Xee Y. v. Berryhill

Background

Xee Y. sought disability insurance benefits under Title II of the Social Security Act. She alleged disability beginning September 11, 2014, based on mental-health conditions, chronic pain and fibromyalgia, high blood pressure, gastrointestinal problems, dizziness and headaches, sleep problems, kidney stones, and other impairments. The administrative law judge (ALJ) found that she was last insured on December 31, 2014, and that she had severe impairments including mild scoliosis, lumbar degenerative disc disease, major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, cognitive defects, and pain disorder.

The ALJ determined that Xee Y.’s impairments did not meet or equal the requirements of the listed impairments considered under the Social Security regulations. The ALJ found that she had the residual functional capacity (her work ability after considering her limitations) to perform medium work with physical restrictions and to perform simple, routine tasks with occasional superficial contact with supervisors, coworkers, and the public. Although she could not return to her past work, the ALJ found that jobs existed in significant numbers that she could perform. The ALJ therefore found her not disabled through December 31, 2014. The Appeals Council declined further review.

The parties filed cross-motions for summary judgment, asking the court to decide the case based on the administrative record. Xee Y. argued that the ALJ improperly evaluated the opinions of psychologist Bobbi Gerling and therapist Bea Vue-Benson.

Vue-Benson’s opinion

Vue-Benson completed a psychological medical source statement on February 10, 2017. She described extreme or serious limitations in many areas, including attention, memory, completing a normal workday, handling work stress, responding to workplace changes, interacting with the public, and maintaining concentration. She also stated that Xee Y. would likely miss more than four workdays per month.

The ALJ gave Vue-Benson’s opinion no weight. The court explained that Vue-Benson was an “other source” rather than an acceptable medical source under the regulation discussed in the opinion. As a result, the ALJ had greater discretion in evaluating her opinion and was not required to apply every factor used for opinions from treating medical sources.

The court found substantial evidence supporting the ALJ’s decision. Vue-Benson’s opinion was issued more than two years after the date last insured and was inconsistent with the records from the relevant period. The records showed that Xee Y. requested less frequent therapy, sometimes did not follow medication instructions, and reported improvement when she took her medication. The court also noted that Vue-Benson’s treatment notes from 2014 described Xee Y.’s attention as good or fair and described her as well groomed, which conflicted with the extreme limitations stated in the 2017 opinion.

Gerling’s assessment

Dr. Bobbi Gerling performed a psychological assessment on September 11, 2014, at the request of Xee Y.’s lawyer in connection with her benefits application. The assessment described major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and pain disorder. Gerling reported very poor test performance and opined that Xee Y. would likely have difficulty learning, memorizing, or recalling new or partly abstract information. Gerling also cautioned that language and cultural factors could have affected the testing and that Xee Y. might not have understood the tasks.

The ALJ gave the assessment little weight, finding that its degree of limitation was not fully consistent with the overall evidence. The court agreed. It noted that Gerling saw Xee Y. only once, that the assessment was prepared in connection with the benefits application, and that the testing itself contained cultural and linguistic limitations. The court also relied on evidence that Xee Y. had held semi-skilled jobs, maintained a driver’s license, and had prior findings allowing simple, repetitive work with brief and superficial contact with others.

The court further concluded that Gerling’s principal work-related limitation—difficulty learning, memorizing, or recalling new or partly abstract information—was consistent with the ALJ’s restriction to simple, routine tasks. The court therefore found no error in the ALJ’s treatment of Gerling’s assessment.

Ruling

Applying the substantial-evidence standard, under which the court reviews for legal error and adequate evidentiary support without reweighing the evidence, the court concluded that the ALJ’s decision was supported by the record. Judge Steven E. Rau denied Xee Y.’s motion for summary judgment, granted the Commissioner’s motion for summary judgment, and dismissed the matter. The order did not state that the dismissal was with or without prejudice.