T.R. v. Berryhill

Background

T. R. sought judicial review of the Social Security Administration’s final decision denying her applications for disability insurance benefits and Supplemental Security Income. She alleged disability beginning June 15, 2013, based on conditions and symptoms including Sjögren’s syndrome, fibromyalgia, lupus, arthritis, depression, anxiety, asthma, allergies, chronic pain, and fatigue.

The Administrative Law Judge found that T. R. had several severe impairments but that they did not meet or equal a listed impairment. The Administrative Law Judge found that she had the residual functional capacity—the most she could still do in a work setting—to perform light work, with only occasional overhead reaching with either arm. Based on vocational-expert testimony, the Administrative Law Judge found that she could perform past work in data entry, customer service sales, and reception, as well as other jobs such as bench assembler and cashier. The Administrative Law Judge therefore found her not disabled.

Issues and analysis

T. R. challenged the weight given to the opinion of Dr. Jennifer Lake, whom the opinion identifies as her treating physician, and the evaluation of T. R.’s reports about the intensity and limiting effects of her symptoms.

Dr. Lake’s December 2015 medical-source statement described extensive physical limitations, including limits on lifting, sitting, standing, walking, postural activities, reaching, and repetitive upper-extremity activities. Dr. Lake also stated that T. R.’s symptoms would frequently interfere with attention and concentration, that she might need to recline periodically, and that she would likely miss work frequently. The Administrative Law Judge gave partial weight to the mental-health portion of Dr. Lake’s opinion and little weight to its physical portion.

The court did not decide whether the Administrative Law Judge properly weighed Dr. Lake’s physical opinion. Instead, it held that the Administrative Law Judge needed to reconsider that opinion after conducting a proper evaluation of T. R.’s symptoms.

The court found several problems in the symptom analysis. Although an Administrative Law Judge may consider a lack of objective medical support, the court explained that symptoms cannot be rejected solely because examination findings do not fully support them. The court also found that the record did not support describing T. R.’s treatment as “very minimal and extremely conservative.” Over about three years, she had more than 30 treatment visits and received prescription pain medication, injections, nerve blocks, radiofrequency ablation, physical therapy, and cervical-fusion surgery.

The court also found unclear the Administrative Law Judge’s statement that T. R. had not sought the treatment one would expect for the limitations she alleged. The court said that, on remand, the Administrative Law Judge must identify the medical evidence supporting any such conclusion. In addition, the court found that the record did not support the statement that treatment had been effective throughout the relevant period, because T. R. continued to report headaches, neck pain, lower-back pain, and fatigue and continued to use medication after several treatments and surgery.

The court further found the reasoning for limiting T. R. only as to overhead reaching unclear. Because the symptom analysis could have affected the residual functional capacity and the hypothetical questions posed to the vocational expert, the Administrative Law Judge might also need to obtain new vocational-expert testimony.

Ruling

Judge Elizabeth Cowan Wright ordered a new symptom analysis addressing T. R.’s treatment, medications, neck pain, lower-back pain, headaches, fatigue, work history, and other relevant factors. If the Administrative Law Judge gives less weight to T. R.’s symptoms, the Administrative Law Judge must clearly state the reasons and supporting evidence and must reconsider Dr. Lake’s opinion as appropriate.

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