Ritchie v. Berryhill

Background

Melanie M. Ritchie sought review of the Social Security Administration’s decision concerning Supplemental Security Income and Social Security Disability Insurance. The administrative law judge found that she was disabled from October 9, 2015 through October 25, 2017, but concluded that her disability ended on October 26, 2017 because of medical improvement. The parties did not dispute the finding that she was disabled during the earlier period. The dispute concerned only the period beginning October 26, 2017.

The administrative law judge relied heavily on records concerning Ritchie’s spinal cord stimulator. Those records described substantial relief shortly after the device was implanted and stated that she could return to work on October 25, 2017, subject to restrictions against bending, lifting, or twisting for three months. The administrative law judge gave significant weight to the statement that she could return to work but little weight to the accompanying physical restrictions. He found that, after October 26, 2017, she could perform sedentary work with additional restrictions and that jobs existed in significant numbers that she could perform.

The record contained very little medical evidence after the permanent spinal cord stimulator was implanted on September 25, 2017. The latest relevant back-treatment note was from October 11, 2017. The only medical record during the period under review concerned an examination for abdominal pain, not back treatment. At the hearing, Ritchie testified that the stimulator reduced but did not eliminate her pain, that she had good and bad days, and that she continued to have difficulty sitting, standing, bending, walking, and performing household activities.

Court’s Analysis

The court held that the administrative law judge had not adequately developed the record. In a Social Security disability case, the administrative law judge has an affirmative duty to obtain necessary medical information, even when the claimant has a lawyer. That duty included addressing the apparent conflict between the treating doctor’s statement that Ritchie could return to work and the doctor’s restrictions against bending, lifting, and twisting.

The court found that the administrative law judge did not give adequate reasons for assigning little weight to those restrictions. The court also found that the administrative law judge should have sought clarification from the treating doctor and obtained any additional treatment records from the period after the permanent implantation.

The court further concluded that the administrative law judge did not properly evaluate Ritchie’s testimony about her pain and functional limitations. The decision largely relied on the positive reports made shortly after the procedures, without determining whether those reports reflected sustained improvement. The administrative law judge also did not expressly consider the required factors for evaluating reported symptoms, and the court found that the record did not support some of the specific restrictions included in the residual functional capacity finding.

The court stated that these errors were not harmless because additional evidence could affect the evaluation of the treating doctor’s opinion, Ritchie’s testimony, her residual functional capacity, and the ultimate disability determination. The court did not decide whether Ritchie was disabled after October 25, 2017.

Disposition

Judge Debra Freeman granted Ritchie’s motion for judgment on the pleadings and denied the Commissioner’s cross-motion. The case was remanded for further proceedings under sentence four of 42 U.S.C. § 405(g).

On remand, the administrative law judge was directed to seek clarification from the treating doctor about the functional restrictions; obtain complete records from medical sources who treated or evaluated Ritchie’s back after the permanent spinal cord stimulator implantation; and obtain a medical source statement with a function-by-function assessment, or a consultative examination if necessary. The administrative law judge must then reweigh the medical opinions, reevaluate Ritchie’s reported symptoms, reassess her residual functional capacity, and, if appropriate, obtain additional testimony from a vocational expert.