Mike S. v. Saul

Background

Mike S. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s decision denying his application for disability insurance benefits. He alleged that his disability began on October 22, 2014, when he experienced a stroke. The record described continuing problems involving gait, balance, mobility, focal function, and vestibular function.

The administrative law judge conducted the required five-step disability analysis. The judge found that Mike S. was not gainfully employed, had severe impairments, and did not have an impairment that met or equaled a listed impairment. The judge determined that Mike S. could perform light work with stated physical and safety restrictions. Because he could not perform his past relevant work, the judge relied on testimony from a vocational expert and found that other jobs existed in the national economy that he could perform. The administrative law judge therefore found him not disabled.

Parties’ Arguments

Mike S. argued that the administrative law judge improperly rejected the opinion of Dr. William R. Rossing, his treating neurologist. Dr. Rossing had treated Mike S. during and after the stroke and later stated that Mike S. had chronic limitations that prevented gainful employment.

The Commissioner argued that the administrative law judge properly considered the entire record. The administrative law judge had given Dr. Rossing’s opinion little weight because it was issued more than two years after the date last insured, was considered conclusory, and did not identify specific work-related limitations.

Court’s Analysis

The court explained that, under the applicable Social Security regulations, a treating physician’s opinion generally receives greater weight and may receive controlling weight when it is well supported by medical evidence and is not inconsistent with other substantial evidence. Regardless of the weight assigned, the administrative law judge must give good reasons for the decision.

The court found that the administrative law judge did not adequately explain the reasons for discounting Dr. Rossing’s opinion. Although the opinion was issued after the relevant insured period, it addressed Mike S.’s medical history over time, and Dr. Rossing had treated him during the stroke and periodically afterward. The later date therefore did not automatically make the opinion irrelevant.

The administrative law judge also called the opinion conclusory without explaining why. The court stated that an administrative law judge should examine the underlying medical record to determine whether it supports an otherwise conclusory opinion. Here, the court found that the record appeared to support Dr. Rossing’s opinion, including evidence that Mike S. needed assistance moving and was at high risk for falls.

Finally, the court rejected the stated reason that the opinion lacked specific vocationally relevant limitations. The court explained that a medical opinion must address the related impairment and its nature and severity, but it need not contain specific vocational limitations.

Disposition

The court granted Mike S.’s motion for summary judgment and denied the Commissioner’s motion for summary judgment. It remanded the matter to the Commissioner for further proceedings under sentence four of 42 U.S.C. § 405(g).

On remand, the administrative law judge must evaluate Dr. Rossing’s opinion about persistent cerebrovascular risk factors, postural instability, vocal dysfunction, and chronic vestibular dysfunction; give good reasons for the weight assigned to that opinion; and reconsider the residual functional capacity finding and the decisions at steps four and five. The court did not itself decide whether Mike S. is entitled to disability benefits.