Cheryl J. v. Saul

Background

Cheryl J. challenged the Commissioner of Social Security’s denial of her application for disability insurance benefits. She alleged disability based in part on posttraumatic stress disorder, depression, and anxiety. After an administrative law judge denied her application and the Appeals Council declined review, the parties filed cross-motions for summary judgment.

Cheryl J. argued that the administrative law judge erred by failing to recognize autism-spectrum disorder as a medically determinable impairment and by improperly determining her residual functional capacity, meaning the most work she could perform despite her limitations. She also challenged the evaluation of her work history and statements about the intensity and effects of her symptoms.

Autism-Spectrum Disorder

The court upheld the administrative law judge’s finding that autism-spectrum disorder was not a medically determinable impairment under the regulations applicable to Cheryl J.’s 2015 application. At that time, evidence establishing such an impairment had to come from an acceptable medical source, such as a licensed physician or psychologist.

The autism assessment was conducted by Tamara Phillips, a licensed marriage and family therapist, who was not an acceptable medical source under the applicable regulations. Although Barbara Lushkin, a licensed psychologist, cosigned the diagnostic summary, the court found no evidence that Lushkin participated in the assessment or diagnosis. The court likewise found no evidence that Dr. Craig J. Vine participated in Cheryl J.’s treatment or diagnosis merely because he supervised Orman’s work. The court therefore concluded that the administrative law judge did not err in finding that the record lacked an autism-spectrum diagnosis or treatment by an acceptable medical source.

Residual Functional Capacity

The administrative law judge limited Cheryl J. to simple, routine, repetitive work involving only superficial interactions with others, with no conflict resolution or counseling. The administrative law judge gave little weight to a medical source statement prepared by Megan Gassner and cosigned by Deb Orman, and partial weight to the opinions of state-agency psychologists.

Gassner and Orman were not acceptable medical sources under the applicable regulations, but their opinions were still evidence that the administrative law judge was required to consider. Their statement described serious limitations, including difficulty maintaining concentration, persistence, and pace; difficulty dealing with coworkers, supervisors, and the public; and symptoms that could interfere with maintaining employment.

The court held that the administrative law judge did not adequately explain how the medical source statement was evaluated in light of Orman’s treatment notes and the other medical evidence. The administrative law judge relied on the statement’s checklist format and perceived internal inconsistencies, but did not clearly analyze whether the opinions were supported or contradicted by the underlying treatment records. The court also concluded that the administrative law judge appeared to draw personal conclusions about Cheryl J.’s work abilities from the treatment notes without clearly connecting those conclusions to the opinion evidence.

Disposition

Judge Tony N. Leung ordered that Cheryl J.’s motion for summary judgment was granted in part and denied in part, and that the Commissioner’s motion for summary judgment was granted in part and denied in part. The Commissioner’s decision was affirmed as to steps one through three of the disability analysis and vacated as to steps four and five. The matter was remanded to the Commissioner under sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with the opinion.

Because the residual-functional-capacity analysis had to be conducted again, the court did not reach Cheryl J.’s remaining argument about the consideration of her work history and symptom statements.