Jose M. A. v. Kijakazi

Background

Jose M. A. 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 from physical and mental conditions, including back and neck pain, limitations involving his left arm, pain radiating into his legs, balance problems, falls, and depression.

The administrative law judge found severe physical impairments involving the major joints, arthropathies, and the spine. The administrative law judge recognized an affective disorder but found it non-severe, concluding that it caused no more than mild limitations in understanding and applying information, interacting with others, concentrating and maintaining pace, and adapting or managing himself. The administrative law judge then found that Jose M. A. could perform restricted light work and could adjust to jobs such as counter clerk, bakery worker, and usher.

Mental impairments

The court held that the administrative law judge erred at step two of the disability evaluation by finding that Jose M. A.’s mental impairment was non-severe. The administrative law judge gave little weight to the opinions of state agency psychologists Vivian Pearlman, Ph.D., and Russell Ludeke, Ph.D., who identified moderate limitations in areas including understanding, remembering, applying information, concentration, persistence, and pace.

The court agreed that the lack of an examining or treating relationship could be considered when weighing those opinions. But it found that the other reasons given were erroneous. The medical records cited as inconsistent with the psychologists’ opinions actually documented findings including a sad or dysphoric mood, anxiety, impaired concentration, poor insight, poor judgment, poor motivation, severe major depressive disorder, serious and persistent mental illness, and a need for partial hospitalization. The record also did not contain the significant additional mental-health treatment that the administrative law judge said occurred after the psychologists issued their opinions.

The court further held that the administrative law judge failed to consider Jose M. A.’s statements about his mental-health symptoms at step two. The court explained that the patient-completed generalized anxiety and depression questionnaires were subjective evidence but remained relevant to determining whether the mental impairment was severe. Because the administrative law judge did not later account for the effects or functional limitations of the mental impairments, the court found the errors were not harmless.

Medical opinions and residual functional capacity

The court also held that the administrative law judge erred in evaluating opinions from treating physician Dr. Kelly Collins. The administrative law judge discounted those opinions because one relied on a functional capacity evaluation, because Dr. Collins had stated that Jose M. A. had no medical reason for his pain and might benefit from working, and because the opinions appeared inconsistent with imaging, other diagnostic evidence, and physical examinations.

The court found those reasons inadequate. Dr. Collins had ordered the functional capacity evaluation to confirm limitations she had already identified, and reliance on that evaluation was comparable to relying on an imaging study ordered by a physician but performed by another provider. The court also found that Dr. Collins’s statements about there being no medical reason for the pain referred to the lack of imaging or other objective findings fully explaining it, not to the absence of a chronic pain syndrome. The court concluded that the administrative law judge failed to account for the psychological component of that syndrome. It also found that Dr. Collins’s statement that people with chronic pain syndrome may do better working was consistent with her later opinion that Jose M. A. could work only with significant restrictions.

The court did not find that the administrative law judge erred in evaluating the opinions of state agency physical consultants Gregory Salmi, M.D., and Paul Ossman, M.D. However, it directed the administrative law judge to reconsider those opinions if the reevaluation of Dr. Collins’s opinions warranted it. The court likewise did not find error in one stated reason for discounting Dr. Thomas Nelson’s opinion, but held that the administrative law judge could not discount workers’ compensation opinions across the board merely because they were prepared in that setting. Reconsideration of Dr. Nelson’s opinion might also be warranted after reevaluating Dr. Collins’s opinions and the psychological component of Jose M. A.’s pain.

Disposition

The court granted Jose M. A.’s motion for summary judgment and denied the Defendant’s motion for summary judgment. It reversed the Commissioner’s decision and remanded the matter to the Social Security Administration under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings. On remand, the administrative law judge must reconsider whether the mental impairments are severe, reevaluate the specified medical opinions, consider Jose M. A.’s statements about his mental-health symptoms, and reassess the relevant functional limitations. If the residual functional capacity changes, the administrative law judge should pose a new question to a vocational expert.