E.S. v. Kijakazi

Background

E.S. applied for supplemental security income in August 2017, alleging disability beginning April 4, 2017. After the application was denied, an administrative law judge held a hearing and found E.S. not disabled at step four of the Social Security Administration’s five-step process. The administrative law judge found that E.S. had severe spinal stenosis and degenerative disc disease, but determined that she could perform light work with certain restrictions and could return to her past work as a user support analyst. The Appeals Council denied review, making the administrative law judge’s decision the Commissioner’s final decision.

E.S. sought review under 42 U.S.C. § 405(g). The parties filed cross-motions for summary judgment, asking the court to rule based on the administrative record.

Court’s Analysis

The court held that the administrative law judge did not give adequate reasons for rejecting E.S.’s testimony about the intensity, persistence, and effects of her pain. The administrative law judge relied on allegedly minimal examination findings, supposed inconsistencies in E.S.’s statements, generally normal gait observations, and findings that she appeared well-developed and not in acute distress. The court concluded that these reasons improperly selected isolated or routine observations while overlooking other evidence, including imaging, continuing pain, spinal conditions, limited movement, falls, weakness, and treatment for pain. The court therefore found that the rejection of E.S.’s symptom testimony was not supported by substantial evidence.

The court also found that the administrative law judge inadequately evaluated the medical opinions. The administrative law judge rejected the opinion of physician’s assistant Stephanie Yeh as overly restrictive and found the opinions of state-agency consultants Drs. DeSouza and Herman persuasive. The court held that the administrative law judge improperly relied on selected gait and examination findings and failed to separately explain the opinions’ supportability and consistency as required by the applicable regulations. On remand, the administrative law judge must reevaluate all three opinions and, because Yeh’s opinion was at least as supportable and consistent with the longitudinal record as the consultants’ opinions, consider the additional regulatory factors concerning treatment relationship, specialization, and other relevant factors.

The court further held that the administrative law judge failed to adequately develop the record regarding E.S.’s need to alternate sitting and standing or walking during the workday. The state-agency consultants’ opinions did not address that limitation, and the administrative law judge rejected Yeh’s opinion on the issue before independently deciding that E.S. needed to change positions only momentarily each hour. Because the record contained no adequate medical opinion supporting that finding, the administrative law judge was required to obtain further evidence if he again rejected Yeh’s opinion on this issue, such as through a consultative examination or a medical expert’s opinion.

Disposition

The court held that the errors affected the residual functional capacity assessment and the vocational-expert hypothetical used to determine whether E.S. could perform her past work. The court therefore granted E.S.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further proceedings.

The remand requires the administrative law judge to reconsider E.S.’s symptom testimony, reevaluate the medical opinions, reassess the residual functional capacity, and determine at steps four and five whether E.S. can perform her past work or whether other work exists in significant numbers. If the administrative law judge again rejects Yeh’s opinion about E.S.’s need to change positions, the administrative law judge must further develop the record on that issue. The court declined to order immediate payment of benefits because it was not clear that proper evaluation of the evidence would require a finding that E.S. was disabled.