Barbara M. v. Saul

Background

Barbara M. challenged the Commissioner of Social Security’s denial of her application for disability insurance benefits under Title II of the Social Security Act. She alleged disability based primarily on chronic back and leg pain, complex regional pain syndrome, and related symptoms following a work injury and multiple procedures. The administrative law judge found that she could perform sedentary work with restrictions, including limits on sitting, standing, walking, and use of her left hand.

The parties filed cross-motions for summary judgment, which ask the court to decide whether the administrative decision was supported by the record. Barbara M. argued that the residual functional capacity assessment—the administrative law judge’s determination of what work-related activities she could still perform—should have included self-pacing and additional concentration limits. She also argued that the administrative law judge improperly evaluated opinions from treating physicians Dr. Hess and Dr. Will.

Court’s Analysis

The court concluded that substantial evidence supported the administrative law judge’s decision not to include a self-pacing limitation. The functional capacity evaluation recommended allowing Barbara M. to self-pace, but the court found that the record did not show a treating source had prescribed that limitation. The administrative law judge also considered medical findings, treatment, daily activities, and Barbara M.’s statements about pain and pacing.

The court also upheld the decision not to include additional cognitive limitations. Although the record contained evidence that pain and medication could affect concentration, the administrative law judge reasonably found no more than mild limitations in mental functioning based on the medical evidence, reported activities, and observations that Barbara M. was generally alert and had reasonable attention and concentration.

The court upheld the administrative law judge’s decision to give little weight to Dr. Hess’s opinions. It agreed that the opinion that Barbara M. was permanently and totally disabled addressed an issue reserved for the Commissioner. Although the administrative law judge incorrectly described Dr. Hess’s forms as lacking references to examination findings or objective evidence, the court determined that the decision as a whole addressed the different parts of Dr. Hess’s opinions and was supported by substantial evidence.

The court reached a different conclusion regarding Dr. Will’s opinion that Barbara M. would likely be absent from work about three times per month because of her impairments or treatment. The administrative law judge gave that part of the opinion little weight but did not identify the evidence contradicting it. The court noted Barbara M.’s frequent appointments and extensive treatment, as well as vocational-expert testimony that an employer would tolerate no more than two missed days per month. The court held that the administrative law judge needed to explain the reasons for the weight assigned to Dr. Will’s absenteeism opinion so the court could determine whether the residual functional capacity finding was supported by substantial evidence.

Disposition

The court granted in part and denied in part Barbara M.’s motion for summary judgment and granted in part and denied in part the Commissioner’s motion for summary judgment. It affirmed the Commissioner’s decision at steps one through four except for consideration of Dr. Will’s opinion about absenteeism, vacated the decision at step five, and remanded the matter to the Commissioner under sentence four of 42 U.S.C. § 405(g) for further proceedings. The court did not reach Barbara M.’s remaining step-five arguments concerning the vocational expert’s hypothetical questions and a qualified rehabilitation consultant’s opinion. On remand, the administrative law judge was also directed to make clear that the residual functional capacity and vocational-expert hypotheticals included the limitation to unskilled work. Judge Tony N. Leung signed the order.