T.R. v. Berryhill

Background

T. R. sought judicial review of the Acting Commissioner of Social Security’s final decision denying her applications for disability insurance benefits and Supplemental Security Income. She alleged disability beginning June 15, 2013, based on Sjögren’s syndrome, fibromyalgia, lupus, arthritis, depression, anxiety with panic attacks, asthma, and allergies.

After a hearing, Administrative Law Judge Micah Pharris found that T. R. had severe impairments involving chronic pain and fatigue, including conditions variously diagnosed as Sjögren’s syndrome, sicca syndrome, myofascial pain syndrome, lupus, chronic pain syndrome, cervical degenerative disc disease, and mild lumbar degenerative disc disease. The Administrative Law Judge found that her impairments did not meet or equal a listed impairment and determined that she could perform light work, with only occasional bilateral overhead reaching. Based on vocational-expert testimony, he found that she could perform past work as a data-entry worker, customer-service sales representative, and receptionist, as well as other jobs such as bench assembler and cashier. He therefore found her not disabled.

Issues and analysis

T. R. challenged the weight given to the opinions of Dr. Jennifer Lake, her treating physician, and the evaluation of her subjective symptoms. Dr. Lake’s December 2015 medical-source statement described extensive physical restrictions, including limits on lifting, sitting, standing, walking, reaching, bending, and other activities. The Administrative Law Judge gave partial weight to the mental portion of Dr. Lake’s opinion and little weight to its physical portion.

The court explained that a treating physician’s opinion may be given controlling weight when it is supported by medically acceptable techniques and is not inconsistent with substantial evidence in the record. The court disagreed with the Administrative Law Judge’s statement that physicians could not determine the impairments from which a claimant suffers and assign limitations. It also noted that opinions that a claimant is unable to work do not receive special deference because the ultimate disability determination belongs to the Commissioner. The court did not finally decide whether the physical portion of Dr. Lake’s opinion was properly weighed because the symptom analysis required reconsideration.

The Administrative Law Judge accepted that T. R.’s medically determinable impairments could reasonably cause her alleged symptoms but found that her statements about their intensity, persistence, and limiting effects were not entirely consistent with the evidence. The court found several problems with that analysis. The record showed that over approximately three years T. R. sought treatment more than 30 times and received narcotic pain medication, injections, nerve blocks, radiofrequency ablation, physical therapy, and cervical-spine fusion surgery. The court therefore found that describing her care as “very minimal and extremely conservative” was unsupported.

The court also found unclear the Administrative Law Judge’s assertion that T. R. had not sought treatment that would be expected for the limitations she alleged. If the Administrative Law Judge relied on that reasoning again, the court directed him to identify the medical evidence supporting it. The court further found that the record did not support the conclusion that treatment had been effective throughout the relevant period. T. R. continued to report headaches, cervical pain, lower-back pain, and fatigue, including after surgery and other treatments.

Because the Administrative Law Judge’s analysis was partly unsupported and the evidence did not so strongly discredit T. R.’s symptoms that the result was necessarily required, the court ordered a new symptom analysis. On remand, the Administrative Law Judge was directed to consider T. R.’s treatment, medications, work history, and other relevant factors; clearly explain any reduced weight assigned to her symptom reports; reconsider the weight given to Dr. Lake’s opinion; and, if necessary, obtain updated vocational-expert testimony.

Disposition

The order states:

- T. R.’s motion for summary judgment was granted in part and denied in part. - The Commissioner’s cross-motion for summary judgment was denied. - The case was remanded to the Commissioner under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with the order. - The case was dismissed with prejudice.

The order was signed by United States Magistrate Judge Elizabeth Cowan Wright.