Elizabeth B. v. Kijakazi

Background

Elizabeth B. sought disability and disability insurance benefits under Title II of the Social Security Act. She alleged that pain from injuries to her lumbar, thoracic, and cervical spine and right shoulder, along with depression and emotional distress, prevented her from working. The administrative law judge found that she had severe spinal impairments, but found her depression and anxiety non-severe. The judge determined that she could perform light work with additional restrictions, could not perform her past relevant work, but could perform other jobs such as cashier and storage-facility rental clerk. The judge therefore found that she was not disabled.

After the Appeals Council declined review, Elizabeth B. filed this action under 42 U.S.C. § 405(g). The parties filed cross-motions for summary judgment, asking the court to decide whether the administrative law judge’s decision was legally supported.

Mental impairments and medical opinions

The court held that the administrative law judge’s evaluation of the evidence concerning Elizabeth B.’s depression and anxiety was not supported by substantial evidence, meaning adequate relevant evidence in the record.

The administrative law judge gave only limited persuasive value to examining psychologist Dr. Carol W. Fetterman’s opinion, stating that it was supported by an examination and generally consistent with other findings but did not identify Elizabeth B.’s maximum functional capacity. The court found that the judge failed to explain which portions of the opinion were persuasive and ignored Dr. Fetterman’s finding that Elizabeth B. had a “fair,” or moderate, ability to complete a normal workday or workweek without psychiatric interruptions and might have difficulty handling work-related stress.

The administrative law judge rejected examining psychologist Dr. Terrance Riley’s opinion, including his statement that Elizabeth B. did not appear able to work at that time. The court found that the judge did not adequately explain which evidence was inconsistent with Dr. Riley’s opinion or account for the fact that Dr. Riley’s evaluation occurred about a year after the state agency consultants’ findings.

The administrative law judge did not discuss treating psychotherapist Dr. Carol Fabric’s opinion, which described Elizabeth B.’s depression and anxiety and concluded that she was totally disabled from her own work. The court rejected the Commissioner’s explanations offered after the administrative decision because the court must review the reasons and factual findings stated by the administrative law judge.

Subjective symptom testimony

The court also held that the administrative law judge failed to provide the specific, clear, and convincing reasons required to reject Elizabeth B.’s testimony about the intensity and effects of her symptoms. The judge used a general statement that her testimony was not entirely consistent with the medical and other evidence, but did not identify the specific inconsistencies.

The court also found insufficient support for the judge’s references to homeopathic treatment, normal functioning without prescription medication, strenuous activities, and Elizabeth B.’s uncertainty about returning to part-time work. The record showed that she had also pursued physical therapy, acupuncture, a lumbar nerve-root block, and shoulder injections. It also showed that activities cited by the administrative law judge caused increased pain. The court concluded that the judge had not adequately considered these facts or Elizabeth B.’s reasons for relying on the treatment she used.

Other medical evidence

The court declined to decide Elizabeth B.’s separate argument concerning other treating medical providers. Even assuming an error in that part of the administrative law judge’s analysis, the court found that Elizabeth B. had not identified a harmful error because the residual functional capacity already included a need to change positions between sitting and standing at will.

Remand and disposition

The court determined that the errors concerning the medical evidence about mental impairments and the subjective symptom testimony were not harmless because they went to the heart of the disability determination and could have affected the assessment of Elizabeth B.’s mental limitations and ability to work.

Elizabeth B. requested either an award of benefits or further proceedings. The court concluded that the record was not fully developed, that unresolved issues remained, and that it was not clear Elizabeth B. would necessarily be found disabled if the improperly discounted evidence were credited. The court therefore granted Plaintiff’s motion for summary judgment, denied Defendant’s motion for summary judgment, and remanded for further proceedings consistent with the order.