Plaza v. Commissioner of Social Security

Background

Jenny Marie Plaza sought review of the Commissioner of Social Security’s final decision denying her Social Security Disability Insurance benefits under Title II of the Social Security Act. She alleged disability beginning January 4, 2016, based on insomnia, sciatica, pain, anxiety, depression, and asthma. The administrative law judge found severe impairments involving degenerative disc disease and depressive disorder, but concluded that Plaza could perform light work with limits to simple, one- and two-step instructions and tasks. The judge found her not disabled.

The administrative law judge gave little weight to several opinions from Plaza’s treating physician, Dr. Brian Delaney, and greater weight to opinions from consultative examiners. The judge also relied on the Medical-Vocational Guidelines, commonly called the grids, without testimony from a vocational expert. Plaza challenged that decision in the district court. The Commissioner opposed her motion and sought judgment affirming the denial.

Court’s Analysis

The court identified three significant errors.

First, the administrative law judge mischaracterized the medical evidence. The judge described a June 2016 lumbar-spine magnetic resonance imaging scan as showing only mild or early degenerative disc disease, but the report described a disc herniation, an annular tear, deformity of the thecal sac, disc narrowing, bulging discs, and extensions reaching the nerve roots. A July 2016 lumbar X-ray also showed moderate degenerative changes. The court concluded that the administrative law judge improperly substituted a non-medical interpretation for medical evidence and relied on that mistaken interpretation when discounting Dr. Delaney’s opinions. The court also found that, if the judge believed Dr. Delaney’s opinions were inconsistent with the medical evidence, the judge should have sought clarification before rejecting them.

Second, the administrative law judge failed to address Plaza’s reports that her medications caused drowsiness, insomnia, disorientation, and difficulty concentrating. The record included reports of side effects from Zoloft, muscle relaxants, and Wellbutrin, as well as emergency-room notes linking some symptoms to Wellbutrin. The court held that the judge was required to consider these complaints and clearly explain any decision to discount them when determining Plaza’s residual functional capacity, meaning her ability to perform work-related activities on a sustained basis.

Third, the administrative law judge relied exclusively on the grids even though the judge had recognized non-strength-related limitations, including depression, limits to simple tasks, and moderate difficulties with concentration, persistence, and pace. The court explained that when such limitations significantly reduce the range of available work, the grids cannot alone determine whether a claimant is disabled. The administrative law judge had not explained why Plaza’s non-strength-related limitations had only a negligible effect. If those limitations significantly reduced her work capacity, vocational-expert testimony would be required.

The court rejected Plaza’s separate argument that the administrative law judge had to include asthma, vision impairment, uterine fibroids, and psoriasis in the residual-functional-capacity assessment. The court found substantial evidence supporting the conclusion that those conditions were non-severe or caused no documented work-related limitations.

Disposition

Judge Debra Freeman granted Plaza’s motion for judgment on the pleadings to the extent it sought remand for further administrative proceedings and denied the Commissioner’s cross-motion. The court remanded the case under sentence four of 42 U.S.C. § 405(g). On remand, the administrative law judge must reassess the mischaracterized medical evidence, reconsider Dr. Delaney’s opinions and provide adequate reasons for the weight assigned to them, reevaluate Plaza’s complaints about symptoms and medication side effects, reconsider her residual functional capacity, and determine whether vocational-expert testimony is needed. The court did not decide that Plaza was entitled to benefits.