Diaz v. Commissioner of Social Security

Background

Mayra Diaz brought this action under 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking review of the Commissioner of Social Security’s final decision denying her application for Supplemental Security Income. Diaz proceeded without a lawyer. The Commissioner moved for judgment on the pleadings, asking the court to uphold the administrative decision and dismiss the case.

Diaz alleged that she could not work because of conditions including fibromyalgia, bilateral carpal tunnel syndrome, obstructive sleep apnea, degenerative disc disease of the cervical spine, asthma, headaches, depression, anxiety, and obesity. The administrative law judge found that Diaz had not engaged in substantial work activity, had several severe impairments, and did not have an impairment meeting or equaling a listed impairment. The administrative law judge determined that Diaz could perform light work with restrictions involving hand use, neck movement, balancing, climbing, environmental exposure, and simple work. Based in part on vocational testimony, the administrative law judge concluded that jobs existed in significant numbers in the national economy that Diaz could perform.

Issue

The principal issue was whether the administrative law judge properly evaluated the opinions of Diaz’s treating medical sources when determining her residual functional capacity—the most work she could perform despite her impairments.

Under the treating-physician rule applicable to this case, an administrative law judge generally must give controlling weight to a treating source’s opinion when it is well supported by medically acceptable techniques and is not inconsistent with the other substantial evidence. If the opinion is not given controlling weight, the administrative law judge must explain the weight assigned by considering regulatory factors, including the length and nature of the treatment relationship, supporting evidence, consistency with the record, and the source’s specialization.

Court’s Analysis

The court held that the administrative law judge did not properly apply the treating-physician rule. The administrative law judge declined to give controlling weight to Dr. Tolis’s opinions, which addressed Diaz’s ability to work, lifting, standing, walking, sitting, and other limitations. The administrative law judge also gave Dr. Faskowitz’s opinions “very little weight,” stating that they were poorly supported by his treatment notes.

The court found that these explanations were too general. The administrative law judge relied mainly on summary citations to other portions of the record and did not adequately explain how the treating sources’ opinions conflicted with the evidence. The court also found that the administrative law judge did not adequately evaluate the length and nature of Diaz’s treatment relationship with Dr. Faskowitz or the fact that he was her pain-management doctor.

The court further noted that the treatment notes were not necessarily inconsistent with the limitations described by Dr. Tolis and Dr. Faskowitz. Brief examinations showing findings such as a full range of motion, an abnormal gait, or no acute distress did not by themselves resolve whether Diaz could carry weight or stand, walk, and sit for extended periods without breaks. The court also found that the administrative law judge appeared to give more weight to the opinion of Dr. Gregory Grabon, a one-time consultative examiner, without adequately explaining why that opinion was preferred over the treating sources’ conflicting opinions.

Disposition

Judge Sarah Netburn granted Diaz’s motion for judgment on the pleadings. The court vacated the Commissioner’s denial of benefits and remanded the case to the Commissioner for proper analysis under the treating-physician rule. The court denied the Commissioner’s cross-motion for judgment on the pleadings. It also denied Diaz’s motion for pro bono counsel and directed the clerk to terminate the related docket entry. The decision did not award Diaz benefits; it required further administrative proceedings.