Romero v. Commissioner of the Social Security Administration

Background

Annette Sanabria Romero sought judicial review under the Social Security Act of the Commissioner’s decision finding that she was not disabled from December 23, 2014, through August 22, 2017. The administrative law judge (ALJ) found that Romero had severe upper-extremity, obesity, and knee impairments. The ALJ determined that she had the residual functional capacity (RFC)—the most she could do despite her limitations—to perform light work with restrictions. Relying on vocational-expert testimony, the ALJ found that Romero could perform her past work as a clerk typist and residence supervisor.

Romero challenged the ALJ’s handling of the medical record, the spinal-disorder listing, the RFC assessment, her reports of symptoms, and the finding that she could perform past relevant work. The parties submitted a joint stipulation instead of separate motions for judgment on the pleadings.

Failure to Develop the Record

The court held that the ALJ did not satisfy the duty to develop the record. The only functional assessment came from Dr. Rita Figueroa’s one-time consultative examination. Dr. Figueroa described Romero’s limitations as “marked,” “mild,” and “moderate,” but did not explain what those terms meant in practical work-related abilities.

Romero’s treating physicians, including Dr. Enrique Sanz, Dr. Esteban Cuartas, and Dr. Gina Del Savio, had treated her repeatedly over extended periods but had not provided opinions describing her functional abilities. The ALJ did not request those opinions. The court found that Dr. Figueroa’s assessment was also in tension with treatment records describing antalgic or abnormal gait, back and leg problems, and hand and wrist impairments. Because the record contained a vague assessment from a single examination and no functional assessments from the treating physicians, the court found an important gap requiring remand.

Treating-Physician Rule

The court also held that the ALJ did not properly apply the treating-physician rule. That rule requires consideration of factors such as the length and frequency of treatment, the nature of the treatment relationship, supporting medical evidence, consistency with the record, and the physician’s specialty.

The ALJ gave only “some” weight to the treating physicians’ opinions and stated that their workers’ compensation disability opinions had no evidentiary value because workers’ compensation and Social Security use different standards. The court found that these reasons effectively treated the workers’ compensation setting as a basis for disregarding the treating physicians’ opinions. The ALJ did not adequately discuss the treating physicians’ medical findings, their specialties, the consistency of their findings with Romero’s reported limitations, or the differences between their findings and Dr. Figueroa’s assessment.

Spinal-Disorder Listing

The court further found that the ALJ failed to address Listing 1.04, concerning disorders of the spine, even though Romero identified spinal conditions as disabling and the medical evidence documented several spinal diagnoses. The court determined that the failure to address the potentially applicable listing independently supported remand.

Disposition

The court found that the ALJ failed to develop the record, failed to satisfy the treating-physician rule, and failed to address an applicable listing. Pursuant to sentence four of 42 U.S.C. § 405(g), which authorizes a court to reverse or modify the Commissioner’s decision and remand for further proceedings, the court vacated the Commissioner’s decision and remanded the case. Plaintiff’s motion was granted, the Commissioner’s motion was denied, and the court did not reach the parties’ remaining arguments.