Dias v. Berryhill, 1:18-cv-10280

Background

Annie Dias applied for disability insurance benefits alleging mental (generalized anxiety disorder, major depressive disorder) and physical impairments (post-stroke effects, degenerative disc disease, carpal tunnel); the ALJ denied benefits and the Appeals Council affirmed.
Key contested evidence included a 2016 consultative report by state agency consultant Dr. Vladimir Yufit ("2016 Yufit Report") that contained functional limitations (short sit/stand/walk durations, hand limitations, environmental restrictions) and a series of psychodiagnostic opinions by Dr. Sokol (2014–2016).
The ALJ discussed portions of the record that tended to undercut disability (normal physical exams, no residual stroke effects) but did not expressly address certain portions of the 2016 Yufit Report or some of Dr. Sokol’s supportive findings.
Magistrate Judge Cabell issued an R&R finding (inter alia) that any failure to list anxiety as severe was harmless and recommending remand because the ALJ did not indicate the weight given to the unaddressed portions of the 2016 Yufit Report and to parts of Dr. Sokol’s reports.
The Commissioner objected, arguing the ALJ had effectively reviewed and discounted the contested parts (some were merely claimant statements) and that the record otherwise supported denial; the District Court conducted de novo review.
The District Court adopted the R&R in part and remanded for further proceedings, holding that the ALJ failed to explain the weight given to certain consultative findings and that the court could not infer those findings were reviewed or were merely subjective statements.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the Appeals Council erred by not listing anxiety as a severe impairment	Dias: Council should have recognized anxiety as severe	Commissioner: No basis to conclude error; if any, harmless	Court adopted R&R on unobjected portions and found no reversible error / any error harmless
Whether the ALJ and Council failed to consider post-stroke records	Dias: Recent post-stroke records were not adequately considered	Commissioner: ALJ and Council had access and summarized the records	Court agreed that ALJ and Council referenced post-stroke records; no reversible omission on this point
Whether the ALJ failed to address and weigh certain limitations in the 2016 Yufit Report and Dr. Sokol’s supportive findings	Dias: ALJ omitted and did not assign weight to limitations that support disability (e.g., severe sit/stand/walk limits, hand and environmental restrictions)	Commissioner: ALJ discussed relevant findings and record shows substantial evidence of nondisability; thus further discussion would be pointless	Court: ALJ did not explain weight given to those portions; because the omitted limitations were material and not presented to the vocational expert, remand is required
Whether the unaddressed portions of the 2016 Yufit Report are merely claimant subjective complaints (thus not medical opinions) and whether the court can infer ALJ discounted them	Dias: Portions are substantive medical findings supporting disability	Commissioner: Many entries prefaced by "She told me that..." are mere recitation of subjective complaints and not independent medical opinions; court can infer they were discounted	Court: Cannot determine from the record whether those entries are independent medical opinions or mere recitations; cannot infer ALJ reviewed and discounted them; remand required for clarification

Key Cases Cited

Tassel v. Astrue, 882 F. Supp. 2d 143 (D. Me. 2012) (ALJ need not discuss every piece of medical evidence but must explain key weighing decisions)
Nguyen v. Callahan, 997 F. Supp. 179 (D. Mass. 1998) (failure to address evidence that supports claimant may require remand because court cannot determine if evidence was overlooked or discredited)
Weng v. Holder, 593 F.3d 66 (1st Cir. 2010) (court may sometimes infer a trier of fact discredited material that merely duplicated rejected testimony)
Rodriguez Pagan v. Secretary of Health & Human Servs., 819 F.2d 1 (1st Cir. 1987) (opinions based solely on claimant's subjective statements merit less weight than independent clinical assessments)