Davis v. Commissioner of Social Security

Background

Ernestina Theresa Davis brought this action under 42 U.S.C. § 405(g) challenging the Commissioner of Social Security’s denial of her application for disability insurance benefits. Davis alleged that she became disabled on June 30, 2014. After a hearing, Administrative Law Judge Anne Sharrard denied the claim. The Appeals Council declined review, making the administrative decision subject to review by the district court.

The administrative law judge found that Davis had severe impairments including mild scoliosis, lower-lumbar disc bulges, cervical disc abnormalities with mild stenosis, chronic pain syndrome, and vertigo. The judge determined that Davis could perform light work with restrictions, including limits on lifting, climbing, standing, walking, reaching, and exposure to pulmonary irritants. The judge found that Davis could perform her past work as a hair stylist and, alternatively, could perform other jobs existing in significant numbers in the national economy.

Davis moved for judgment on the pleadings, meaning she asked the court to rule based on the administrative record. The Commissioner cross-moved for judgment on the pleadings and argued that the administrative decision was supported by sufficient evidence and used the correct legal standards.

Treating-Physician Evidence

Dr. Muhammad Sanni Adam completed forms stating that Davis had asthma and scoliosis, had been disabled since August 2006, required home-care assistance, and needed help with several daily activities. The administrative law judge gave Dr. Adam’s opinion little weight, describing it as vague and incomplete and stating that it was inconsistent with findings from consultative examiner Dr. Sharon Revan.

The court held that the administrative law judge failed to follow the treating-physician rule. Under that rule, an administrative law judge must first determine whether a treating physician’s opinion deserves controlling weight. If it does not, the judge must consider specified factors, including the treatment relationship, supporting medical evidence, consistency with the record, and the physician’s specialty, and must give good reasons for the weight assigned.

The court found that the administrative law judge did not explicitly consider those factors. The court also found that, because the judge considered Dr. Adam’s opinion vague and incomplete, the judge should have sought clarification rather than rejecting the opinion for that reason alone. In addition, the judge did not adequately explain why Dr. Adam’s opinion was unsupported or discuss relevant evidence from pain-management treatment, imaging, and earlier records from Siri Medical Associates.

The court further found that the administrative law judge used Dr. Revan’s opinion inconsistently. The judge relied on some findings from Dr. Revan’s examination to discount Dr. Adam’s opinion but did not explain why other findings, including a positive straight-leg-raise test and tenderness, were not considered in the same way.

Additional Evidence Before the Appeals Council

Davis submitted records from four 2015 and 2016 visits with Dr. Fenar Themistocle at Interborough Interventional Pain Management. Those records described painful and limited functioning, an antalgic gait, positive examination tests, and severe lower-back pain radiating to the lower extremities.

The Appeals Council rejected the records with the statement that they did not show a reasonable probability of changing the outcome. The court held that this explanation was insufficient because Dr. Themistocle qualified as a treating source and the records potentially contradicted some of Dr. Revan’s findings, supported Davis’s reports of pain, and could have affected the evaluation of Dr. Adam’s opinion. The court therefore directed that the records be considered on remand.

Other Argument

Davis also argued that the administrative law judge failed to consider medication side effects. The court did not decide that issue, or the Commissioner’s argument that substantial evidence supported the residual-functional-capacity and symptom findings, because the errors already identified required remand.

Disposition

The court granted Davis’s motion for judgment on the pleadings, denied the Commissioner’s cross-motion, and remanded the case for further proceedings consistent with the opinion. The clerk was directed to terminate the pending motions and close the case.