Jones v. Saul

Background

Willie L. Jones sought judicial review of the Commissioner of Social Security’s final decision denying his applications for Disability Insurance Benefits and Supplemental Security Income. He alleged that back and left-shoulder problems, gout, high blood pressure, obesity, and acid reflux prevented him from working. The administrative law judge found that Jones was not disabled, determined that he could perform light work with no overhead work using his left arm, and concluded that he could perform jobs such as inspector and hand packager, mail clerk, or small parts assembler.

Both sides moved for judgment on the pleadings, which asks the court to decide the case based on the existing record when there is no material factual dispute. Jones argued that the administrative law judge violated the treating-physician rule by giving little weight to the opinions of Dr. David Shein, his treating physician. Jones also argued that the judge improperly evaluated his testimony about pain and limitations. The Commissioner argued that the medical opinions and testimony were properly evaluated and that substantial evidence supported the decision.

Analysis

Magistrate Judge Barbara Moses concluded that the administrative law judge violated the treating-physician rule. Because Jones filed his claims before March 27, 2017, the applicable rule generally required the administrative law judge to give controlling weight to a treating physician’s well-supported opinion that was not inconsistent with the record, or to give good reasons for assigning it less weight. The administrative law judge instead relied largely on his own interpretation of examination findings and imaging, without adequately addressing the treatment relationship, Dr. Shein’s orthopedic expertise, or the consistency of his opinions with the record.

The report identified several non-trivial factual errors. The administrative law judge stated that Jones had a full range of motion, negative straight-leg-raise tests, and no assistive-device use. The record, as described in the report, showed reduced lumbar and left-shoulder motion, repeated positive straight-leg-raise findings, and use of a prescribed corset. The administrative law judge also relied on improvement from physical therapy that concerned Jones’s right knee, rather than the back, shoulder, or mobility problems involved in his disability claim. The report further noted that later injections were less successful and that Dr. Shein prescribed oxycodone for severe pain.

The report also concluded that the administrative law judge improperly evaluated Jones’s testimony. The judge relied on the same inaccurate medical facts and on daily activities such as shopping, preparing light meals, and personal care. The report explained that those activities did not necessarily conflict with Jones’s claimed inability to sit or stand for long periods or walk more than a short distance. The administrative law judge also did not adequately consider the type, dosage, effectiveness, and side effects of Jones’s treatment.

Because the medical-opinion analysis and symptom evaluation were flawed, the residual functional capacity finding—the determination of what a person can still do despite medical limitations—was not supported by substantial evidence. The report found that the errors were not harmless because the administrative law judge rejected restrictions identified by both physicians and did not adequately address Jones’s ability to sit, stand, and walk.

Recommendation and procedure

The report recommended that Jones’s motion be granted, the Commissioner’s motion be denied, and the action be remanded for further proceedings. It recommended that the administrative law judge reevaluate the medical opinions, obtain new opinion evidence if necessary, reassess Jones’s symptoms, and reformulate his residual functional capacity. The document is a report and recommendation by Magistrate Judge Moses to Judge Lorna G. Schofield, not a final district-court order in the text provided. The parties were given 14 days to file objections.