Mark S. E. v. Kijakazi

Background

Mark S. E. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s final decision denying his application for disability insurance benefits. He alleged disability beginning June 1, 2017, based primarily on post-traumatic stress disorder, anxiety, depression, and cervical arthritis. An administrative law judge (ALJ) found severe depression, anxiety, and post-traumatic stress disorder, but determined that Mark S. E. retained the capacity to perform work with several mental and environmental restrictions. The ALJ concluded that he could not return to his past work but could perform jobs such as cleaner, industrial washing machine operator, or laundry worker.

Mark S. E. moved for summary judgment, and the Commissioner filed a competing summary-judgment motion. Mark S. E. argued that the ALJ failed to include a limitation identified by psychological consultants, inadequately explained why she rejected an opinion from Dr. Rochelle Gredvig, failed to fully develop the record, and improperly evaluated his statements about the severity and effects of his symptoms.

Psychological Consultants’ Opinions and Residual Functional Capacity

The psychological consultants found that Mark S. E. could sustain simple one- to two-step tasks, had occasional difficulty sustaining concentration, persistence, and pace, would do best with brief and superficial interaction with others, and should not perform fast-paced tasks. The ALJ found these opinions persuasive and expressly described the one- to two-step limitation in her decision. However, the residual functional capacity (RFC)—the most a person can still do despite impairments—limited Mark S. E. to simple, routine tasks without fast-paced production requirements but did not expressly include the one- to two-step limitation.

The court held that when an ALJ finds an opinion persuasive, the ALJ must include its limitations in the RFC or explain why a limitation was omitted. The court found the omission significant because the jobs identified at the final step of the disability analysis were classified as requiring Level 2 reasoning, while one- to two-step instructions corresponded to Level 1 reasoning. If the one- to two-step limitation applied, those identified jobs would not have been available to Mark S. E. The court therefore required the ALJ on remand either to include that limitation in the RFC or explain its omission.

Dr. Gredvig’s Opinion

The court upheld the ALJ’s decision to find Dr. Gredvig’s August 2019 opinion unpersuasive. Dr. Gredvig had assessed marked limitations in several areas, including working with others, responding to supervisors, dealing with ordinary work stress, and traveling to unfamiliar places, and had stated that Mark S. E. would miss more than four days of work per month.

The court concluded that the ALJ’s reasons were supported by substantial evidence. Dr. Gredvig’s treatment notes generally showed improvement, normal or appropriate mood and affect, and cooperative behavior. The court also cited records from other providers, Mark S. E.’s reported activities, and the limited explanations and clinical findings supporting the check-box questionnaire. The court further noted that an opinion that a claimant cannot work addresses an issue reserved for the Commissioner.

Development of the Record and Symptom Evaluation

The court rejected Mark S. E.’s argument that the ALJ had to obtain additional medical opinions about his physical limitations. Although an RFC must be supported by medical evidence, the law does not require a specific medical opinion to support every RFC finding. The court found that medical records, physical examinations, imaging, treatment history, reported activities, and other evidence supported the ALJ’s physical RFC findings.

The court also upheld the ALJ’s evaluation of the intensity, persistence, and limiting effects of Mark S. E.’s symptoms. The court found substantial evidence supporting the ALJ’s conclusions that his symptoms improved with treatment, that mental-status findings were inconsistent with disabling severity, and that his reported activities were inconsistent with the degree of limitation he claimed.

Disposition

The court granted in part and denied in part Mark S. E.’s motion for summary judgment. It also granted in part and denied in part the Commissioner’s motion for summary judgment. The court reversed the Commissioner’s decision and remanded the matter under sentence four of 42 U.S.C. § 405(g) for further proceedings limited specifically to addressing the psychological consultants’ one- to two-step task limitation: the ALJ must include it in the RFC or explain why it was not included.