Lenore B. v. Kijakazi

Background

Lenore B. sought judicial review of an administrative law judge’s denial of her application for disability insurance benefits under Title II of the Social Security Act. She filed the application in August 2015, alleging disability beginning February 4, 2011. An administrative law judge issued an unfavorable decision in 2017. After an earlier court proceeding, the parties agreed to send the matter back to the Social Security Administration for further proceedings. The Appeals Council then vacated the 2017 decision and ordered a new evaluation of a psychological report and Lenore B.’s maximum residual functional capacity, meaning the most work she could still perform despite her impairments.

After a July 2021 hearing, the administrative law judge again found Lenore B. not disabled. The judge found several severe impairments, including spinal degenerative disease, joint conditions, major depressive disorder, generalized anxiety disorder, panic disorder, Sjogren’s syndrome, and obesity. The judge determined that she could perform light work with certain restrictions and occasional interaction with the public. Although she could not return to her past relevant work, the judge found that she could perform other jobs identified by a vocational expert.

Court’s Analysis

The court held that the administrative law judge committed reversible error at step two and later stages of the disability analysis. At step two, the judge failed to assess the severity of four conditions: cervical radiculopathy, post-traumatic stress disorder, personality disorder, and learning disorder. The court explained that step two is a screening stage intended to eliminate only claims involving very minor impairments. The record contained diagnoses and other evidence concerning cervical radiculopathy and post-traumatic stress disorder, and it also contained evidence of personality and learning disorders.

The court rejected the Commissioner’s argument that any step-two error was harmless because the conditions were considered later. The decision did not address post-traumatic stress disorder or personality disorder in the later analysis, and it incorrectly concluded that Lenore B. did not have cervical radiculopathy or a learning disorder. As a result, the administrative law judge did not account for the resulting limitations when determining the residual functional capacity or deciding whether she could work.

The court also found that the administrative law judge failed to adequately develop the record. Administrative proceedings in Social Security cases require the judge to fairly develop the evidence, including when the claimant has a mental illness or when the evidence is unclear or inadequate. The court directed the administrative law judge to hold another hearing, question Lenore B. and other interested witnesses in detail about the limitations caused by each impairment, and contact treatment providers for detailed opinions about those limitations.

The court identified additional problems with the evaluation of medical opinions. The administrative law judge gave less weight to opinions from Dr. Zuniga and Dr. O’Dowd, but the court found that some reasons were unsupported, insufficiently specific, or based on an incomplete or mischaracterized reading of the record. The court also noted that the administrative law judge did not adequately apply the factors governing the evaluation of a treating provider’s opinion.

Finally, the court found that the reasons given for discounting Lenore B.’s testimony about her symptoms were not sufficiently clear and convincing. Among other things, the administrative law judge relied on an incomplete description of evidence concerning cervical radiculopathy, one report that Lenore B. was doing well, and her ability to travel out of state on one occasion. The court said the administrative law judge could not rely on those points without explaining how they contradicted her claimed limitations or showed that she could function in a workplace.

Disposition

Judge Robert Illman granted Lenore B.’s motion for summary judgment, denied the Commissioner’s cross-motion, and remanded the case for further proceedings consistent with the order. The remand required another hearing and additional evidence-gathering and evaluation. The order did not award benefits or make a final finding that Lenore B. was disabled.