B.T. v. Kijakazi

Background

B.T. sought review of the Social Security Administration Commissioner’s final decision denying his application for disability insurance benefits under Title II of the Social Security Act. He applied on June 26, 2019, alleging that his disability began on February 17, 2018. The agency denied the application initially and on reconsideration. After a hearing before an administrative law judge (ALJ), the ALJ issued an unfavorable decision on March 30, 2021. The Appeals Council denied review, making the ALJ’s decision the final administrative decision.

B.T. claimed disability based on back, leg, and ankle pain, which he attributed to a December 2017 stroke that caused neurological damage and depression. At the hearing, he testified that weakness and pain limited his ability to stand, walk, sit, and carry items, and that he experienced fatigue, forgetfulness, and trouble concentrating. He was not represented by counsel at the hearing.

The ALJ found that B.T. had severe impairments including a history of stroke, hypertension, type 2 diabetes, obstructive sleep apnea, lower-back and knee pain, and an adjustment disorder involving depression and anxiety. The ALJ determined that B.T. could perform a restricted range of medium work, could not return to his past work, but could perform jobs such as night janitor, hand packager, and laundry worker. The ALJ therefore found him not disabled.

Issues

B.T. asked the court to reverse and remand the Commissioner’s decision on three grounds:

The court reviewed the decision under 42 U.S.C. § 405(g). Under that standard, a court may set aside the Commissioner’s decision only if it contains legal error or is not supported by substantial evidence, meaning relevant evidence that a reasonable person could accept as adequate support for the conclusion.

Lack of Counsel

The court held that B.T. did not show prejudice or unfairness resulting from his lack of counsel. Although an ALJ must carefully develop the record when a claimant is unrepresented, the court found that any missing follow-up questions about education, interactions with others, memory, concentration, or other subjects would not have changed the outcome. The court also concluded that the ALJ reasonably relied on the medical evidence and that B.T. had not shown that counsel would likely have corrected a material error.

Medical Opinions

The court held that substantial evidence supported the ALJ’s evaluation of the medical opinions. As to treating doctor James Luu, the ALJ reasonably found his opinions unpersuasive because they were not supported by his own records, lacked diagnostic testing, and relied substantially on B.T.’s self-reporting. The court said the ALJ distinguished Dr. Luu’s conclusions from the objective findings in his records.

The court also found that the ALJ adequately explained the treatment of the state agency consultants’ opinions. The ALJ compared those opinions with the medical evidence and adopted additional mental limitations while declining to impose further restrictions. The court found that the ALJ adequately explained why the consultative neurologist’s opinion was persuasive, including the examination findings that B.T. walked without an assistive device, had normal range of motion, and had largely normal strength. The ALJ also modified that opinion somewhat in light of B.T.’s reports of pain.

Finally, the court found that the ALJ adequately explained the treatment of consultative psychologist Aparna Dixit’s opinion. Reading the ALJ’s decision as a whole, the court concluded that the ALJ relied on Dr. Dixit’s findings that B.T.’s memory and abstract thinking were unimpaired, that he had no significant cognitive deficits, and that he could follow a three-step command and perform serial mathematical tasks.

B.T.’s Symptom Testimony

The court held that the ALJ gave specific, clear, and convincing reasons for discounting B.T.’s testimony about left-side weakness, slowed movement, difficulty remaining on his feet, fatigue, and the need for reminders. The ALJ identified conflicts between B.T.’s statements and medical findings, including examinations showing minimal residual effects from the stroke, normal strength and range of motion, independent walking, and no need for a cane. The ALJ also relied on B.T.’s reported ability to drive, shop for groceries, and perform some household chores with help.

Disposition

Judge Laurel Beeler granted the Commissioner’s cross-motion for summary judgment and denied B.T.’s motion for summary judgment. The order resolved the two motions and left the Commissioner’s denial of benefits in place.