Irene S. A. v. Kijakazi

Background

Irene S. A. sought judicial review of an administrative law judge’s decision denying her application for disability insurance benefits under Title II of the Social Security Act. The Appeals Council declined to review the decision, making it the Commissioner of Social Security’s final decision for purposes of review in district court. Both parties moved for summary judgment.

The administrative law judge found that Irene had not engaged in substantial gainful activity during the relevant period. At step two of the required five-step disability analysis, the judge found severe impairments involving the cervical spine, obesity, and a sclerotic lesion on the right humeral head. The judge found right knee pain, fibromyalgia, and myofascial pain syndrome non-severe or not medically determinable. The judge did not mention or analyze numerous other conditions, including trigger finger, osteoarthrosis, lumbosacral conditions, enthesopathy, rheumatism, fibrosis, right shoulder conditions, lumbago, muscle spasms, and cervical sprain.

The administrative law judge then found that Irene could perform light work with specified limitations. Based on vocational-expert testimony, the judge found that she could perform her past work as a card room attendant II and data processing auditor, and therefore was not disabled.

Court’s Analysis

The court reviewed whether the administrative decision was supported by substantial evidence—relevant evidence that a reasonable person could accept as adequate—and whether the administrative law judge applied the law correctly. Although Irene’s briefing raised challenges to the evaluation of medical opinions, her testimony, and her residual functional capacity, the court independently identified errors at step two and in the development of the record. It therefore did not decide those three claims as then presented.

The court held that the administrative law judge wrongly treated Irene’s right knee pain as lacking clinical or diagnostic evidence of functional limitations. The record included evidence of right knee and leg sprains and a treating physician’s opinions about chronic pain, difficulty using stairs and walking on uneven surfaces, inability to ambulate effectively, and other limitations.

The court also held that the administrative law judge improperly rejected fibromyalgia largely because the medical records did not consistently identify at least 11 tender points. The court explained that, although Social Security Ruling 12-2p describes evidence relevant to establishing fibromyalgia as a medically determinable impairment, Ninth Circuit authority does not require documentation identifying the specific number and location of tender points at that level of detail. The court found that the administrative law judge also failed to account for Irene’s documented widespread pain and tender points when evaluating later steps and formulating her residual functional capacity.

The court further found harmful omissions because the administrative law judge failed to analyze more than a dozen other diagnosed conditions at step two or later in the disability analysis. The court concluded that these conditions were not considered at step three, when the residual functional capacity was formulated, or beyond. Because the omissions could have affected the disability determination, the court did not treat them as harmless.

The court also held that the administrative law judge did not adequately develop the record. An administrative law judge has a duty to fully and fairly develop the record when the evidence is ambiguous or inadequate for proper evaluation, even when the claimant has a lawyer. The court found that duty especially important here because the limitations associated with the various conditions had not been sufficiently developed.

Remand Instructions and Disposition

The court ordered a new administrative hearing. At that hearing, Irene and other interested witnesses were to be questioned at length about the limitations caused by each discussed impairment. The administrative law judge was ordered either to subpoena Dr. Bocobo to testify or to send him and other relevant physicians detailed questionnaires about the limitations associated with each impairment. Unless Irene was found disabled, any new decision was required to properly evaluate and weigh the medical opinions and address the standards discussed by the court. The Commissioner was also ordered to consider Irene’s other arguments on remand.

The court denied Irene’s request for a remand for calculation and payment of benefits. It found that the record was not fully developed, including regarding the effect of a claimed expectation that Irene would miss four or more workdays per month and the vocational consequences of that absence rate. The court concluded that further administrative proceedings were necessary.

The court granted Irene’s motion for summary judgment, denied the Commissioner’s cross-motion, and remanded the case for further proceedings consistent with the opinion.