packager and hospital cleaner.

Mental impairments

The court held that the administrative law judge improperly rejected Rosemarie V.’s testimony about the severity of her mental symptoms. The judge used general language stating that the testimony was inconsistent with the record but did not identify which testimony was rejected or connect it to particular evidence. The court also found that the judge improperly characterized mental-status examinations as generally unremarkable and relied on isolated periods of improvement with medication even though the record showed that Rosemarie V.’s condition fluctuated.

The court also found errors in the treatment of three opinions. The administrative law judge gave little weight to examining psychologist Dr. Laura Catlin’s opinion, therapist Jena Nawy’s opinion, and medical expert Dr. David Jarmon’s opinion. According to the court, the reasons given were not adequately specific or supported by substantial evidence. The judge improperly discounted opinions as based on Rosemarie V.’s self-reports, failed to provide adequate record citations, and relied on selected evidence of improvement. The court further stated that the judge could not use limited observations of Rosemarie V.’s concentration during the hearing to undermine Dr. Catlin’s examining opinion.

The court declined to decide whether Rosemarie V. met the mental-impairment listing requirements because reconsideration of the medical opinions could affect the assessment of the four mental-functioning areas, known as the “Paragraph B” criteria. The court ordered the administrative law judge to reevaluate that assessment after reconsidering the medical opinions.

Physical impairments

The court found that the administrative law judge improperly rejected Rosemarie V.’s testimony about her cardiac symptoms, including dizziness and fatigue. The judge relied on the absence of ongoing heart treatment and normal findings during some examinations, but the court held that these reasons did not adequately contradict her testimony or cite the specific supporting evidence.

The court also found that the judge misread the evidence concerning Rosemarie V.’s left hand. Although the judge described Dr. Eugene McMillan’s examination as showing normal strength, the examination reported substantially weaker grip strength in Rosemarie V.’s left hand than in her right. The court held that the judge therefore improperly rejected her testimony and incorrectly found the left-hand impairment non-severe at the second step of the disability analysis. Because the residual functional capacity assessment did not account for the reduced grip strength, the error was not harmless.

As to asthma, the court found that the record supported the administrative law judge’s description of the objective medical evidence and the finding that asthma was not severe at step two. But the judge still had to consider Rosemarie V.’s testimony about asthma attacks, inhaler use, and shortness of breath when assessing severity and residual functional capacity. Because the judge improperly discounted that testimony and did not add asthma-related limitations to the residual functional capacity, the court required reconsideration of asthma at steps two and four.

Residual functional capacity and vocational testimony

The court concluded that the residual functional capacity assessment was not supported by substantial evidence because it was affected by the errors involving the medical opinions, symptom testimony, and left-hand impairment. The court also found that the vocational expert’s hypothetical was defective because it likely did not include the correct limitations. On remand, the administrative law judge must reassess the residual functional capacity and provide a new hypothetical to the vocational expert.

Disposition

The court granted Rosemarie V.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further proceedings. The required reconsideration includes the medical opinions, symptom testimony, Paragraph B mental limitations, asthma and left-hand impairment at steps two and four, residual functional capacity, and whether jobs exist in significant numbers under a revised vocational-expert hypothetical. The court declined to order immediate payment of benefits because it was not clear that proper evaluation of the evidence would require a finding of disability. The clerk was directed to enter judgment and close the file.