Mai V. v. O'Malley

Background

Mai V. sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s final decision denying her applications for disability insurance benefits and supplemental security income. She alleged disability beginning October 7, 2019, based on moyamoya disease, multiple strokes, diabetes, diabetic neuropathy, left carotid stenosis, and mental-health conditions.

The administrative law judge found that Mai V. had severe impairments including obesity, diabetes, a stroke caused by moyamoya disease, depression, and anxiety. The judge found that she could perform a limited range of light work, but included no left-hand restrictions. Based on testimony from a vocational expert, the judge concluded that Mai V. could not perform her past work as a home attendant but could perform other jobs, including small-products assembler, inspector and hand packager, and garment sorter.

Mai V. challenged the decision on two grounds: that the administrative law judge failed to account for the lasting effects of her strokes in assessing her residual functional capacity, meaning the most work she could still perform; and that the judge improperly evaluated the medical opinion of Dr. Sarah Hammes. The Commissioner opposed the challenge and moved for summary judgment, asking the court to affirm the decision.

Left-Hand Limitations

The court held that substantial evidence did not support the administrative law judge’s decision to include no left-hand limitations in the residual functional capacity. Before Mai V.’s December 2020 stroke, medical evidence documented ongoing left-sided problems following her November 2018 stroke. In October 2020, she reported that her left hand and leg were weaker or less functional than the right, and Dr. Ward Jankus agreed that about 80% functionality was realistic. In November 2020, Dr. Sarah Hammes documented left-hand weakness, numbness, and tingling.

The court also found that the administrative law judge mischaracterized or failed to resolve confusion in Mai V.’s hearing testimony about which stroke she meant and when her left-hand problems began. The court noted that the record identified strokes in 2013, 2017, 2018, and 2020, while the hearing repeatedly referred to a “first” or “second” stroke. Because the jobs identified at the final step of the disability analysis required frequent reaching and handling and at least occasional fingering, the error was not harmless. The court remanded for the administrative law judge to consider whether Mai V.’s left-hand limitations met the 12-month duration requirement, giving particular attention to her testimony and the related medical evidence.

The court did not require the administrative law judge to obtain testimony from a medical expert or order another consultative examination, although it stated that the judge could choose to do so on remand.

Dr. Hammes’s Medical Opinion

Dr. Hammes completed a medical source statement in January 2021, shortly after Mai V.’s December 2020 stroke. The opinion described substantial restrictions, including limits on lifting, standing, walking, sitting, changing positions, using the left foot, and handling or fingering with the left hand.

The administrative law judge found the opinion unpersuasive, partly because it was allegedly inconsistent with examination findings, treatment notes, other providers’ observations, the course of treatment, consultative examinations, and Mai V.’s overall functioning. The court held that these general references did not adequately explain how the judge considered the regulatory factors of supportability and consistency. Supportability concerns how well a medical source explains and supports an opinion; consistency concerns how well the opinion fits with evidence from other sources.

The court also rejected the administrative law judge’s treatment of Dr. Hammes’s opinion as addressing only the effects of the December 2020 stroke. The court stated that considering each stroke in isolation disregarded the chronic and progressive nature of moyamoya disease, and that the confusion about the stroke dates led the administrative law judge to misunderstand the scope of Dr. Hammes’s opinion. The court therefore remanded for consideration of Dr. Hammes’s opinion under 20 C.F.R. §§ 404.1520c and 416.920c.

Dr. Jankus’s Findings

The court rejected Mai V.’s separate argument that the administrative law judge’s restriction against constant handling, fingering, or reaching was inconsistent with Dr. Jankus’s finding that her left arm and hand functioned at about 80%. Dr. Jankus also observed symmetric strength, a smooth gait, only trace clumsiness and weakness in the left hand, and no severe fine-motor problems. The court held that these objective findings were not inconsistent with handling, fingering, or reaching two-thirds or more of the time. The court noted, however, that Dr. Jankus did not identify specific left-arm or left-hand work restrictions.

Disposition

Judge John F. Docherty granted the relief requested in Mai V.’s brief, reversed the Commissioner’s decision, and remanded the matter under sentence four of 42 U.S.C. § 405(g) for further administrative proceedings. The remand requires consideration of whether any left-hand limitations satisfied the 12-month duration requirement and reconsideration of Dr. Hammes’s medical opinion under the applicable regulations. The court denied the Commissioner’s motion for summary judgment.