Carreras v. Commissioner of Social Security

Background

Wallner Alfredo Carreras sought judicial review under 42 U.S.C. §§ 405(g) and 1383(c)(3) of the Commissioner of Social Security’s final decision denying his applications for Disability Insurance Benefits and Supplemental Security Income. Carreras alleged disability based on spinal problems and sciatica. An administrative law judge (ALJ) found that he had severe lumbar and cervical spine disorders and had undergone an L5-to-S1 spinal fusion, but concluded that he could perform sedentary work with several restrictions. Based on that finding, the ALJ ruled that Carreras was not disabled.

The Commissioner moved for judgment on the pleadings, meaning a decision based on the parties’ written submissions and the administrative record, asking the court to uphold the ALJ’s decision and dismiss the case. Carreras did not oppose the motion.

Court’s Analysis

The court held that the ALJ failed to fulfill the duty to develop the administrative record. The record contained no operative or pre-operative reports for Carreras’s reported May 2016 back surgery, and there was a seven-month gap in treatment records. The medical expert whose opinion the ALJ gave some weight identified unresolved inconsistencies about whether the surgery occurred, the level of the spine involved, and the reason for the surgery.

The missing records were important because the ALJ relied both on evidence that Carreras had improved after surgery and on the medical expert’s concern that it was unclear whether or why the surgery had occurred. The ALJ also relied on these matters when evaluating the consistency of Carreras’s statements about the severity of his pain. Without records establishing whether the surgery occurred, its nature, and its purpose, the court could not properly review the ALJ’s evaluation of Carreras’s statements against the medical evidence.

The court rejected the argument that the agency had satisfied its duty merely because the ALJ had requested records from several medical providers and Carreras’s counsel had stated at the hearing that the record was complete. The court stated that the Commissioner, rather than the court, must resolve evidentiary conflicts and that the ALJ had to obtain the missing records or explain the inconsistency if no records existed.

Disposition

Judge Sarah Netburn denied the Commissioner’s motion. The case was remanded to the Commissioner for further development of the record. The court directed that the agency seek evidence showing whether Carreras’s surgery occurred, the exact nature of the surgery, and the reason for it, to the extent the surgery was relevant. The Clerk was requested to terminate the motion, close the case, and mail a copy of the opinion to Carreras as a pro se plaintiff.