Moore v. Berryhill

Background

Delmar A. Moore sought review of the Commissioner of Social Security’s decision denying his applications for Social Security Disability and Supplemental Security Income benefits. Moore alleged epilepsy, depression, and anxiety. After hearings in 2016, 2017, and 2018, an Administrative Law Judge (ALJ) found that Moore was not disabled. The Appeals Council denied review.

The ALJ found that Moore had severe epilepsy, seizures, depression, and anxiety disorders, but that none met or equaled a listed impairment. The ALJ determined that Moore could perform light work with restrictions against driving, working at unprotected heights, and operating power tools or heavy machinery. Because the ALJ found that Moore could perform other jobs existing in significant numbers in the national economy, the ALJ denied benefits.

Moore argued that he was disabled under the epilepsy listing, that the ALJ improperly discounted the opinion of his treating psychiatrist, Peter Heiman, M.D., and that the ALJ improperly evaluated his testimony about his symptoms and limitations.

Standards and Issues

The court reviewed whether the Commissioner applied the correct legal standards and whether the decision was supported by substantial evidence, meaning relevant evidence that a reasonable person could accept as adequate. The court considered the parties’ cross-motions for judgment on the pleadings, which are decided when the material facts are not disputed and one party is entitled to judgment based on the law.

The court focused on three issues: whether Moore met the epilepsy requirements in Listing 11.02A or 11.02B; whether the ALJ properly applied the treating-physician rule to Dr. Heiman’s mental residual functional capacity opinion; and whether the ALJ properly evaluated Moore’s testimony.

Epilepsy Listing

The court upheld the ALJ’s conclusion that Moore did not establish the required adherence to prescribed treatment for Listing 11.02A or 11.02B. The listings required qualifying seizures despite adherence to prescribed treatment for the specified period.

The record contained evidence that Moore sometimes missed medication doses or took less medication than prescribed. The court relied on reports from Dr. Boro, Dr. Gulati, and medical expert Dr. Willer supporting the ALJ’s finding that Moore had not shown the required treatment adherence. The court acknowledged that the record also contained evidence that Moore was sometimes compliant, but held that the evidence supporting the ALJ’s finding was substantial and required deference to that finding.

Treating Psychiatrist’s Opinion

The court found that the ALJ did not properly apply the treating-physician rule to Dr. Heiman’s opinion. Under that rule, a well-supported opinion from a treating medical source receives controlling weight when it is not inconsistent with other substantial evidence. If controlling weight is not given, the ALJ must consider factors such as the length and nature of the treatment relationship, supporting evidence, consistency with the record, and the doctor’s specialization. The ALJ must also give good reasons for the weight assigned.

The ALJ gave Dr. Heiman’s opinion only “some weight,” stating that it was based on limited treatment notes, lacked a neuropsychiatric evaluation, appeared to rely more on subjective complaints than objective evidence, and conflicted with Moore’s daily activities. The court found that this explanation was insufficient. The statement about subjective evidence was conclusory, and the ALJ did not adequately address whether Dr. Heiman’s opinion was consistent or inconsistent with the entire record.

The court also rejected the view that Moore’s ability to perform simple household tasks and prepare meals necessarily conflicted with Dr. Heiman’s opinions about Moore’s concentration, cognitive abilities, and social interaction. Although the record contained medical findings that contradicted Dr. Heiman’s opinion, it also contained evidence supporting it, including opinions from Dr. Mahoney and observations in hospital records. The court stated that the ALJ had to resolve those conflicts while applying the treating-physician rule.

The court further explained that the ALJ has a duty to develop the record when a relevant medical report contains a conflict or ambiguity that must be resolved. Because the ALJ identified the limited nature of Dr. Heiman’s treatment notes but did not seek clarification or otherwise adequately address the missing support, the court held that the ALJ failed to provide good reasons for discounting the opinion. That failure required remand.

Evaluation of Moore’s Testimony

The court did not reach the merits of Moore’s argument that the ALJ improperly evaluated his testimony. The ALJ’s assessment relied at least partly on the treatment record, and that record could change after the case was remanded for further consideration of Dr. Heiman’s opinion.

Disposition

The court granted Moore’s motion for judgment on the pleadings and denied the Commissioner’s cross-motion for judgment on the pleadings. It vacated the Commissioner’s denial of benefits and remanded the case for further proceedings. The court upheld the ALJ’s finding concerning the epilepsy listing, but required further proceedings because the ALJ had not properly evaluated the treating psychiatrist’s opinion.