T.L. v. Kijakazi

Background

T.L. applied for disability insurance benefits under Title II of the Social Security Act, alleging that he became disabled on January 20, 2016. The application was denied initially and on reconsideration. After a hearing, Administrative Law Judge Serena S. Hong denied the application on May 3, 2021. The Appeals Council denied T.L.’s appeal on March 28, 2022, making the administrative law judge’s decision the Commissioner’s final decision. T.L. then sought judicial review under 42 U.S.C. § 405(g).

The administrative law judge found that T.L. had not engaged in substantial gainful activity since the alleged onset date and had severe impairments including degenerative disc disease, left rotator cuff tendinitis syndrome, and coronary artery disease after stent placement. She found that these impairments did not meet or equal a listed impairment. She determined that T.L. had the residual functional capacity—the most he could still do despite his limitations—to perform light work with additional restrictions. Although he could not perform his past work as a cook, machinist, or janitor, she found that he could perform jobs such as ticket seller, ticket taker, and sales attendant. She therefore found him not disabled at the fifth step of the disability evaluation.

The court’s review

The parties filed cross-motions for summary judgment, asking the court to decide whether the Commissioner’s decision was supported by the law and the evidence. The court focused on the administrative law judge’s treatment of Dr. Vu’s medical opinions and T.L.’s symptom testimony.

Dr. Vu’s medical opinions

Dr. Vu, a physical medicine and rehabilitation specialist, treated T.L. for lumbar radiculopathy. She documented low-back pain radiating into his left thigh and calf, MRI findings including a large L4–L5 disc bulge and moderate spinal narrowing, and functional limitations involving sitting, standing, walking, lifting, changing positions, and possible monthly absences.

The administrative law judge found Dr. Vu’s opinions not persuasive, stating that they were not supported by examination findings, specific references, and adequate explanations. But the administrative law judge relied largely on medical findings concerning T.L.’s heart condition, such as a normal electrocardiogram and a stress test, without explaining how those findings conflicted with Dr. Vu’s opinions about T.L.’s back condition. The court found that this reasoning appeared irrelevant to Dr. Vu’s opinions and did not adequately address other providers who examined or treated T.L.’s back. The court also found that the administrative law judge improperly relied on T.L.’s daily activities for the same reasons that made her treatment of his symptom testimony inadequate.

T.L.’s symptom testimony

T.L. testified that back pain prevented him from carrying heavy items, twisting, and bending, and that he sometimes needed to rest because of pain or an increased heart rate. He said he could walk for about 15 minutes before needing a break and explained that his pool exercises were intended to help his back and heart rather than being ordinary swimming.

The administrative law judge relied on T.L.’s walking, reported swimming, and 2017 trip to Vietnam as inconsistent with his allegations. The court held that these were not specific, clear, and convincing reasons supported by substantial evidence. The administrative law judge did not address T.L.’s testimony that his doctors recommended walking and aquatic exercise, that he took breaks while walking, or that his pool activity was not necessarily swimming. The court also found that the trip to Vietnam occurred before T.L.’s 2019 heart attack and that the administrative law judge did not explain why the trip or planned activities contradicted his testimony about his back symptoms.

Residual functional capacity and unresolved issues

Because the administrative law judge improperly discounted Dr. Vu’s opinions and T.L.’s symptom testimony, the court concluded that the residual functional capacity finding was not supported by substantial evidence. The court also stated that the Commissioner would need to reconsider T.L.’s age category at the time of the hearing and consider all of his impairments, including any limitations related to headaches and cervical radiculopathy. The court did not decide those issues because they would be reconsidered on remand.

Disposition

The court concluded that further administrative proceedings were appropriate because the record did not clearly establish that T.L. would be found disabled even if the evidence were properly evaluated. It therefore granted T.L.’s motion for summary judgment, denied the Commissioner’s motion for summary judgment, and remanded the matter for further proceedings. The Clerk was directed to enter judgment and close the file.