Gomez v. Commissioner of Social Security

Background

Victor Jose Gomez sought disability insurance benefits under Title II of the Social Security Act. He alleged disability beginning March 13, 2015, based on physical pain and mental-health conditions. After a hearing, Administrative Law Judge Lynn Neugebauer found that Gomez had severe spinal, left-knee, and major-depressive impairments, but retained the residual functional capacity (RFC)—his ability to work despite his impairments—to perform medium work limited to simple, routine tasks. The ALJ found that Gomez could not return to his prior porter job but could perform other jobs in the national economy. The Appeals Council declined review, making the ALJ’s decision the Commissioner’s final decision.

The parties filed cross-motions for judgment on the pleadings under Federal Rule of Civil Procedure 12(c). The district court reviewed whether the Commissioner applied the correct legal standard and whether substantial evidence supported the decision. Substantial evidence means relevant evidence that a reasonable person could accept as adequate to support a conclusion.

Failure to Develop the Record and Reliance on the Grids

The court held that the ALJ failed to develop the record at the step-five inquiry, where the Commissioner must determine whether a claimant can perform other work. The ALJ relied on the Medical-Vocational Guidelines, commonly called the Grids, even though the record included both exertional limitations—such as limits on lifting, carrying, standing, and walking—and nonexertional limitations, including pain, depression, and postural restrictions.

The court explained that when nonexertional limitations may significantly reduce the range of available work, the ALJ must obtain useful testimony from a vocational expert. Although vocational expert Christina Boardman testified about the classification and strength level of Gomez’s past porter work, the ALJ did not ask hypothetical questions addressing Gomez’s particular physical and mental limitations. The expert also did not identify jobs in the national economy that Gomez could perform. The court therefore found that the record did not adequately support the step-five determination.

Insufficient Support for the Medium-Work RFC

The court also held that substantial evidence did not support the finding that Gomez could perform medium work. Medium work involves lifting up to 50 pounds at a time and frequent lifting or carrying of objects weighing up to 25 pounds. Gomez testified that lifting grocery bags caused pain, and physical therapist Rajeshkumar Patel recorded that Gomez was unable to carry items or lift and move boxes because of pain. Dr. Michelle Torres-Acosta also recommended limits on lifting, pushing, pulling, carrying, stooping, bending, and reaching.

The court found that the ALJ did not adequately explain how this evidence supported a medium-work capacity. It further held that the ALJ improperly gave significant weight to the one-time consultative examination by Dr. Cheryl Archbald while giving substantially less weight to opinions from treating physician Dr. Angel Ruiz and Dr. Torres-Acosta. The ALJ relied on generally normal examination findings but did not adequately address evidence of reduced motion, muscle spasms, pain, and other limitations.

Function-by-Function Assessment

The court held that the ALJ also failed to assess Gomez’s work-related abilities on a function-by-function basis before assigning an exertional work level. Those functions included standing, sitting, walking, lifting, carrying, pushing, pulling, and relevant mental and environmental abilities. The court recognized that an ALJ does not always need to provide a separate written discussion of every function, but found remand appropriate here because the ALJ did not address all relevant limitations and did not cite medical evidence supporting the medium-work conclusion.

Mental Functioning and Language Issue

The court upheld the ALJ’s assessment of Gomez’s mental functioning. The record generally showed logical thought, normal thought content and perception, intact memory, cooperative behavior, clear speech, and largely intact concentration and attention. The court gave little weight to GAF scores of 50 and 59 because the providers did not explain the reasons for those scores or the periods to which they applied, and the scores did not provide a reliable long-term picture of Gomez’s mental functioning.

The court did not decide Gomez’s argument that the ALJ should have made a language determination. It concluded that the regulation on which Gomez relied had been revised to remove that requirement.

Disposition

The court concluded that the Commissioner’s decision was not supported by substantial evidence. It reversed and remanded the case for further proceedings consistent with the opinion. The court stated that the additional medical evidence submitted to the Appeals Council should be considered on remand, but that the new evidence was not the basis for the remand. The opinion does not state separate dispositions for the parties’ cross-motions beyond the order reversing and remanding the Commissioner’s decision.