Ljena L. v. Commissioner of Social Security

Background

Ljena L. applied for Disability Insurance Benefits and Supplemental Security Income Benefits under the Social Security Act in January and February 2019. She initially alleged disability beginning July 12, 2013, but amended the alleged onset date to July 10, 2015 at her hearing. The applications were denied initially and on reconsideration. After a hearing at which Ljena L. appeared with an attorney and testified with an interpreter, Administrative Law Judge Dennis Katz denied the applications on December 22, 2020. The Appeals Council denied review, making the Administrative Law Judge’s decision the Commissioner’s final decision.

The Administrative Law Judge found that Ljena L.’s breast cancer status after lumpectomy and radiation, and mild lumbar degenerative disc disease with dextroscoliosis, were severe impairments. The Administrative Law Judge found that her anxiety and depression were not severe. He determined that she had the residual functional capacity—the most she could still do despite her impairments—to perform medium work, including lifting and carrying up to 50 pounds, standing and walking for six hours in an eight-hour workday, sitting for six hours, and frequently reaching, handling, and fingering. He found that she could perform her past work as a food service or cafeteria worker and, alternatively, could perform other jobs existing in significant numbers in the national economy.

The parties filed a joint stipulation instead of separate motions for judgment on the pleadings. Judgment on the pleadings asks the court to decide the case based on the existing pleadings and record. The court reviewed whether the Commissioner applied the correct legal standard and whether substantial evidence—relevant evidence that a reasonable person could accept as adequate—supported the decision.

Medical Opinion Evidence About Fatigue

The court held that the Administrative Law Judge inadequately evaluated the opinion evidence concerning fatigue. Dr. David MacKinnon, who performed a consultative physical examination in April 2019, diagnosed general fatigue and opined that Ljena L. should avoid more than mild to moderate physical exertion because of that fatigue. The Administrative Law Judge discounted this opinion as conclusory.

The court found that explanation inadequate. Dr. MacKinnon stated that his conclusion was based on his examination, and the record showed consistency between his opinion and assessments from treating providers. PA Jennifer Wins Robinson reported fatigue and opined that Ljena L. would need unpredictable rest periods. Dr. Robert Thompson also documented fatigue. Dr. Maureen Empfield reported decreased energy, exhaustion, lethargy, and related symptoms, and counselor Lauren Davis reported easy fatigue and decreased energy.

The court also found that the Administrative Law Judge improperly discounted the opinions of PA Robinson and Dr. Thompson without addressing how those opinions agreed with one another and with Dr. MacKinnon’s opinion. The Administrative Law Judge found Ljena L. capable of medium work without reconciling that conclusion with the medical opinions describing work-related limitations from fatigue.

The Commissioner relied in part on the opinion of Dr. T. Schmidt-Deyoung, a non-examining State Agency review physician. The court found that opinion insufficient by itself to support the denial. Dr. Schmidt-Deyoung had described Dr. MacKinnon’s opinion as consistent with and supported by the record but did not explain how that assessment could be reconciled with the conclusion that Ljena L. could perform medium work. The review also occurred before the record included the later assessments from PA Robinson and Dr. Thompson.

Medical Opinion Evidence About Mental Impairments

The court separately found that the Administrative Law Judge inadequately evaluated the evidence about anxiety and depression. The Administrative Law Judge discounted counselor Lauren Davis’s opinion partly because it was issued after the date last insured. But the Administrative Law Judge accepted Dr. Melissa Antiaris’s opinion even though it also was issued after that date. The court also noted that the timing of Davis’s assessment did not affect the evaluation of the Supplemental Security Income application.

The Administrative Law Judge further found Davis’s opinion inconsistent with generally benign mental-status examinations. The court concluded that this was not a reasonable reading of the treatment history, which repeatedly described Ljena L. as depressed or anxious and as having a flat, constricted, or blunt affect. The court also found that the Administrative Law Judge placed too much weight on Ljena L.’s ability to appear relatively appropriate during brief and infrequent appointments, because functioning in supportive treatment settings does not necessarily show the ability to function in regular employment.

The court emphasized that other treating providers reported significant work-related concerns. Dr. Empfield described a serious and persistent chronic mental disorder. PA Robinson opined that Ljena L. could not perform even low-stress work, would need frequent unscheduled breaks, and would need to rest unpredictably. Dr. Thompson likewise believed that she could not perform even low-stress work.

The court found that the opinion of Dr. Antiaris, who conducted one consultative psychiatric examination, did not adequately support the conclusion that Ljena L.’s mental impairments were non-severe and imposed no work-related limitations. The court also found the opinions of the non-examining State Agency reviewers insufficient for the same reason.

Disposition

The court concluded that further administrative proceedings were necessary to properly assess the medical opinion evidence concerning the effect of fatigue, anxiety, and depression on Ljena L.’s ability to work. It granted Ljena L. judgment on the pleadings and remanded the matter for further proceedings consistent with the Decision and Order. The Clerk was directed to enter final judgment and close the file. The decision did not award benefits or decide that Ljena L. was disabled.