Jesse M. v. Commissioner of Social Security

Background

Jesse M. applied for Supplemental Security Income and Disability Insurance Benefits in January 2019, alleging that his disability began on April 1, 2009. The Social Security Administration denied the applications. After an earlier related proceeding resulted in a remand for additional administrative proceedings, an administrative law judge held a second hearing and again denied benefits on May 11, 2022.

The administrative law judge found that Jesse M. had severe degenerative disc disease in his lumbar and cervical spine, post-traumatic stress disorder, depressive and anxiety disorders, and attention-deficit/hyperactivity disorder. The judge determined that Jesse M. could perform light work with several restrictions, including simple and repetitive tasks, limited contact with other people, no driving as a job requirement, and use of a hand-held device for ambulation. The judge found that he could not return to his past work as a truck driver but could perform other jobs existing in significant numbers in the national economy.

The parties filed competing motions for judgment on the pleadings. This procedure asks the court to decide the case based on the administrative record and the parties’ written arguments.

Issues and Analysis

Development of the record. Jesse M. argued that the administrative law judge should have taken additional steps to obtain treatment records from several providers. The court rejected this argument as to Grace Adepoju, a nurse practitioner. The judge held the record open, gave counsel opportunities to obtain the missing records, asked about them at the hearing, and granted additional time. Counsel later told the judge that he could not locate Adepoju or obtain additional records and did not request further assistance or time.

The court also concluded that the lack of additional efforts to obtain records from Dr. Yvelyne Abellard did not, by itself, require a remand. Counsel had multiple opportunities to seek more time or help and instead asked the administrative law judge to issue a decision. The court likewise found no reversible error concerning a gap in records from pain-management providers because the record contained extensive treatment evidence and Jesse M. acknowledged that the providers’ findings before and after the gap were essentially the same.

Cane use. The court found that the administrative law judge did not adequately explain why the residual functional capacity finding allowed Jesse M. to use a cane for walking but not for standing. The record included Jesse M.’s testimony and statements from treating physicians indicating that he needed a cane for both walking and standing. The vocational expert testified that a person who needed a cane only for ambulation could perform certain representative jobs, but a person who needed a cane for standing as well could not perform those jobs. Because the distinction could affect the disability determination, the court required a remand for a clearer explanation and reconsideration.

Medical opinions about physical limitations. The administrative law judge found the opinions of Dr. Sabita Sarkar, Dr. Charles Pastor, and Dr. Suelane Do Ouro unpersuasive, while finding the opinion of consultative examiner Dr. Daniel Schwartz and the opinions of state-agency reviewers persuasive. The court held that this analysis was inadequate. Although the administrative law judge could consider the lack of contemporaneous treatment notes, she failed to consider the important consistency among the three treating providers’ opinions over an extended period. The court also found that the judge relied too heavily on clinical notes from Dr. Igor Khelemsky, who treated Jesse M. for attention-deficit/hyperactivity disorder and did not give an opinion about his work-related physical restrictions.

Medical opinions about mental limitations. The administrative law judge found opinions from Adepoju and Dr. Abellard unpersuasive and relied substantially on the consultative examination by Dr. David Schaich and state-agency reviewers. The court found that the judge inaccurately stated that there was no regular or consistent mental-health treatment apart from Dr. Khelemsky. Adepoju and Abellard both reported monthly treatment, and prescription records showed that Abellard prescribed psychiatric medication in 2020 and 2021.

The court also found that the administrative law judge failed to account for the consistency among the treating providers’ opinions, each of whom described limitations more serious than those in the residual functional capacity finding. The court concluded that the judge placed too much weight on a single consultative examination and on Khelemsky’s treatment notes, which did not assess Jesse M.’s ability to meet the basic mental demands of work.

Disposition

The court held that remand was required so the Social Security Administration could reconsider Jesse M.’s need to use a cane and the medical opinions concerning his physical and mental limitations. Magistrate Judge Gary R. Jones granted Jesse M.’s motion for judgment on the pleadings, denied the Commissioner’s motion, and remanded the case for further proceedings consistent with the decision. The court directed that a different administrative law judge conduct the proceedings, that the proceedings be completed within 120 days, and that a final decision be issued within 60 days of any appeal by Jesse M. if the remand decision again denied benefits. The clerk was directed to enter final judgment for Jesse M. and close the file.