Stephan v. Kijakazi

Background

Nita Stephan applied for disability insurance benefits and supplemental security income. She initially alleged disability beginning August 1, 2008, and later moved through counsel to amend the alleged onset date to August 20, 2020. She also withdrew her request for a hearing concerning the disability-insurance application. After a hearing at which Stephan and a vocational expert testified, the Administrative Law Judge (ALJ) found that Stephan had not been disabled through the date of the ALJ’s decision.

The ALJ found severe impairments including major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, uterine fibroids, fibromyalgia, and varicose veins. The ALJ determined that these impairments did not meet or medically equal a listed impairment. The ALJ assessed a residual functional capacity (RFC), meaning the most a person can do despite her limitations, for light work with restrictions to routine, repetitive tasks, limited judgment and workplace changes, occasional interaction with others, and concentration on simple rather than complex tasks.

The ALJ found that Stephan could not perform her past relevant work but could perform other jobs identified by the vocational expert, including marker, mail clerk, and router. Based on that testimony, the ALJ found her not disabled. Stephan and the Commissioner then filed competing motions for summary judgment, asking the district court to rule based on the administrative record.

Issues and Analysis

A district court reviewing a Social Security decision must uphold it unless the ALJ applied the wrong legal standard or the factual findings lack substantial evidence. Substantial evidence means relevant evidence that a reasonable person could accept as supporting the conclusion. The court considered Stephan’s arguments that the ALJ improperly evaluated her testimony, the opinion of her primary care physician Daniel S. Tseng, M.D., and the statement of her friend Katheryn Coffman.

Physical-symptom testimony. The court held that the ALJ gave sufficiently specific, clear, and convincing reasons for partially rejecting Stephan’s testimony about the severity of her physical pain. The ALJ considered largely normal physical examinations, treatment for varicose veins, improvement in the uterine fibroids with medication, and the absence of specialized or emergency treatment for fibromyalgia. The court stated that the ALJ was required to consider the full record, including evidence relating to fibromyalgia, but was not required to disregard other relevant medical evidence.

Mental-health testimony. The court agreed with Stephan that the ALJ did not adequately explain the partial rejection of her testimony about her mental-health symptoms. The ALJ relied in part on Stephan’s inconsistent attendance at psychiatric appointments and her lack of emergency or inpatient treatment. But the ALJ did not address possible reasons for those circumstances, including Stephan’s testimony that anxiety and panic made it difficult to drive, attend appointments, function, concentrate, and remember. The court also stated that mental-health symptoms can improve and worsen over time, so the ALJ needed to explain the significance of that evidence rather than relying simply on periods of improvement.

Medical opinion. The court rejected Stephan’s challenge to the ALJ’s evaluation of Dr. Tseng’s opinion. The ALJ found the opinion unpersuasive because it was not supported by the objective physical examinations, which showed some soft-tissue tenderness but no deficits in strength, sensation, or gait, and because it appeared to rely substantially on Stephan’s subjective reports. The court concluded that the ALJ sufficiently explained the opinion’s lack of supportability and consistency with the record.

Lay-witness statement. The court also rejected Stephan’s challenge to the treatment of Coffman’s statement. Under the regulations applicable after March 2017, the ALJ was not required to evaluate evidence from nonmedical sources using the same requirements that apply to medical opinions. The ALJ therefore did not err by finding Coffman’s statement somewhat persuasive only to the extent it was consistent with the objective medical evidence.

Harmless error and remedy. The court found that the ALJ’s error concerning Stephan’s mental-health testimony was not harmless because fully crediting that testimony could result in a more restrictive RFC and could change the ultimate disability determination. The court declined to order benefits under the credit-as-true rule, which can require an award when the record is fully developed, the ALJ gave legally insufficient reasons for rejecting evidence, and crediting that evidence would require a disability finding. Instead, the court concluded that further administrative proceedings would be useful so the ALJ could properly address Stephan’s mental-health testimony and determine whether additional evaluation was needed.

Disposition

The court granted Stephan’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the case for further administrative proceedings. The order did not direct an award of benefits.