Daniella Easterbrook v. KILOLO KIJAKAZI, Acting Commissioner of Social Security

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 21-2193
DANIELLA EASTERBROOK,
Plaintiff - Appellant,
v.
KILOLO KIJAKAZI, Acting Commissioner of Social Security,
Defendant - Appellee.
Appeal from the United States District Court for the Eastern District of Virginia, at
Alexandria. Claude M. Hilton, Senior District Judge. (1:20-cv-01414-CMH-JFA)
Argued: October 25, 2023 Decided: December 11, 2023
Amended: December 11, 2023
Before KING and GREGORY, Circuit Judges, and Joseph R. GOODWIN, United States
District Judge for the Southern District of West Virginia, sitting by designation.
Reversed and remanded by published opinion. Judge Gregory wrote the opinion, in which
Judge King and Judge Goodwin joined.
ARGUED: Clifford Michael Farrell, MANRING & FARRELL, Dublin, Ohio, for
Appellant. Matthew James Mezger, OFFICE OF THE UNITED STATES ATTORNEY,
Alexandria, Virginia, for Appellee. ON BRIEF: Jessica D. Aber, United States Attorney,
Richmond, Virginia, Catherine M. Yang, Assistant United States Attorney, OFFICE OF
THE UNITED STATES ATTORNEY, Alexandria, Virginia, for Appellee.

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GREGORY, Circuit Judge:
Daniella Easterbrook appeals from the district court’s order affirming the Social
Security Administration’s denial of her application for disability benefits. Easterbrook
argues that the Administrative Law Judge (ALJ) erred by failing to articulate a “good
reason,” supported by substantial evidence in the record, for according little weight to the
opinions of her treating physician.
We agree that the ALJ erred and accordingly reverse and remand for reconsideration
of Easterbrook’s application for disability benefits.
I.
Easterbrook was 56 years old at the time of her administrative hearing. She earned
a high school diploma, completed two years of college, and worked for twenty years in
retail. Since 2011, Easterbrook has experienced persistent back pain. Her pain has
increased in severity over the years and is often accompanied with symptoms such as
headaches, neck pain, and weakness and numbness in her bilateral upper extremities.
When her work schedule changed to back-to-back early and late shifts, the long hours
proved too difficult on her body and she was terminated. Easterbrook collected
unemployment benefits for three months, and then applied for disability benefits.
Dr. John Kim is Easterbrook’s primary care physician. Dr. Kim has treated
Easterbrook since 2013 and sees Easterbrook approximately four to six times annually.
While treating Easterbrook, Dr. Kim has referred her to other health care providers, ordered

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diagnostic tests, and prescribed medications to mitigate her ongoing pain and
accompanying symptoms.
The administrative record details seven visits between Easterbrook and Dr. Kim
since the alleged onset of her disability on March 9, 20161:
• March 21, 2016: Easterbrook visited with Dr. Kim for her back pain. Dr. Kim
opined that Easterbrook was unable to lift anything greater than ten pounds.
• January 4, 2017: At a visit with Dr. Kim, Easterbrook received a cervical epidural
steroid injection for her back pain. Once again, Dr. Kim indicated that Easterbrook
could not lift more than ten pounds.
• January 24, 2017: Easterbrook visited with Dr. Kim and again complained of severe
back and neck pain.
• March 22, 2018: During a visit, Dr. Kim noted that Easterbrook’s continuous back
and neck pain was caused, at least in part, by degenerative disc disease and cervical
spine problems.
• August 2018: Dr. Kim opined that Easterbrook’s neck pain was unchanged and that
her weakness in her bilateral upper extremities was worsening.
• January 15, 2019: Easterbrook complained of worsening neck pain, weakness in
her arms and hands, and headaches radiating from her neck. Dr. Kim’s notes
indicate that he believed Easterbrook had chronic back pain.2
• August 1, 2019: Easterbrook reported 10/10 back and neck pain intermittently,
weakness in her arms and hands, and continued headaches. She also stated that she
woke up from pain, even after taking her medication. She additionally told Dr. Kim
of her ongoing clumsiness, prohibiting her from completing basic household tasks,
1 In her briefs, Easterbrook also describes three meetings before the alleged onset
date. On August 8, 2015 and September 25, 2015, Dr. Kim met with Easterbrook and noted
that Easterbrook’s pain was a 9/10. Appellant’s Br. 6. Additionally, on November 15,
2015, Dr. Kim documented Easterbrook’s complaints of right leg pain, which she rated
10/10 with sudden movement. Id.
2 Specifically, Dr. Kim believed the chronic back pain was a result of degenerative
disc disease and a herniated nucleus pulposus causing severe left radiculopathy and weakness.

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in addition to drowsiness from her medication. At the end of this visit, Dr. Kim
recommended Easterbrook not pursue employment of any kind.
The record additionally contains two MRIs of Easterbrook’s cervical spine. The
first MRI is from November 13, 2015. It revealed a protruding disc at C5-C63 and spinal
stenosis—the narrowing of Easterbrook’s spinal canal as a result of pressure on her spinal
cord and nerves.
Easterbrook had a second MRI in January 2017. This MRI revealed mild right-
sided swelling of the uncovertebral joints at C3-C44 and mild left-sided swelling of the
uncovertebral joints at C4-C55. The MRI showed the same protruding disc and spinal cord
and nerve compression previously found at C5-C6. The MRI additionally displayed
cervical spondylosis—the degeneration of the spinal disks in Easterbrook’s neck.
The record also contains documentation of four of Easterbrook’s visits to other
health care providers while under Dr. Kim’s care.
The first visit, in late 2015, was to University of Georgetown Hospital. In her intake
questionnaire, Easterbrook stated that her back pain began in 2011 and had gradually
worsened over time. Easterbrook noted that her pain was aggravated by standing or
bending forward and alleviated by sitting. At her follow-up visit on December 14, 2015,
3 The C5-C6 spinal motion segment is located in the lower cervical spine, near the
base of the neck. It provides flexibility and support to the neck.
4 The C3-C4 spinal motion segment is located in the middle of the cervical spine. It
supports head and neck rotation, as well as control of the diaphragm.
5 The C4-C5 spinal motion segment is located in the lower cervical spine. It supplies
sensation for parts of the neck, shoulders, and arms.

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Easterbrook rated her pain 7/10. The treating physician noted that Easterbrook had a multi-
year history of worsening pain in her back and neck that went into her hands bilaterally,
despite physical therapy. The physician also wrote that Easterbrook noticed increasing
clumsiness and numbness in her hands.
Second, on March 30, 2017, at Dr. Kim’s recommendation, Easterbrook attended
an initial comprehensive pain consultative examination. The consultation was conducted
by Yelena Goldshteyn, P.A., and supervised by Dr. Beverly A. Wittenburg.
At the consultation, Easterbrook described her back, neck, and arm pain as
continuous, throbbing, dull, aching, shooting, stabbing, and burning. Easterbrook stated
that her pain was periodically accompanied by numbness, tingling, a pins-and-needles
sensation, burning, and swelling. She noted that her pain began roughly five years ago and
normally rated a 6/10. Easterbrook also described difficulty closing her hands in the
morning, a tightness along her cervical spine bilaterally, and a gradual deterioration of her
condition. Easterbrook reported that sitting, standing, lifting, prolonged upper extremity
activity, and cold or damp weather all aggravated her pain, while resting, avoiding strenuous
activity, lying down, stretching, pain medication, and massages all mitigated her pain.
At the end of the consultation, P.A. Goldshteyn and Dr. Whittenburg recommended
Easterbrook return for cervical epidural steroid injections to alleviate her pain. Because
cervical epidural steroid injections caused Easterbrook allergic reactions in the past,
Easterbrook elected not to return for the recommended injections.
Easterbrook’s third visit, on October 23, 2017, was to Dr. Babak Kalantar, a spine
specialist. Dr. Kalantar evaluated Easterbrook’s 2015 and 2017 MRIs and concluded that

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both showed moderate, symptomatic stenosis with spinal cord and nerve compression at
C5-C6. Dr. Kalantar noted that Easterbrook was positive for Hoffmann’s Syndrome—a
rare form of hypothyroid myopathy causing muscle atrophy. At this visit, Easterbrook
complained of persistent and bilaterally radiating neck pain, rated 10/10. She also reported
increased clumsiness, imbalance, and cervical pain from moving her neck.
In his assessment of Easterbrook and her MRIs, Dr. Kalantar said that there was a
“likelihood for progression” of her symptoms and that the “only treatment to halt progression
is surgical decompression.” A.R. 349.6 Despite this recommendation, he noted that “surgery
may not result in improvement of symptoms.” Id. In his report, Dr. Kalantar indicated
Easterbrook “would like to consider her options” before proceeding with surgery. Id.
Fourth and finally, Easterbrook visited Dr. Warren Levy, a cardiologist, on February
13, 2018. Dr. Levy said Easterbrook appeared to have either a heart rhythm disorder or an
elevated heartbeat disorder with a long first-degree atrioventricular block.
II.
On January 31, 2017, Easterbrook filed for Period of Disability and Disability
Insurance Benefits, alleging a disability beginning on March 9, 2016. Because of her
extensive physical workplace limitations, she requested to be considered fully disabled. In
her application, Easterbrook submitted her relevant medical records and a medical source
statement from Dr. Kim. A medical source statement includes a health care professional’s
6 A.R., used throughout, refers to the Administrative Record submitted by the Social
Security Administration.

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diagnoses, opinion of severity, and recommended workplace limitations for their patient.
Dr. Kim submitted his medical source statement based on his ongoing relationship with
Easterbrook as her primary treating physician since 2013.
In the medical source statement, dated March 20, 2017, Dr. Kim opined that
Easterbrook was suffering from stenosis, cervical spondylosis, and a pinched nerve in her
neck—known as cervical radiculopathy. Dr. Kim deemed Easterbrook’s pain severe and
her complaints “very credible.” A.R. 336.
Dr. Kim noted numerous physical workplace limitations, stating that Easterbrook’s
prognosis was “very poor.” A.R. 333. By his assessment, Easterbrook could only sit, stand,
and walk for less than two hours in an eight-hour workday. She could not sit upright for six
out of eight hours in an eight-hour workday. She could sit for no more than one hour at a
time in an eight-hour workday. He also noted that Easterbrook was “less than occasionally”
capable of reaching in all directions, handling, fingering, feeling skin receptors, and pulling
controls with both extremities. A.R. 334. Dr. Kim stated that Easterbrook was unable to
use her feet for pushing and pulling, could occasionally bend, squat, and kneel, but could
never stoop, turn her head from side to side, or move her head up and down. Dr. Kim opined
that Easterbrook could only occasionally carry less than five pounds.
In concluding his opinion, Dr. Kim said he believed Easterbrook was incapable of
working even a low-stress job because her condition required frequent, hourly breaks, in
addition to traditional workplace breaks. He also concluded her condition would cause her
to be absent from work more than three times per month.

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After reviewing her application, the state agency denied Easterbrook full disability
benefits on June 26, 2017. Although the agency agreed that Easterbrook suffered from
degenerative disc disease, hyperlipidemia, and disorders of the muscle, ligament, and
fascia, they ultimately concluded that she was still able to perform various workplace
functions. Easterbrook requested reconsideration on August 3, 2017.
On February 15, 2018, the state agency again denied Easterbrook’s application. The
agency found that Easterbrook suffered from the same conditions as previously noted, in
addition to a severe heart rhythm disorder. The same workplace activity designations were
given, though the agency added that Easterbrook was precluded from crawling. The state
agency physician reviewing her application noted that Easterbrook was limited in her
ability to handle, finger, and feel, but did not specify to what degree. Easterbrook filed a
Request for Hearing before an ALJ on February 26, 2018.
On September 17, 2018, Dr. Kim wrote a letter concerning Easterbrook’s condition
to provide additional information to aid the Social Security Administration’s decision. He
stated that he diagnosed Easterbrook with degenerative disc disease and stenosis, both of
which contributed to radiating pain causing weakness and numbness in Easterbrook’s
bilateral upper extremities. He explained that because Easterbrook’s daily pain required
frequent use of opioid pain medication, she was functionally limited in her ability to work.
Dr. Kim concluded that Easterbrook should be considered fully disabled.
Additionally, Dr. Kim completed a second medical source statement on August 3,
2019. Referencing Easterbrook’s 2015 and 2017 MRIs, Dr. Kim opined that Easterbrook
suffered from severe stenosis, chronic pain, cervical radiculopathy, and bilateral upper

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extremity weakness and numbness. He further chronicled Easterbrook’s use of opioid pain
medications and epidural injections, as well as surgical recommendations. Dr. Kim
indicated the same physical workplace limitations as in his March 2017 medical source
statement. Dr. Kim stated that he believed Easterbrook’s condition would only worsen and
that her disability was not likely to change.
The hearing before an ALJ that Easterbrook had requested was held on October 11,
2019. At the hearing, an ALJ took testimony from Easterbrook and from a vocational
expert. On January 16, 2020, the ALJ issued a 15-page opinion denying Easterbrook
benefits. The relevant portion states:
The opinions in these forms from Dr. Kim are given very little weight as they
are extreme in light of Dr. Kim’s own treatment notes and the medical
evidence of record as a whole including her only treatment as medications.
The only consistent objective finding in Dr. Kim’s treatment notes was his
mention of 4/5 strength in the bilateral upper extremities, which would not
support all of the extreme limitations provided by Dr. Kim. Dr. Kim merely
checked off boxes on a form and did not provide a narrative report containing
specific clinical findings to support all the extreme limitations. He
apparently relied quite heavily on the subjective report of symptoms and
limitations provided by [Easterbrook], and seemed to uncritically accept as
true most, if not all, of what [Easterbrook] reported. Yet as noted above,
despite [Easterbrook’s] extreme allegations of pain, weakness, and
numbness, she has not sought treatment except medication. [Dr. Kim] did
not order further testing such as rheumatological lab work, x-rays, or EMG
testing. Dr. Kim’s opinions are without substantial support from the other
evidence of record, which renders it less persuasive.
A.R. 21 (emphasis added).
The ALJ additionally spoke of Dr. Kim’s assessment of Easterbrook’s strength and
lifting ability, stating: “I give his opinions about her lifting ability some weight since he has been
her primary care physician for several years, but the overall medical evidence of record supports

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that she could lift and/or carry twenty pounds occasionally since the only consistent finding on
exams was 4/5 strength in the bilateral upper extremities.” A.R. 21 (emphasis added).
Easterbrook filed an administrative Request for Review of the ALJ’s decision, but
the Appeals Council declined review on September 16, 2020. After exhausting her
remedies through the Social Security Administration, Easterbrook filed a complaint in the
United States District Court for the Eastern District of Virginia. The magistrate judge
issued a Report and Recommendation concurring with the ALJ and denying Easterbrook
disability benefits. The district court adopted the Report and Recommendation, affirming
the denial of Easterbrook’s application for disability benefits. Easterbrook timely
appealed.
III.
We review de novo the Commissioner’s denial of disability benefits under 42
U.S.C.A. § 405(g). Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). On review, we
“must uphold the factual findings of the [ALJ] if they are supported by substantial evidence
and were reached through application of the correct legal standard.” Id. (quoting Johnson
v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam)).
“Substantial evidence is ‘such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.’” Shelly C. v. Comm’r of Soc. Sec. Admin., 61 F.4th
341, 353 (4th Cir. 2023) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)).
Thus, in undertaking this review, we consider whether the ALJ examined all relevant
evidence and offered a sufficient rationale in crediting such evidence. See Milburn Colliery
Co. v. Hicks, 138 F.3d 524, 528 (4th Cir. 1998).

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IV.
Easterbrook contends that the ALJ erred by failing to articulate a “good reason,”
supported by substantial evidence in the record, for according “very little weight” to Dr. Kim’s
opinions as her primary care physician. We agree.
The ALJ’s opinion suffers from two shortcomings. First, the ALJ failed to articulate
how Dr. Kim’s opinions were (1) not well-supported by medically acceptable clinical and
laboratory techniques and (2) inconsistent with other substantial evidence in the record.
Thus, it was improper for the ALJ not to apply the “treating source rule” to Dr. Kim’s
opinions. Second, in justifying her determination to afford Dr. Kim’s opinions “very little
weight,” the ALJ failed to provide adequate justification using the six factors from 20
C.F.R. § 404.1527(c)(2)(i)–(vi).
When reviewing whether an applicant is eligible for disability benefits, the ALJ
must evaluate every medical opinion in the record “regardless of its source.” 20 CFR
§ 404.1527(b)–(c). In Easterbrook’s application, this includes the medical opinions of
Drs. Kim, Kalantar, Levy, and Whittenburg; P.A. Goldshteyn; and the two state agency
physicians.
In addition, the ALJ must adhere to the “treating source rule.” Mitchell v.
Schweiker, 699 F.2d 185, 187 (4th Cir. 1983). Under the “treating source rule,” the
applicant’s treating physician’s opinion is entitled to controlling weight in the ALJ’s
analysis, unless there is persuasive, contradictory evidence.7 Id.
7 The regulation defines a “treating source” as the applicant’s “acceptable medical
source who provides [the applicant] . . . with medical treatment or evaluation and who has,

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Medical opinions from “treating sources” are given controlling weight because “these
sources are likely to be the medical professionals most able to provide a detailed, longitudinal
picture of [the applicant’s] medical impairment(s) and may bring a unique perspective to the
medical evidence that cannot be obtained from the objective medical findings alone or from
reports of individual examinations.” 20 C.F.R. § 404.1527(c).8 This rationale is well-established
in Fourth Circuit case law and in other circuits. See, e.g., Vitek v. Finch, 438 F.2d 1157 (4th
Cir. 1971); Oppenheim v. Finch, 495 F.2d 396 (4th Cir. 1974); Colgan v. Kijakazi, 22 F.4th
353 (2d Cir. 2022); Cole v. Asture, 661 F.3d 931 (6th Cir. 2011).
Dr. Kim is considered Easterbrook’s “treating source.” Dr. Kim has treated
Easterbrook since 2013 and sees Easterbrook approximately four to six times annually.
Thus, the two have an “ongoing treatment relationship,” as described in the regulations.
20 CFR § 404.1527(a)(2). Additionally, in treating Easterbrook, Dr. Kim has referred her
to other health care providers, ordered diagnostic tests, and prescribed medications to
mitigate her ongoing pain and accompanying symptoms. Consequently, he is in the best
position to speak about her cumulative care.
A treating source’s opinions are entitled to “controlling weight” if their opinions are
“(1) ‘well-supported by medically acceptable clinical and laboratory diagnostic
or has had, an ongoing treatment relationship with [the applicant].” 20 C.F.R.
§ 404.1527(a)(2).
8 In cases filed after March 27, 2017, a different regulation governs this evaluation.
However, the new regulation is not applicable to this case because Easterbrook filed for
disability benefits on January 31, 2017. Therefore, the treating physician rule and 20
C.F.R. § 404.1527(c) apply.

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techniques’ and (2) ‘not inconsistent with the other substantial evidence’ in the record.”
Arakas v. Comm’r of Soc. Sec. Admin., 983 F.3d 83, 106 (4th Cir. 2020) (citing 20 CFR
§ 404.1527(c)(2)). If the ALJ determines the treating source’s medical opinions should not
receive controlling weight, the ALJ turns to the following factors to determine the
appropriate weight: “(1) the length of the physician’s treatment relationship with the
claimant, (2) the physician’s frequency of examination; (3) the nature and extent of the
treatment relationship; (4) whether the medical evidence in the record supports the
physician’s opinion; (5) the consistency of the physician’s opinion with the entirety of the
record; and (6) the treating physician’s specialization.” Shelley C., 61 F.4th at 354; see 20
C.F.R. § 404.1527(c)(2)(i)–(vi). Using these factors, the ALJ must then articulate a “good
reason” for the less-than-controlling-weight afforded to the treating source’s opinions. See
20 CFR § 404.1527(c)(2) (“We will always give good reasons in our notice of
determination or decision for the weight we give your treating source’s medical opinion.”
(emphasis added)).
In this case, the ALJ erred when she determined that Dr. Kim’s opinions did not meet
the two criteria necessary to be given “controlling weight.” Further, because Dr. Kim’s
opinion was entitled to controlling weight, the ALJ was unable to articulate a compelling
“good reason” for affording his opinions less than controlling weight.
A.
In her application for disability benefits, Easterbrook submitted her most recent
diagnoses from Dr. Kim. The application also included Dr. Kim’s opinions stating
Easterbrook’s physical workplace limitations in light of her diagnoses. The state agency

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physicians reviewing Easterbrook’s application, as well as the ALJ, concurred with Dr. Kim’s
diagnoses, but not the physical workplace limitations. The ALJ stated that Dr. Kim’s
opinions of Easterbrook’s physical workplace limitations were “extreme” in light of the
accompanying diagnoses.
Dr. Kim based his diagnoses primarily on Easterbrook’s 2015 and 2017 cervical
spine MRIs. An MRI is a medically acceptable clinical or laboratory diagnostic technique.
See Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017). From the 2015 MRI, Dr. Kim
saw a protruding disc at C5-C6 and spinal stenosis. Two years later, the 2017 MRI
displayed similar, worsening diagnoses. Based on the diagnoses from both MRIs, Dr. Kim
recommended that Easterbrook be subject to specific physical workplace limitations.
However, Dr. Kim’s recommendations were not limited to his assessment of
Easterbrook’s MRIs alone. In addition to the MRIs, Dr. Kim referred Easterbrook to
various other health care providers for her condition, including a pain management
consultant, spine specialist, heart specialist, and physical therapist. It is acceptable medical
practice to refer patients to outside health care providers in order to obtain a more complete
diagnosis. See Green-Younger v. Barnhart, 335 F.3d 99, 102 (2d Cir. 2003); Germany-
Johnson v. Comm. of Soc. Sec., 313 F. App’x 771, 771 (6th Cir. 2008). Dr. Kalantar, the
spine specialist, concurred with many of Dr. Kim’s assessments of Easterbrook’s diagnoses
after reviewing the 2015 and 2017 MRIs.
Finally, Dr. Kim made his diagnoses, and the accompanying physical workplace
limitations, in light of the continuous documentation of Easterbrook’s ongoing pain, both
from Dr. Kim and the other health care providers to whom she was referred.

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As noted at oral argument, the Commissioner provided no contrary evidence of
Easterbrook’s diagnoses to support the alleged “extreme” nature of Dr. Kim’s opinions of
Easterbrook’s physical workplace limitations. O.A. at 26:59. Neither party requested an
Independent Medical Evaluation (“IME”) of Easterbrook. Id. at 28:38. Therefore, “[a]n
ALJ may not substitute [her] own lay opinion for a medical expert’s when evaluating the
significance of clinical findings.” Arakas, 983 F.3d at 108 (citing Wilson v. Heckler, 743
F.2d 218, 221 (4th Cir. 1984). Because Dr. Kim’s opinions were consistently supported
by the medically acceptable clinical and laboratory diagnostic information provided in the
records, they were entitled to controlling weight by the ALJ.
B.
Dr. Kim’s opinions are consistent with the overwhelming evidence in the record.
Therefore, “[b]ecause the ALJ failed to point to specific objective evidence showing that
Dr. [Kim’s] opinion was ‘inconsistent’ with the record’s other medical evidence, [the ALJ’s]
analysis, or lack thereof, has ‘frustrate[d]’ this reviewing court’s ‘meaningful review.’”
Shelley C., 61 F.4th at 354 (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)).
First, the ALJ discredited Dr. Kim’s opinions because “Dr. Kim merely checked off
boxes on a form and did not provide a narrative report containing specific clinical findings
to support all the extreme limitations.” A.R. 21. This statement is inaccurate. Dr. Kim
checked off boxes because that was the required reporting format. He also provided
notations in the margins relevant to Easterbrook’s condition. And he submitted a narrative
letter with Easterbrook’s application that provided details about Easterbrook, her condition,
her prior treatment, the current scope of her disability, and his prognosis for Easterbrook’s

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condition. The ALJ’s misstatement cannot justify her treatment of Dr. Kim’s opinions
because the substantial evidence in the record shows Dr. Kim’s opinions offered far more
than a cursory review of Easterbrook’s condition.
Second, the ALJ explained that she accorded little weight to Dr. Kim because “[h]e
apparently relied quite heavily on the subjective report of symptoms and limitations provided
by [Easterbrook], and seemed to uncritically accept as true most, if not all, of what
[Easterbrook] reported.” However, this reliance “hardly undermines his opinion as to her
functional limitations, as ‘[a] patient’s report of complaint, or history, is an essential diagnostic
tool.’” Arakas, 983 F.3d at 108 (quoting Green-Younger, 335 F.3d at 107). Dr. Kim
documented Easterbrook’s level of pain at nearly every visit, calling it “very credible.”
Further, the other health care providers with whom Easterbrook visited likewise noted her
pain, never once indicating skepticism. Easterbrook’s pain has been documented in the
record since 2011 and its sources are consistent with her diagnoses. It is not the role of the
ALJ to call into question an applicant’s pain level when that pain level is well-supported
by substantial evidence in the record. Id. Dr. Kim’s reliance on Easterbrook’s pain
therefore counsels in favor of affording his opinions controlling weight because her
ongoing pain is supported by the substantial evidence in the record.
Third, the ALJ claimed that “[t]he only consistent objective finding in Dr. Kim’s
treatment notes was his mention of 4/5 strength in [Easterbrook’s] bilateral upper
extremities.” A.R. 21. This evidence, the ALJ stated, conflicted with the “extreme”
physical workplace limitations Dr. Kim recommended for Easterbrook, such as her ability
to lift only five pounds. Id. The ALJ offered this as a “good reason” to afford Dr. Kim’s

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opinions less than controlling weight. See 20 C.F.R § 404.1527(c)(2)(iv)–(v). However,
this is an improperly limited view of the record.
Dr. Kim’s notes from his visits with Easterbrook establish persistent, worsening
pain. They show a progression of clumsiness and numbness in her bilateral upper
extremities, increasing weakness, and side effects of her opioid pain medication.
Easterbrook’s other health care providers also noted pain, clumsiness, numbness,
weakness, and medication side-effects. These findings are other “consistent objective
findings in Dr. Kim’s treatment notes,” as well as the treatment notes of other health care
providers. Additionally, Dr. Kim’s recommended physical workplace limitations were not
based solely on Easterbrook’s strength. Rather, he reached his conclusion based on the
medical record as a whole. His opinions were not made in a vacuum and were not
inconsistent with substantial recorded evidence.
Fourth, the ALJ discounted Dr. Kim’s opinions because of what he did not do—
namely, “order further testing such as rheumatological lab work, x-rays, or EMG testing.”
A.R. 21. The ALJ’s disregard of Dr. Kim’s opinions on this basis undermines Dr. Kim’s
role as a medical expert and instead substitutes the ALJ’s opinion for what was medically
necessary or prudent to resolve Easterbrook’s condition. The Commissioner did not
request an IME of Easterbrook, and thus must rely on the evidence of the record to
determine medical necessity and prudence. Dr. Kim, as well as Easterbrook’s other health
care providers, did not find those assessments necessary for her treatment. The ALJ is
beholden to the medical evidence in the record and cannot afford Dr. Kim’s opinions less
than controlling weight based on perceived omissions in care.

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Fifth, the ALJ was critical of Dr. Kim’s “extreme” opinions of Easterbrook’s
condition and accompanying physical workplace limitations because Easterbrook chose
not to, as of the time of her hearing, undergo the surgery suggested by Dr. Kalantar. The
ALJ concluded that Easterbrook’s reliance on more conservative treatment methods, such
as medication, demonstrated that Easterbrook’s condition was not as extreme as Dr. Kim
suggested. This is an incomplete assessment. Dr. Kalantar’s notes included more nuance
than noted by the ALJ, as he concluded that “[s]urgery may not result in [the] improvement
of symptoms.” A.R. 349. Much as it is beyond the role of a health care provider to force
his patient to undergo the most extreme, risky, costly, or painful treatment, so it is an abuse
of the role of an ALJ, and indeed the role of the Social Security Administration, to require
that an applicant undergo such treatment before they receive disability benefits. An
applicant need not “prove” the legitimacy of her pain by submitting to such treatment
methods. Instead, a well-developed record of pain, and attempts to mitigate that pain—
whether liberal or conservative—should be enough to preserve patient autonomy when
applying for disability benefits.
It is reasonable that Easterbrook wanted to try other, non-surgical options before
undergoing a risky, costly, and painful surgery that was not guaranteed to resolve her pain.
The record suggests that the other alternatives Easterbrook took, such as opioid pain
medication, consultation with pain management specialists, and physical therapy, were
reasonable. The fact that Easterbrook did not choose the most extreme treatment option
does not undermine Dr. Kim’s finding that she had extreme pain.

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Sixth and finally, the ALJ was doubtful of Dr. Kim’s “extreme” opinions of
Easterbrook’s condition and accompanying physical workplace limitations because
Easterbrook declined cervical epidural steroid injections.
When pain management consultants recommended the injections, Easterbrook
underwent preliminary allergy testing that indicated she would “most likely” not be allergic
to the steroids in the injections. A.R. 402. But Dr. Kim had previously prescribed
Easterbrook oral steroids for her pain, and Easterbrook had reacted poorly. A.R. 52. She
“felt pressure in her veins and felt [the] closing of her throat.” Id. Because of her reaction
to the oral steroids, Easterbrook declined the steroid injections in favor of a different pain
management approach.
The ALJ chose to discount Dr. Kim’s opinions about the intensity of Easterbrook’s
pain in part because Easterbrook declined the injections. But again, a patient’s refusal to
pursue a specific type of medical treatment does not automatically call into question the
severity of her pain. That is especially true here, where Easterbrook’s past experience with
steroids made her understandably cautious about taking steroids again.
In light of Easterbrook’s long-documented history of pain and cautious attitude
towards medical interventions, Dr. Kim offered her alternative pain management approaches.
His willingness to accommodate Easterbrook’s reticence and recommend less invasive
options was not a reason for the ALJ to afford his opinions less than controlling weight.
Accordingly, Dr. Kim’s opinions should have been given “controlling weight”
under the treating source rule. His opinions are both well-supported by the evidence in the
record and consistent with the substantial evidence provided therein.

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V.
For the foregoing reasons, we conclude that the ALJ erred by failing to articulate a
“good reason,” supported by substantial evidence in the record, for according little weight
to Dr. Kim’s opinions as Easterbrook’s treating source physician. We therefore reverse the
Commissioner’s decision and remand for a determination consistent with this opinion.
REVERSED AND REMANDED

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