Debbie L. D. v. O'Malley

Background

Debbie L. D. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s decision denying her applications for Disability Insurance Benefits and Supplemental Security Income. She alleged that she became disabled on May 2, 2019. After the Social Security Administration denied her applications and reconsideration request, an administrative law judge held a hearing on May 10, 2022. Debbie was represented by counsel and testified. A vocational expert also testified that she could perform her past work as a home health aide and, alternatively, could perform other jobs existing in significant numbers in the national economy.

The administrative law judge found several severe physical impairments, including lumbar degenerative disc disease, chronic pain syndrome, orthostatic hypotension, and chronic obstructive pulmonary disease. The judge also found that Debbie had non-severe migraine headaches, gastroesophageal reflux disease, vertigo, major depressive disorder, and anxiety. The judge found mild limitations in all four areas of mental functioning considered under the disability regulations, but assessed a work capacity involving medium work with physical and environmental restrictions and no mental restrictions.

Issues

Debbie argued that the work-capacity assessment was unsupported because it did not include the mild mental limitations found at the second step of the disability analysis and did not explain their omission. She also argued that the administrative law judge improperly rejected Certified Nurse Practitioner Katie Swanson’s opinion that Debbie needed a walker.

Court’s analysis

The court held that an administrative law judge must consider all impairments, including non-severe impairments, when determining residual functional capacity. Residual functional capacity means the most a person can still do despite physical or mental limitations. A finding of mental impairment at the second step does not automatically require mental restrictions in the residual functional capacity assessment. But when the assessment leaves out mental impairments entirely, the administrative law judge must explain why.

Here, the administrative law judge found mild limitations in understanding and applying information, interacting with others, concentrating and maintaining pace, and adapting or managing oneself. The judge did not include any mental limitations in the residual functional capacity assessment and gave no specific explanation for that omission. The court found that the boilerplate explanation provided was insufficient. Because the assessment was incomplete, the court found that substantial evidence—relevant evidence that a reasonable person could accept as adequate—did not support the conclusion that Debbie could perform her past work. The finding that she could perform other unskilled work did not correct the problem because the record did not adequately address her ability to meet the mental demands of that work.

On the walker issue, the court upheld the administrative law judge’s evaluation of Nurse Swanson’s opinion. The judge found the opinion unpersuasive because clinical findings and objective evidence did not show an ongoing need for a walker. The records cited by the judge included examinations showing normal strength, sensation, gait, and range of motion, as well as a January 2022 emergency-room examination with normal neurological findings. Debbie testified that she used a walker daily in the house because of occasional dizziness, but used it outside only sometimes. The court concluded that a reasonable person could accept the evidence supporting the administrative law judge’s finding, even though evidence also supported Debbie’s position.

Disposition

The court granted in part and denied in part Debbie L. D.’s motion for judgment on the administrative record. It also granted in part and denied in part the defendant’s motion. The court remanded the case to the Commissioner under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with the order. The remand requires further consideration of the mild mental limitations and their effect, if any, on residual functional capacity; the court did not reject the administrative law judge’s finding concerning the walker.