ALJ erred by relying solely on medical evidence

Where Social Security regulations provide that an administrative law judge, or ALJ, may not disregard a person’s statements about the intensity, persistence and limiting effects of symptoms solely because they are not substantiated by medical evidence, the ALJ erred by discounting a woman’s claims and looking only to the medical record.

Background

In February 2017, Stephanie applied for disability insurance benefits. After the ALJ issued an unfavorable decision, this appeal followed. Among other things, Stephanie contends that the ALJ erred by rejecting her allegations of neck and arm pain from cervical degenerative disc disease solely because they were inconsistent with the objective medical evidence. She asserts that “an ALJ may not reject a claimant’s pain allegations solely because the objective medical evidence does not support those allegations.”

Standard

The regulations set out a two-step process for evaluating a claimant’s symptoms. “First, the ALJ looks for objective medical evidence showing a condition that could reasonably produce the alleged symptoms,” “in the amount and degree[] alleged by the claimant.” Step One is a “threshold” inquiry[] at which the “‘intensity, persistence, or functionally limiting effects’ of the claimant’s asserted pain” or other symptoms are not considered.

Assuming the claimant clears the first step, the ALJ moves on to Step Two. There, “the ALJ must evaluate the intensity, persistence, and limiting effects of the claimant’s symptoms to determine the extent to which they limit [her] ability,” to work on a regular and continuing basis. “The second determination requires the ALJ to assess the credibility of [subjective] statements about symptoms and their functional effects,” after considering all the relevant evidence in the record.

The ALJ must give specific reasons, supported by “references to the evidence,” for the weight assigned to the claimant’s statements. But because “[s]ymptoms cannot always be measured objectively through clinical or laboratory diagnostic techniques,” an ALJ “may ‘not disregard an individual’s statements about the intensity, persistence, and limiting effects of symptoms solely because the objective medical evidence does not substantiate’ them.”

Analysis

The ALJ satisfied Step One by finding that Stephanie’s “medically determinable impairments could reasonably be expected to cause the alleged symptoms,” but then erred at Step Two by discrediting Stephanie’s alleged symptoms solely because “[t]he objective evidence of record does not support the severity of the symptoms alleged.” In concluding that Stephanie’s neck and arm pain were less severe or functionally limiting than alleged, the ALJ explained that Stephanie “generally presents with normal neck range of motion” and “has neck strength on examination,” and other examination and imaging findings were either normal or showed only mild abnormalities. This analysis fails to consider the types of subjective evidence required by the regulations and the Fourth Circuit.

As Stephanie contends, the ALJ relied exclusively on the inconsistencies between the objective medical findings and her allegations of severe pain in concluding that her symptoms did not rise to the level of severity she claimed. Each piece of evidence cited by the ALJ constitutes an objective medical finding resulting from imaging or an examination. Entirely absent is any discussion of considerations other than the objective evidence, such as Stephanie’s daily activities or course of treatment, supporting the ALJ’s finding that Stephanie’s symptoms are less severe than alleged.

An ALJ may properly consider the lack of objective medical evidentiary support when determining whether a claimant’s symptoms rise to the level of severity alleged, but the ALJ must also consider and discuss other types of evidence, including subjective evidence, before she can properly conclude that the claimant’s symptoms are less severe than alleged.

Thus, the ALJ erred by discounting Stephanie’s allegations of pain based solely on the objective medical evidence. Accordingly, the court cannot find that the ALJ’s assessment of Stephanie’s report of symptoms and limitations is supported by substantial evidence.

Stephanie also argues that the ALJ erred by failing to account for her hand tremors in the hypothetical posed to the vocational expert and in the residual functional capacity, or RFC, assessment. The ALJ should discuss the evidence of Stephanie’s tremors and whether they impact her work-related functioning.

The court observes that Stephanie has long reported difficulties with memory and concentration; nevertheless, her physicians often noted normal memory and concentration. On remand, the ALJ should explicitly address the conflicting evidence and provide a coherent rationale explaining her assessment of Stephanie’s reported memory and concentration problems.

Finally, the ALJ’s conclusory statement that Stephanie would not be disabled from “unskilled” sedentary work “[e]ven if [she] had a severe mental impairment with moderate limitations in her abilit[ies] to understand, remember or apply information and concentrate[,] persist and maintain pace,” is not an adequate substitute for a proper RFC assessment.

Report and recommendation issued.

Stephanie v. Kijakazi, Case No. 4:20-cv-00039, Jan. 21, 2022. WDVA at Danville (Hoppe). VLW 022-3-026. 20 pp.