Gonzalez v. Commissioner of Social Security

Background

Dolores Enid Gonzalez sought review under 42 U.S.C. § 405(g) of the Social Security Administration’s final decision denying her applications for disability insurance benefits and supplemental security income. Gonzalez alleged disability beginning October 22, 2018, after back surgery and continuing symptoms including low-back pain, pain radiating into her right leg, muscle spasms, hand symptoms, and difficulty with activities such as walking, sitting, standing, bathing, dressing, shopping, cooking, and housework.

An administrative law judge found that Gonzalez had severe degenerative disc disease in her cervical and lumbar spine but retained the capacity to perform a limited range of light work. The administrative law judge concluded that Gonzalez could perform past work as an administrative assistant, day-care supervisor, and secretary, as well as other jobs existing in significant numbers in the national economy. The Appeals Council denied review.

The parties filed cross-motions for judgment on the pleadings, which asks the court to decide the case based on the written submissions and administrative record.

The Court’s Analysis

Treating Neurosurgeon’s Opinions

The court held that the administrative law judge did not properly evaluate two assessments from Gonzalez’s treating neurosurgeon, Dr. Konstantinos Margetis. Among other limitations, Dr. Margetis stated that Gonzalez could sit for four hours in an eight-hour workday, stand or walk for one hour, sit or stand for only 15 minutes at a time, take unscheduled breaks, lift less than 10 pounds only occasionally, and likely miss work once or twice each month.

Because Gonzalez’s applications were filed under the newer regulations, the administrative law judge was required to explain the opinions’ supportability and consistency. Supportability concerns how well a medical source explains and supports an opinion; consistency concerns how well the opinion fits with the other evidence in the record. The court found that the administrative law judge did not address supportability at all. The administrative law judge summarized Dr. Margetis’s assessments but rejected them based principally on a consultative examiner’s findings and treatment notes that allegedly showed greater functional abilities.

The court also found the consistency discussion insufficient. The administrative law judge did not identify the treatment notes relied on or address evidence that appeared to support Dr. Margetis’s opinions, including records describing an unsteady or antalgic gait and pain that significantly affected daily activities. The court therefore concluded that the administrative law judge had not provided enough explanation to permit meaningful review.

Gonzalez’s Reports of Pain and Other Limitations

The court separately held that the administrative law judge did not properly evaluate Gonzalez’s subjective complaints. The administrative law judge found that Gonzalez’s medically determinable impairments could reasonably cause her alleged symptoms but stated that her reports about their severity and effects were not entirely consistent with the evidence.

The court explained that, in those circumstances, the administrative law judge had to assess the complaints using relevant factors, including daily activities; the location, duration, frequency, and intensity of pain; factors that worsen symptoms; medication type, dosage, effectiveness, and side effects; other treatment; measures used for relief; and other functional limitations.

The court found that the administrative law judge did not clearly identify the weight given to Gonzalez’s statements or provide specific reasons for discounting them. The administrative law judge discussed some daily activities and symptoms but did not meaningfully consider Gonzalez’s testimony about physical therapy, injections, narcotic medication, surgery, continuing pain despite treatment, and planned additional testing and possible surgery. The court also noted that the record contained medical evidence concerning pain, treatment, and limitations in daily activities.

Harmless Error

The court determined that these errors were not harmless. Dr. Margetis’s opinions and Gonzalez’s testimony described limitations that were more restrictive than those included in the administrative law judge’s residual functional capacity finding. Proper consideration of that evidence could have resulted in a different residual functional capacity and therefore could have affected the disability determination.

Disposition

The court granted Gonzalez’s motion for judgment on the pleadings, denied the Commissioner’s cross-motion, and remanded the case pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings. The opinion did not award benefits or decide that Gonzalez was disabled.