Sandra H. v. Berryhill

Background

Sandra H. sought judicial review of the Social Security Administration’s denial of her application for Title XVI Supplemental Security Income. She argued that the administrative law judge (ALJ) failed to adequately develop the administrative record concerning limitations caused by her mental-health impairments and consequently made an incorrect residual functional capacity (RFC) determination.

The ALJ found that Sandra H. had several severe impairments, including major depression, an anxiety disorder with posttraumatic stress disorder and panic symptoms, obesity, headaches, left knee osteoarthritis and meniscus tears, diabetes, and a history of alcohol and drug abuse in remission. The ALJ determined that she could perform sedentary work with physical restrictions, routine and repetitive instructions and tasks, brief and superficial contact with others, and no work in settings where alcohol and drugs were sold, served, or readily available. The ALJ found that she could not perform her past relevant work but could perform other jobs existing in significant numbers in the national economy.

Record Development

The ALJ gave limited weight to opinions from Donala K. Jordan, M.S., and partial weight to opinions from Dr. Alford Karayusuf, M.D. Both offered opinions that, broadly, Sandra H.’s mental-health impairments would prevent consistent interaction with coworkers or the public and would interfere with workplace pace and persistence. The ALJ accepted that she could understand, retain, and follow simple instructions but rejected or limited the opinions concerning social interaction, pace, persistence, and carrying out simple instructions.

The court held that the ALJ was not required to obtain another functional assessment or consultative examination merely because the ALJ did not fully adopt the opinions already in the record. The record included extensive mental-health treatment records, a mental-health consultative examination, opinions from two medical professionals who examined Sandra H., and her own testimony about the severity of her impairments. The court concluded that the record was not obviously incomplete and provided a sufficient basis for the RFC determination.

Weight Given to Medical Opinions and Substantial Evidence

The court explained that Jordan and Dr. Karayusuf were not treating sources under the applicable regulation. Because they were non-treating sources, the ALJ was required to explain the weight given to their opinions, rather than provide the more detailed reasons required for rejecting a treating source’s opinion. The court found that the ALJ assigned explicit weights and explained the reasons for doing so.

The court also concluded that the RFC was supported by substantial evidence, meaning enough evidence that a reasonable person could find it adequate to support the decision. The ALJ relied in part on evidence that Sandra H. remained socially engaged, attended a professional basketball game, walked her dog, went grocery shopping with a friend, visited that friend, cooked, cleaned, and performed other simple tasks. The court stated that the record could support a different conclusion, but that possibility did not prevent the ALJ’s conclusion from being supported by substantial evidence.

The court further rejected arguments that the ALJ improperly relied on possible improvement from future treatment or on Sandra H.’s prior illicit-substance use. It found that the ALJ considered evidence of improvement that had already occurred and did not conclude that future treatment would necessarily improve her condition. It also found that the ALJ did not determine that prior drug use contributed to her other impairments and concluded that Sandra H. would not be disabled even assuming drug use contributed nothing to her mental-health impairments.

Disposition

The court held that the ALJ adequately developed the record, that the RFC findings were supported by substantial evidence, and that the ALJ did not otherwise commit reversible error. Judge Elizabeth Cowan Wright denied Sandra H.’s Motion for Summary Judgment, granted Acting Commissioner Nancy A. Berryhill’s Cross Motion for Summary Judgment, and dismissed the case with prejudice.