Mai V. v. Kijakazi

Background

Mai V. appealed the Commissioner of Social Security’s denial of her applications for disability insurance benefits and supplemental security income. The parties filed cross-motions for summary judgment. Magistrate Judge David T. Schultz recommended granting the Commissioner’s motion and denying Mai V.’s motion. Mai V. objected to that recommendation.

The objection concerned two medical source statements from Mai V.’s treating psychotherapist, Nicole Ward, Psy.D. Dr. Ward issued statements dated December 8, 2014, and July 14, 2016, describing limitations affecting Mai V. The administrative law judge discussed another opinion letter from Dr. Ward dated March 16, 2016, but did not reference or evaluate the two statements at issue.

Court’s Analysis

The court reviewed the disputed portions of the recommendation independently because Mai V. objected. It agreed that the objection had merit. Under the cited Social Security regulation, an administrative law judge must determine the weight given to a treating source’s medical opinion and provide good reasons for that determination when the opinion is not given controlling weight.

The court concluded that the administrative law judge’s failure to discuss the December 2014 and July 2016 statements, or to explain what weight they received, prevented the court from determining whether substantial evidence supported the benefits decision. The court also identified reasons for doubt about whether the statements and their underlying records had actually been considered. For example, the administrative law judge attributed treatment notes from other providers to Dr. Ward and did not address similarities between Dr. Ward’s observations and opinions from other providers that the administrative law judge had rejected.

The court further found that the two unreferenced statements addressed issues not covered in Dr. Ward’s March 2016 letter, including driving, stable work attendance, and maintaining pace at work. The court rejected the Commissioner’s argument that discussion of another provider’s similar limitations effectively evaluated Dr. Ward’s statements, noting that Dr. Ward was a treating source and therefore required a specific assessment with good reasons.

Disposition

The court sustained Mai V.’s objection and rejected the Report and Recommendation. It granted Mai V.’s summary-judgment motion insofar as it sought reversal of the Commissioner’s decision and remand for further proceedings, denied the Commissioner’s summary-judgment motion, reversed the Commissioner’s decision, and remanded the case under sentence four of 42 U.S.C. § 405(g). On remand, the administrative law judge must evaluate Dr. Ward’s December 2014 and July 2016 opinions under 20 C.F.R. § 404.1527.