Dipaolo Koehler v. Commissioner of Social Security

Background

Ginamarie Dipaolo Koehler sought disability insurance benefits under 42 U.S.C. § 405(g), challenging the Commissioner of Social Security’s decision that she was not disabled under the Social Security Act. She alleged that she had been unable to work since August 25, 2015, because of fibromyalgia and other conditions. An administrative law judge found that she had severe fibromyalgia and obesity, but determined that she retained the residual functional capacity—the most she could still do despite her limitations—to perform a restricted range of light work. The administrative law judge also found that she could perform her past work as a medical secretary, medical clerk, and medical records supervisor.

Dipaolo Koehler moved for judgment on the pleadings, asking the court to overturn the administrative decision and remand the matter. The Commissioner cross-moved for judgment on the pleadings. Dipaolo Koehler argued that the administrative law judge improperly evaluated her treating physician’s opinions, obesity, expected absences, and subjective statements about pain and daily limitations.

Record-development issue

The court first considered whether the administrative law judge had failed to develop the record. It found no obvious gaps. The record included medical records from 2014 through 2019, opinions from treating physician Dr. Mark Thomas and state-agency consultant Dr. S. Ahmed, hearing testimony from Dipaolo Koehler and a vocational expert, and a function report. Dipaolo Koehler’s attorney had also stated at the hearing that no evidence was missing and raised no objections to the record.

Because the record was complete and did not contain an ambiguity or conflict requiring clarification, the court held that the administrative law judge was not required to contact Dr. Thomas again or order a consultative examination.

Medical opinions and residual functional capacity

The administrative law judge found Dr. Ahmed’s opinion persuasive and Dr. Thomas’s three assessments unpersuasive. Dr. Thomas had opined that Dipaolo Koehler’s symptoms and limitations prevented full-time competitive work, required frequent changes between sitting and standing, caused substantial restrictions on lifting and walking, and would lead to more than three absences per month. The administrative law judge found those opinions inconsistent with Dr. Thomas’s treatment records and with Dipaolo Koehler’s work history.

The court held that substantial evidence supported this evaluation. For example, Dr. Thomas’s 2019 assessment identified an abnormal gait, but his treatment notes from 2017 and 2018 described no gait problem and a steady gait without an assistive device. The court also found inconsistencies concerning when Dipaolo Koehler’s work-preclusive limitations allegedly began, because she continued working at substantial gainful activity levels until 2015. Under the regulations applicable to her claim, the administrative law judge was required to explain the opinions’ supportability and consistency, not to give automatic preference to a treating physician’s opinion. The court concluded that the administrative law judge adequately did so and could rely on Dr. Ahmed’s opinion when it was supported by the record.

Obesity

Dipaolo Koehler argued that the administrative law judge failed to account for obesity when assessing her residual functional capacity. The court acknowledged that the decision did not discuss obesity in the residual-functional-capacity section. It nevertheless found no basis for remand because the medical opinions and treatment records did not show that obesity worsened her other impairments or limited her ability to perform work-related activities. The court noted that the record repeatedly recognized her body-mass index, but no medical source attributed functional limitations or an exacerbation of her impairments to her weight. The court therefore found that the decision sufficiently accounted for obesity.

Expected absences

Dr. Thomas estimated that Dipaolo Koehler would miss work more than three times per month, and she testified that she had missed work and cosmetology classes because of her symptoms. The court explained that an administrative law judge may need to address expected absences when the record supports a specific absence-related limitation. Here, however, the administrative law judge had rejected Dr. Thomas’s opinions as unpersuasive and found Dipaolo Koehler’s testimony inconsistent with the medical evidence. The court found that the record showed her fibromyalgia was generally stable, tolerable, mild, or well managed, despite periods of worsening. It therefore held that the administrative law judge did not err by declining to separately discuss monthly absences.

Subjective statements

The court held that the administrative law judge properly evaluated Dipaolo Koehler’s statements about the severity of her pain and limitations. The administrative law judge considered evidence that medication and an injection helped manage her pain, treatment notes describing her fibromyalgia as stable or generally well managed, and inconsistencies between her hearing testimony and her function report. For example, her testimony that she could not lift her son or perform cooking and cleaning was inconsistent with treatment records and her report that she prepared her own breakfast each day. The court concluded that substantial evidence supported the decision to discount the alleged severity of her symptoms.

Disposition

The court found substantial evidence supporting the administrative decision and concluded that remand was not warranted. Judge Judith C. McCarthy denied Dipaolo Koehler’s motion for judgment on the pleadings and granted the Commissioner’s cross-motion for judgment on the pleadings. The court directed the clerk to terminate the pending motions and close the case.