Reported / Citable
Background
Edna Villarreal sought Disability Insurance Benefits and Supplemental Security Income, alleging disability beginning August 10, 2021, from hypertension, coronary artery disease, prior strokes, diabetes, fatigue, dizziness, and lower-extremity weakness. Her medical record documented persistently uncontrolled diabetes, cardiac treatment including a coronary stent, residual left-sided weakness, and repeated reports of dizziness and balance problems.
An administrative law judge found Villarreal had severe hypertension, coronary artery disease, cerebrovascular accident, and diabetes, but could perform a restricted range of light work. Relying on vocational-expert testimony, the ALJ found she could work as a housekeeper, cashier II, or material distributor. The Appeals Council denied review, making the ALJ’s August 2024 decision final.
The Court’s Holding
Magistrate Judge Diana Song Quiroga reversed and remanded. The court rejected the argument that an ALJ always must obtain or rely on a fully persuasive medical opinion to formulate an RFC. But it held that the particular RFC here was not supported by substantial evidence.
The ALJ repeatedly characterized Villarreal’s diabetes as controlled, relying on isolated self-reports, despite extensive records showing uncontrolled diabetes, hyperglycemia, hypoglycemic events, and endocrinology warnings. The court also found no logical bridge between the evidence and the ALJ’s conclusion that Villarreal’s reports of daily dizziness and imbalance were inconsistent with the record. Normal strength and range-of-motion findings did not, by themselves, address her ability to balance or walk unassisted.
The errors were prejudicial because a proper assessment of uncontrolled diabetes, dizziness, and imbalance could have produced a different RFC. Since the vocational expert answered a hypothetical matching that unsupported RFC, the testimony did not cure the error.
Key Takeaways
- An ALJ need not invariably obtain a new medical opinion before determining RFC, but the RFC still must rest on substantial evidence in a sufficiently developed record.
- An ALJ may not treat diabetes as controlled when the longitudinal medical record materially shows otherwise.
- When rejecting symptom allegations, the ALJ must connect the evidence to the conclusion; normal motor findings alone do not resolve claimed balance limitations.
Why It Matters
The decision underscores that substantial-evidence review does not permit an ALJ to rely on isolated statements while overlooking a contrary longitudinal treatment record. It also distinguishes strength findings from balance and gait limitations in assessing work capacity.
On remand, the agency must reassess Villarreal’s RFC and any resulting vocational evidence consistent with the court’s findings.