Paul H. v. Kijakazi

Background

Paul H. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s decision denying his claims for disability insurance benefits under Title II and supplemental security income under Title XVI. He alleged disability beginning September 1, 2011, based on physical conditions including chronic back pain, herniated discs, arthritis in his neck and back, and carpal tunnel syndrome in both hands.

An administrative law judge initially found Paul H. not disabled in 2019. In an earlier related proceeding, the court remanded the matter for further proceedings. The Appeals Council later combined the remanded case with a subsequent application and instructed the administrative law judge to reconsider the medical opinions, Paul H.’s pain symptoms, the severity of his impairments, and his residual functional capacity—the most he could still do despite his limitations.

After a May 2022 hearing, a second administrative law judge again found Paul H. not disabled and concluded that he could perform his past work as a customer service representative. Paul H. and the Commissioner filed cross-motions for summary judgment, asking the district court to decide the case based on the administrative record.

Mental-impairment finding

The administrative law judge found severe physical impairments involving degenerative disc disease in the lumbar spine with radiculopathy and joint pain in both hands, but found no medically determinable mental impairment. The court held that this finding was not supported by substantial evidence, meaning adequate relevant evidence in the record.

The court focused on consultative examiner Dr. Katherine Wiebe’s evaluations. After two two-hour sessions, Dr. Wiebe diagnosed unspecified mental and personality disorders and concluded that Paul H. would have difficulty performing a regular job because of psychiatric, personality, and somatic symptoms. The court found that the administrative law judge did not adequately explain why the testing and diagnoses were rejected, why Paul H.’s pleasant behavior and relationships were inconsistent with a severe mental impairment, or why the absence of mental-health treatment undermined Dr. Wiebe’s findings.

The court also held that the error mattered because the administrative law judge did not consider Paul H.’s mental impairments in the residual-functional-capacity analysis, even as non-severe impairments.

Medical-opinion evidence

The court found inadequate the administrative law judge’s reasons for giving only partial weight to Dr. Omar Bayne’s opinion. The administrative law judge accepted Dr. Bayne’s general assessment that Paul H. was limited to a range of light work with additional restrictions but rejected, among other things, a 15-pound lifting limit and limits of four hours each for standing or walking and sitting.

The court held that the records cited by the administrative law judge did not show that Paul H. could lift without pain, and the administrative law judge did not explain why intact upper-extremity strength was inconsistent with a lifting limitation caused by lower-back pain. The court also found that the administrative law judge did not explain why inconsistent cane use, daily walking, exercise, or the need to change positions conflicted with Dr. Bayne’s standing, walking, and sitting limits. The court emphasized that an administrative law judge may weigh medical evidence but may not substitute personal medical judgment for that of a medical professional.

Pain testimony

The court held that the administrative law judge improperly rejected Paul H.’s testimony about the intensity and limiting effects of his pain. Because the administrative law judge found that Paul H.’s impairments could reasonably cause the alleged symptoms and did not find malingering, the administrative law judge needed specific, clear, and convincing reasons supported by substantial evidence to reject the testimony.

The court found problems with all three reasons given: the objective medical evidence, the conservative course of treatment, and Paul H.’s daily activities. The court said the administrative law judge relied on some evidence showing stable or mild findings while overlooking records reporting constant or severe pain, pain rated as high as 9 out of 10, worsening with activity, and difficulty moving. The court also found that the administrative law judge did not explain why inconsistent cane use undermined Paul H.’s testimony.

Regarding treatment, the court said the administrative law judge did not adequately consider evidence that Paul H. reported severe pain, had pursued physical therapy and injections, and had not been advised to undergo surgery because of concerns described in the record. The administrative law judge also failed to consider Paul H.’s age when evaluating the treatment he received.

Regarding daily activities, the court held that walking for 20 minutes, exercising, stretching, driving short distances, shopping, vacuuming, and making the bed did not by themselves show that Paul H. could complete a typical workday. The court said the administrative law judge also failed to address testimony that a friend drove him to shop and helped with groceries, that he could not wash dishes because he could not bend over a sink, that he needed to ice his back for 40 minutes two or three times daily, and that his back had gone out while walking.

Remand and disposition

The court concluded that the errors concerning the mental-impairment evidence, Dr. Bayne’s opinion, and Paul H.’s pain testimony were not harmless. The court did not need to decide Paul H.’s additional arguments about the residual functional capacity because these errors independently required further proceedings.

Paul H. asked for payment of benefits or, alternatively, another remand. The court chose further proceedings because the record was not fully developed and it was not clear that properly crediting the disputed evidence would require a finding of disability. In particular, the vocational expert had not been asked questions incorporating Dr. Wiebe’s mental limitations, and the record did not establish that a sedentary-work limitation would prevent Paul H. from returning to his past work as a customer service representative.

Judge Jacquelyn Corley therefore granted Paul H.’s motion for summary judgment, denied the Commissioner’s cross-motion, and remanded the case for further proceedings consistent with the order. The order disposed of Docket Nos. 20 and 23.