Beazley v. O'Malley

Opinion

FILED IN THE U.S. DISTRICT COURT EASTERN DISTRICT OF WASHINGTON Apr 10, 2024

SEAN F. MCAVOY, CLERK EASTERN DISTRICT OF WASHINGTON

AMY B.,1 No. 1:23-cv-03154-EFS

Plaintiff, ORDER REVERSING THE ALJ’S v. DENIAL OF BENEFITS, AND REMANDING FOR FURTHER MARTIN O’MALLEY, Commissioner of PROCEEDINGS Social Security,2 Defendant.

1 For privacy reasons, Plaintiff is referred to by first name and last initial or as “Plaintiff.” See LCivR 5.2(c). 2 Martin O’Malley became the Commissioner of Social Security on December 20, 2023. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, and section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), he is hereby substituted for Kilolo Kijakazi as the defendant.

Due to post-traumatic stress disorder, chronic migraine without aura, chronic neck pain, panic disorder, exertional compartment syndrome in the lower legs, asthma, obesity, and Ehlers-Danlos syndrome, Plaintiff Amy B. claims she is

unable to work fulltime and applied for disability insurance benefits. She appeals the denial of benefits by the Administrative Law Judge (ALJ) on the grounds that the ALJ improperly assessed Plaintiff’s credibility, improperly evaluated the medical opinion evidence, and erred at step five as a result of her prior errors. As is explained below, the ALJ erred considering Plaintiff’s credibility as to her migraine headaches and erred in evaluating the medical opinions of Anusha Mannava, MD.

This matter is remanded for further proceedings. I. Background In May 2019, Plaintiff filed application for benefits under Title 2, claiming disability beginning May 1, 2019, based on the physical and mental impairments noted above.3 After the agency denied Plaintiff benefits, ALJ Debra Denney held a telephone hearing in June 2022 at which Plaintiff appeared with her representative.4 Plaintiff

and a vocational expert testified.5

3 AR 259, 353. 4 AR 77-110. 5 Id. After the hearing, the ALJ issued a decision denying benefits.6 The ALJ found Plaintiff’s alleged symptoms were not entirely consistent with the medical evidence and the other evidence.7 As to medical opinions, the ALJ found:

• The opinions of state agency evaluator Bruce Eather, PhD, to be persuasive. • The opinions of state agency evaluator Howard Platter, MD, to be persuasive. • The opinions of consultative examiner Lisa Kisenwether, ARNP, to be partially persuasive.

• The opinions of consultative examiner Emma Billings, PhD, to be partially persuasive. • The opinions of treating neurologist Anusha Mannava, MD, to be generally unpersuasive. • The opinions of treating physician Charles Bulfinch, DO, to be generally unpersuasive. • The opinions of treating therapist Martha Burns, LMFT, to be

generally unpersuasive.8

6 AR 15-43. Per 20 C.F.R. § 404.1520(a)–(g), a five-step evaluation determines whether a claimant is disabled. 7 AR 26-35. 8 AR 33-35. The ALJ also found the third-party statement of Plaintiff’s fiancé, William Leitzel, to be less persuasive than the medical opinions.9 As to the sequential disability analysis, the ALJ found:

• Plaintiff met the insured status requirements through December 31, 2024. • Step one: Plaintiff had not engaged in substantial gainful activity since May 1, 2019, the alleged onset date. • Step two: Plaintiff had the following medically determinable severe impairments: migraines, asthma, Ehlers-Danlos syndrome, obesity,

depression, and anxiety. • Step three: Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. • RFC: Plaintiff had the RFC to perform a full range of sedentary work with the following exceptions: [Plaintiff] can lift twenty pounds occasionally and ten pounds frequently; can stand, walk, and sit all six hours in an eight- hour day, with normal breaks; should avoid concentrated exposure to cold, heat, and humidity; no more than occasional exposure to fumes, dusts, odors, unprotected heights, and fast moving machinery; no work on ladders, ropes, or scaffolds; can maintain concentration, persistence, and pace for two hours before needing a break; needs a quiet, characterized as office level, noise environment; can tolerate brief, occasional interactions with coworkers and supervisors and no more than

9 AR 35. very brief to no interaction with the public; should not be assigned teamwork; can tolerate routine changes; and can avoid workplace hazards to complete a normal workday. • Step four: Plaintiff is unable to perform past relevant work of a telemarketer, reservations agent, customer service supervisor, and sales director. • Step five: considering Plaintiff’s RFC, age, education, and work history, Plaintiff could perform work that existed in significant numbers in the national economy, such as a routing clerk (DOT # 222.687-022), and a silver wrapper (DOT # 318.687-018).10

Plaintiff timely requested review of the ALJ’s decision by the Appeals Council and now this Court.11 II. Standard of Review The ALJ’s decision is reversed “only if it is not supported by substantial evidence or is based on legal error,”12 and such error impacted the nondisability determination.13 Substantial evidence is “more than a mere scintilla but less than a

10 AR 20-37. 11 AR 257. 12 Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). See 42 U.S.C. §§ 405(g), 1383(g). 13 Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012) ), superseded on other grounds by 20 C.F.R. § 404.1520(a) (recognizing that the court may not reverse an preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”14 III. Analysis

Plaintiff seeks relief from the denial of disability on three grounds. She argues the ALJ erred when evaluating Plaintiff’s subjective complaints, erred when evaluating the medical opinion evidence, and erred at step five as a result of the prior two errors. The Commissioner argues that the ALJ reasonably discounted Plaintiff’s subjective complaints, properly evaluated the opinions of the treating sources pursuant to the new regulations, and properly relied on vocational expert

testimony at step five.15 The Court disagrees with the Commissioner as to the ALJ’s consideration of Plaintiff’s subjective complaints regarding her migraine

ALJ decision due to a harmless error—one that “is inconsequential to the ultimate nondisability determination”). 14 Hill, 698 F.3d at 1159 (quoting Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997)). See also Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (The court “must consider the entire record as a whole, weighing both the evidence that supports and the evidence that detracts from the Commissioner's conclusion,” not simply the evidence cited by the ALJ or the parties.) (cleaned up); Black v. Apfel, 143 F.3d 383, 386 (8th Cir. 1998) (“An ALJ’s failure to cite specific evidence does not indicate that such evidence was not considered[.]”). 15 ECF No. 12. headaches and the ALJ’s consideration of Dr. Mannava’s opinions. As is explained below, the ALJ’s analysis contains consequential error as to these two issues. A. Symptom Reports: Plaintiff establishes consequential error.

Plaintiff argues the ALJ failed to provide valid reasons for discounting symptom reports and testimony that her impairments of migraine headaches and Ehlers-Danlos syndrome made it difficult for her to engage in any physical activity. The ALJ offered several reasons for discounting Plaintiff’s symptom reports—each reason is addressed below. 1. Standard

The ALJ must identify what symptom claims are being discounted and clearly and convincingly explain the rationale for discounting the symptoms with supporting citation to evidence.16 This requires the ALJ to “show his [or her] work”

16 Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022). Factors to be considered by the ALJ when evaluating the intensity, persistence, and limiting effects of a claimant’s symptoms include: 1) daily activities; 2) the location, duration, frequency, and intensity of pain or other symptoms; 3) factors that precipitate and aggravate the symptoms; 4) the type, dosage, effectiveness, and side effects of any medication the claimant takes or has taken to alleviate pain or other symptoms; 5) treatment, other than medication, the claimant receives or has received for relief of pain or other symptoms; 6) any non-treatment measures the claimant uses or has used to relieve pain or other symptoms; and 7) any other factors concerning the and provide a “rationale . . . clear enough that it has the power to convince” the reviewing court.17 When examining a claimant’s symptoms, the ALJ utilizes a two-step inquiry.

“First, the ALJ must determine whether there is objective medical evidence of an underlying impairment which could reasonably be expected to produce the pain or other symptoms alleged.”18 Second, “[i]f the claimant meets the first test and there is no evidence of malingering, the ALJ can only reject the claimant’s testimony about the severity of the symptoms if [the ALJ] gives ‘specific, clear and convincing reasons’ for the rejection.”19 General findings are insufficient; rather, the ALJ must

identify what symptom claims are being discounted and what evidence undermines these claims.20 “The clear and convincing standard is the most demanding required

claimant’s functional limitations and restrictions due to pain or other symptoms. Soc. Sec. Rlg. 16-3p, 2016 WL 1119029, at *7; 20 C.F.R. § 404.1529(c); Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014). 17 Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022) (alteration added). 18 Molina, 674 F.3d at 1112. 19 Ghanim 763 F.3d at 1163(quoting Lingenfelter, 504 F.3d at 1036). 20 Id. (quoting Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995), and Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002) (requiring the ALJ to sufficiently explain why he discounted claimant’s symptom claims)). in Social Security cases.”21 Therefore, if an ALJ does not articulate specific, clear, and convincing reasons to reject a claimant’s symptoms, the corresponding limitations must be included in the RFC.22

2. Plaintiff’s Testimony On June 14, 2022, Plaintiff appeared with her attorney for a hearing before ALJ Debra Denney.23 Plaintiff testified and a vocational expert testified.24 Plaintiff testified that she lived with her fiancé and he was the sole income for their household.25 She said that she could not work primarily because of migraine headaches.26 She said they are easily triggered and she cannot maintain

friendships and hold conversations because of the migraines.27 She has double

21 Garrison v. Colvin, 759 F.3d 995, 1015 (9th Cir. 2014) (quoting Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002)). 22 Lingenfelter, 504 F.3d at 1035 (“[T]he ALJ failed to provide clear and convincing reasons for finding Lingenfelter’s alleged pain and symptoms not credible, and therefore was required to include these limitations in his assessment of Lingenfelter’s RFC.”). 23 AR 77-110. 24 Id. 25 AR 84. 26 AR 85. 27 Id. vision so reading triggers migraines, but they are also triggered by smells, sounds, and lighting.28 She has Ehlers-Danlos, which causes problems in her joints as well.29 She said that Dr. Bulfinch believes that Ehlers-Danlos is a definite

diagnosis based on information from a local genetics program.30 She can drive within a five mile radius.31 Plaintiff testified that from 2006 through 2016 she worked from home for Royal Caribbean call center.32 They gave her an office with climate control, special lighting, the ability to attend meetings remotely, and flexibility in her schedule.33 When at Royal Caribbean, she was a director and managed managers.34 She left

and took a job with less responsibility thinking that it might alleviate her migraine headaches, but she was fired in less than 90 days because they did not offer accommodations.35 She kept falling asleep in meetings and when driving and left for safety reasons and briefly worked in a pet store and later as a self-employed dog

28 Id. 29 Id. 30 AR 86. 31 Id. 32 Id. 33 Id. 34 AR 87. 35 Id. walker and pet sitter.36 She then worked for a hotel supply company but left after a year because she could not hustle and made only one sale.37 She received unemployment during the pandemic on the advice of a counselor.38 When she

applied for unemployment, she certified that she was able to work and applied for jobs and attended about 6 job interviews in 2021.39 None of the interviewers offered her a job after she told them she needed accommodations.40 Plaintiff said she sees Dr. Bulfinch every four months for Ehlers-Danlos and that he is mainly monitoring her condition and prescribing medication.41 She also sees Dr. Mannava for her migraine headaches.42 She said mostly she is treated by

Dr. Mannava with medication and recently had a brain MRI which showed idiopathic intercranial hypertension, so she would be given a new medication.43 She has not been given Botox injections due to a phobia of needles.44 She said that

36 AR 88. 37 AR 89. 38 Id. 39 AR 90. 40 AR 91. 41 Id. 42 Id. 43 AR 92. 44 Id. she will usually sleep until 10:00 am, then spend an hour stretching or meditating, and then for the next few hours will schedule appointments or do small errands.45 She will have cereal for breakfast and will make dinner with her fiancé because

she cannot use a knife.46 She said that she used to cry throughout the day because she was frustrated doctors had not diagnosed her condition but no longer cries daily.47 She does not read or use computers because they trigger migraines.48 She stated that she can do most household chores, but cannot use her thumbs, and that she showers only three times a week because heat causes headaches, and she no longer gardens because of joint pain.49

Plaintiff said that stress causes her headaches and that she used to get counseling but was no longer in counseling because she thinks her issues are physical.50 She said she lives with her fiancé but her mother is moving closer to help with her care.51 She said she has not scheduled her wedding because her

45 AR 92-93. 46 AR 93. 47 Id. 48 Id. 49 AR 94. 50 AR 95. 51 AR 96. symptoms aren’t controlled and it is hard to plan around that.52 She said that she does not read or use computers because it triggers migraines.53 She said that she can’t work from home because those jobs are mostly computer-based work.54 She

said she also would not be able to work in a warehouse because of the noise, lighting, and smells and the fact that it would require repetitive motions.55 Plaintiff testified that headaches are not as painful as migraines and are on both sides or her head.56 She said she gets headaches about three weeks in a month and gets migraines three to six times in a month.57 She said that she has tried six abortive medications but they did not work and that she has tried treatments

including physical therapy, acupuncture, massage, chiropractic, and craniosacral therapy that did not work.58 She can only drive for five miles or less because she will faint at times or fall asleep due to her conditions.59

52 Id. 53 Id. 54 Id. 55 AR 97. 56 Id. 57 AR 97-98. 58 AR 98. 59 Id. 3. Medical Records Because Plaintiff only challenges the ALJ’s consideration of her subjective complaints and the medical opinions as to physical conditions, the Court only cites

to relevant medical evidence regarding physical issues. On January 19, 2018, Plaintiff presented to Kaylee English, DC.60 Joint restriction was noted in the cervical spine with right rotation and left lateral flexion; in the thoracic spine with extension; in the lumbar spine with right rotation at the L1-2 and L2-3 levels and with left rotation at the L4-5 level; and at the left SI joint with flexion.61 Dr. English diagnosed segmental and somatic

dysfunction in the cervical, thoracic and lumbar spine; segmental and somatic dysfunction in the pelvic region; segmental and somatic dysfunction of the upper and lower extremities; pain in the left ankle; cervicalgia; and myalgia.62 Dr. English opined that Plaintiff’s prognosis was poor due to poor at-home compliance, poor posture, poor biomechanics, and prolonged sitting.63 On March 22, 2018, Plaintiff presented with reports that she felt good overall, with pain in

60 AR 434. 61 Id. 62 Id. 63 AR 435. her right hip and no migraines since her last visit.64 Plaintiff’s examination yielded similar findings and her diagnoses were unchanged.65 On September 5, 2018, Plaintiff presented to David Higginbotham, MD, for a

possible broken foot and to have ADA paperwork completed.66 An X-ray revealed fracture of the proximal PIP joint, which did not require casting but required that Plaintiff wear a hard soled shoe.67 Plaintiff also complained that her anxiety disorder was worse in winter.68 Dr. Higginbotham increased Plaintiff’s dosage of Alprazolam.69 On June 3, 2019, Plaintiff presented to Tyler Chisholm, MD with complaints

of infection in her finger after being pricked with a rose.70 She also requested a referral for headaches and a psychiatrist and help filling out a disability form.71 On

64 AR 437. 65 Id. 66 AR 448. 67 Id. 68 AR 449. 69 Id. 70 AR 559. 71 Id. examination, there was a nodule at the first PIP joint.72 Otherwise, Plaintiff’s examination was within normal limits and she ambulated well.73 On July 1, 2019, Plaintiff presented to PA Amanda Price to establish care.74

Plaintiff reported she was in good health and had no childhood illnesses.75 Plaintiff reported a rose thorn in her fingertip; neck pain of several years after falling from a horse; PTSD resulting from childhood trauma; anxiety; depression well-controlled on medication; 3-4 migraines a month, related to stress and hormones; exertional compartment syndrome in her shins; and a phobia of needles.76 On examination, mood and affect were normal, she appeared well and in no distress and thought

and speech were congruent.77 PA Price diagnosed migraine with aura, not intractable; neck pain; PTSD, which PA Price declined to treat; a retained foreign body; a severe phobia of needles.78 On July 15, 2019, Plaintiff presented to Leonard Galloway, MPT, of Aegis Physical Therapy for evaluation, reporting that several months earlier she had an

72 AR 560. 73 AR 562. 74 AR 565. 75 AR 566. 76 Id. 77 AR 569. 78 AR 570-571. exacerbation of a prior neck injury and had pain radiating into her left arm to the elbow.79 Sensation was intact in all myotomes but trigger points were noted on palpation in the sub-occipital, cervical paraspinal and upper trapezius regions.80

Plaintiff complained that her decreased range of motion was limiting her daily activities.81 Between 1996 and current date, she had been prescribed multiple medications for mental health reasons.82 On August 12, 2019, Plaintiff presented to PA Price for follow-up.83 On examination, she denied headache, was in no distress, and had all normal findings, including normal mood and affect.84

On August 21, 2019, Plaintiff presented to Stephen Davis, PT, of Lakeview Spine Therapy for evaluation.85 Plaintiff described long-standing neck pain which is intermittent and can go as much as nine months without symptoms, as well as three different types of headache symptoms with one being associated with neck

79 AR 472. 80 AR 473. 81 Id. 82 Id. 83 AR 571. 84 AR 573. 85 AR 535. tension.86 On examination, Plaintiff had normal gait and posture, with limited range of motion in the cervical and lumbar spine.87A week later, Plaintiff presented to PT Davis for treatment of neck pain and he noted progress with treatment.88 On

September 3, 2019, Plaintiff presented to PT Davis with midthoracic tightness due to economic stress.89On September 5, 2019, Plaintiff presented to PT Davis with left-sided muscle tension.90On September 10, 2019, Plaintiff presented to PT Davis with a back of head and right frontal headache.91 PT Davis noted that after treatment Plaintiff’s left-sided neck tension subsided but her right headache remained.92 On September 12, 2019, Plaintiff reported that she wakes at night

with deep ache in her neck.93On September 19, 2019, PT Davis noted left-sided lateral neck pain with right-side bending.94 On October 1, 2019, PT Davis noted

86 Id. 87 Id. 88 AR 534. 89 AR 533. 90 AR 531. 91 AR 530. 92 Id. 93 AR 528. 94 AR 526. stiffness in the right scapular.95On October 3, 2019, Plaintiff was seen for neck pain.96 On October 8, 2019, Plaintiff presented to PT Davis with neck pain.97 PT Davis noted that Plaintiff’s range of motion had improved and her right and left

side were balanced in terms of symptoms.98 On October 10, 2019, Plaintiff presented to PT Davis, with suboccipital tightness.99 PT Davis found that her condition was improving.100 On October 1, 2019, Plaintiff presented to PA Price with complaints of diarrhea.101 She reported that she was going to physical therapy for her neck and it was moderately helpful but asked for a different muscle relaxer.102 Plaintiff

denied headache and on examination she was in no distress and all findings were within normal limits.103

95 AR 525. 96 AR 524. 97 AR 523. 98 Id. 99 AR 522. 100 Id. 101 AR 577. 102 Id. 103 AR 578-579. On November 13, 2019, Plaintiff presented to PA Price and reported that in the past doctors had prescribed Vicoprofen but she could not find a doctor who would prescribe both narcotic and benzodiazepine medication together and she

would like a referral to pain management.104 Plaintiff reported that since stopping physical therapy, her neck pain had worsened.105 Plaintiff denied headache and on examination she was in no distress and all findings were normal.106 PA Price started that an MRI had been negative and she did not feel comfortable prescribing narcotics but referred Plaintiff to pain management.107 On December 5, 2019, Plaintiff was examined by Lisa Kisenwether, ARNP,

at the request of the Commissioner.108 Plaintiff’s main complaints were chronic PTSD; migraine without aura; cervical pain, chronic; panic disorder; external compartment syndrome, lower leg, chronic bilaterally; asthma, stable on medication; and depression, stable on medication.109 Plaintiff described PTSD which was increasing in severity; migraines that feel like a pick in the temple, associated with light sensitivity, nausea and loss of consciousness; neck pain that

104 AR 580. 105 Id. 106 AR 581-582. 107 AR 582-583. 108 AR 537. 109 AR 537. is exacerbated by lifting, staying stationary, and reaching overhead; panic attacks; and exertional compartment syndrome in her lower legs.110 She reported that she could care for herself and her two dogs, but that she no longer does grocery

shopping, yard work, or horse riding.111 On examination, Plaintiff was able to walk without assistance, able to get on and off the exam table with no assistance or difficulty, able to sit and rise without difficulty, able to tie and untie her shoes, able to make a fist with both hands, able to touch her thumb to her fingers, able to pick up a coin and able to use buttons and a zipper.112 Her grip was normal.113 Plaintiff was able to tandem walk, walk on heels and toes, hop, bend, squat, and stand on

one leg.114 Her finger-to-nose and heel-to-shin test was normal; station was normal, gait was normal; Romberg test was negative; and she did not use an assistive device.115 Plaintiff had negative straight-leg raising, normal range of motion and no atrophy, spasm or joint deformity.116 Plaintiff had full strength in lower and upper extremities; and range of motion was normal in the neck, back, shoulders, elbows,

110 AR 537-538. 111 AR 538-539. 112 AR 540. 113 Id. 114 AR 541. 115 Id. 116 Id. wrists, thumbs, hips, knees, and ankles.117 Plaintiff’s cardiovascular, respiratory, and neurological systems were normal; and her abdomen was positive only for tenderness in the right lower quadrant.118 There was muscle tenderness noted on

palpation of the spine but no trigger points.119 In the cervical spine, there was straightening and loss of the lordotic curve, secondary to spasm and a slight 1-2mm anterolisthesis of C4/C5.120 ARNP Kisenwether diagnosed PTSD, chronic; migraine without aura; cervical pain, chronic; panic disorder; external compartment syndrome, lower leg, chronic/bilateral; asthma, stable with medication; and depression, stable with medication.121 ARNP Kinsenwether opined that Plaintiff

can stand or walk for eight hours, sit for eight hours, and lift and carry ten pounds frequently and twenty pounds occasionally. 122 She opined that Plaintiff had no limitation in climbing, balancing, stooping, kneeling, crouching, and crawling.123 She opined that Plaintiff could reach occasionally and should avoid exposure to

117 Id. 118 Id. 119 AR 542. 120 AR 542. 121 Id. 122 AR 542-543. 123 AR 543. unprotected heights, heavy machinery, chemicals, gases, dusts, fumes. and excessive noise.!24 On January 15, 2019, Plaintiff presented to PA Price.125 PA Price wrote: is a 37-year-old female who presents to the clinic today for follow-up. Patient begins the appointment vith a long list of symptoms and previous diagnosis that she would like to address. They. are as follows: shronic exertional compartment syndrome, bilateral bursitis, bilateral tendinitis in the knees, psychogenic 5, || onepileptic seizures, panic disorders, selective mutism, separated ribs, severe in unknown cause of bruising, oint hypermobility, double vision, migraines, skin rash, bloating diarrhea, neck pain, dislocated shoulders dilaterally, thumb pain, tilted uterus, tailbone pain, sprained ankles, hip dislocation bilaterally, knees locking dilaterally, tooth resorption, “odd medication side effects “, pes planus, bilateral stress fractures in both feet at 25 years old, difficulty holding pencil, low body. temperature, low blood pressure, sensitivity to heat and cold, iistory. of fainting, fatigue, idiopathic hypersomnia, wrist pain, chronic mild mid back pain, ankle sprain in hip jislocation at 12 years old, bedwetting until age 10 years old, intermittent hand tremor, frequent urination, ‘clumsy joints, giving out “, palpitations, PVCs, perioral dermatitis, ketosis pilaris. >atient reports that she would like to be evaluated for Ehlers-Danlos syndrome. Patient does endorse a history ot joint hypermobility.. She states that she has velvety type skin on the inner parts of her arms. She endorses iry a her abdomen, likely secondary to pregnancy. She does endorse easy bruising. She reports that any. ime she cuts herself that she heals poorly. Patient has not had any lab work due to significant severe needle }2hobia. She denies history of varicose veins, history of heart murmur./4°2] PA Price noted that Plaintiff denied headache and was in no distress on examination with normal findings that included the fact that she had a negative thumb test, no hypermobility in the joints of her hands or elbows, and that knees could not be easily dislocated.!26 PA Price advised Plaintiff of the criteria for Ehlers-Danlos and noted that she highly suspected hypochondriasis, and considered that Plaintiff was applying for SSD.!27 PA Price noted that she refused prescribe opioid pain medication and noted that Plaintiff was told she was not a 124 Td, 125 AR 584. 126 AR 585-586. 127 AR 586.

DISPOSITIVE ORDER, - 23

candidate for a pain management clinic because of her desire to take opioids as necessary and not on a schedule.128 On January 20, 2019, Plaintiff reported to PA Price for follow-up, requesting

referral for Ehlers-Danlos syndrome.129 On examination, Plaintiff denied headache, was in no distress, and all findings were within normal limits. PA Price noted that she believed there was a “significant component for psychiatric care” and noted that “I am concerned that she provides most of the history that is word for word meeting diagnostic criteria of Ehlers-Danlos.”130 PA Price noted further that she was concerned that Plaintiff had brought a sheet in which she had marked every

subjective and objective finding positive before there was even an examination performed, including unfounded medical diagnosis of mitral valve prolapse and aortic root dilation, despite negative echocardiogram.131 On October 16, 2019, Plaintiff presented to Tony Lee, MD of Washington Neurology.132 Plaintiff reported migraines of a 10/10 severity occurring 16+ times a month and lasting 12 hours.133 Plaintiff reported that she had tried multiple

128 AR 586-587. 129 AR 588. 130 AR 590. 131 Id. 132 AR 613. 133 Id. medications including triptans, Topamax, tizanidine, soma, methocarbamol, nortriptyline, Cymbalta, Gabapentin, and Lyrica, but that Vicodin worked.134 On examination, Plaintiff reported chest palpitations, shortness of breath, back pain,

anxiety, depression, and memory loss.135 She was well-groomed; was oriented to person, place, and time, and had normal behavior; had intact recent and remote memory, attention span, and concentration; had full range of motion without pain in the head and neck; had normal breathing; had normal cardiovascular findings; had normal gait and station; had normal musculoskeletal findings; and had a normal cranial nerve assessment.136 Dr. Lee diagnosed Plaintiff with Migraine

with aura, not intractable, without migrainosus; post traumatic stress disorder, chronic; major depressive disorder, recurrent severe without psychotic features, and fear of injections or transfusions.137 On November 15, 2019, Plaintiff reported to PT Davis that she had a migraine the day prior and was tired.138 On December 4, 2019, Plaintiff presented to PT Ryan Sprunger and reported that she had neck pain at a 7/10 and that it

134 Id. 135 Id. 136 AR 614. 137 AR 614. 138 AR 633. goes to a 10/10.139 She said that used to shop at small stores but now has to shop at Walmart or Costco due to financial concerns and has no friends nearby because she recently moved.140 She reported that she lost her job in 2016, and has not been able

to recover.141 On examination, she had normal gait and posture, had full mobility to sit and rise and get on the exam table without assistance, and she was tender at trigger points in the left scalenes and the right upper thoracic region.142 PT Springer assessed Plaintiff with chronic neck pain associated by Plaintiff with intermittent migraines triggered by anxiety, smells, lights, stress, or physical exertion.143 On December 10, 2019, Plaintiff presented to PT Sprunger.144 She

reported having a migraine the day prior but had fully recovered.145 On January 7, 2020, Plaintiff presented to PT Davis and reported that she had neck pain 50% of the time and that it has improved but that since her migraine medication was not refilled she now was having 4-6 migraines a month.146 On January 14, 2020,

139 AR 618. 140 Id. 141 Id. 142 AR 619. 143 Id. 144 AR 616. 145 Id. 146 AR 631. Plaintiff presented to PT Davis, reporting that she had hypermobility and wondered if she had a connective tissue disorder.147 She reported that her migraines were more severe since her medication was not refilled.148 On January

21, 2020, Plaintiff presented to PT Davis and complained that insurance would not pay for adequate testing and her health was not being addressed.149 On January 29, 2020, Plaintiff presented to PT Davis and reported that she remained concerned that she had a connective tissue disorder like Ehlers-Danlos Syndrome.150 PT David notes left greater than right cervical tenderness with improved relaxation and normal tone following treatment.151 He noted overall

hypermobility.152 On January 31, 2020, Plaintiff presented to neurologist Ahusha Mannava, MD, for evaluation of headaches.153 Plaintiff reported headaches since age 5, and then the onset of migraines in 2000 after she suffered a concussion.154 Plaintiff

147 AR 629. 148 Id. 149 AR 625. 150 AR 623. 151 Id. 152 Id. 153 AR 746. 154 Id. reported 31 headaches in a month with 20 severe headaches in a month.155 They are like a pick in the right temple; occasionally are accompanied by bright spots or a couple hours, light and sound sensitivity, nausea, dizziness, fatigue, and neck

tenderness; and are triggered by smell, lights, alcohol, and foods.156 She reported they are relieved by hydrocodone and sumatriptan helps if taken early.157 On examination, Plaintiff was in no distress and systems were normal with the exception of bilateral occipital tenderness and stiffness.158 A detailed neurological examination was normal.159 Dr. Mannava diagnosed chronic migraine headaches.160

On February 27, 2020, Plaintiff presented to Brenna Hayes of Virginia Mason Memoria Hospital for genetic counseling.161 Ms. Hayes ultimately opined that she could not make a diagnosis and that genetic testing was recommended.162

155 Id. 156 Id. 157 Id. 158 AR 748-749. 159 AR 749. 160 Id. 161 AR 644-647. 162 AR 647. On April 27, 2020, Plaintiff had a follow-up appointment with Dr. Mannava.163 She refused a trail of Botox due to fear of injections.164 Plaintiff stopped taking one medication due to dizziness but reported that her migraine

frequency decreased from 3-4 a month to 2 per month in the last 2 months with migraines lasting 4-5 days.165 Plaintiff requested narcotic pain medication, which Dr. Mannava refused to prescribe.166 Plaintiff was in no distress and a detailed neurological examination was normal.167 Dr. Mannava diagnosed chronic migraine and post traumatic headaches, intractable.168 Dr. Mannava added Ubrelvy as a medication.169

On June 23, 2020, Plaintiff presented to Charle Bulfinch, DO, to establish care.170 Plaintiff reported a history of anxiety and depression, migraines treated in the past by narcotics as necessary, and pain in multiple joints related to Ehlers-

163 AR 752. 164 Id. 165 Id. 166 Id. 167 AR 753. 168 Id. 169 Id. 170 AR 741. Danlos.171 On examination, all findings were normal.172 Dr. Bulfinch diagnosed Plaintiff with mild intermittent asthma; anxiety; Ehlers-Danlos syndrome, benign hypermobile form; and migraine.173

On August 17, 2020, Plaintiff presented to geneticist Susie Ball, MS DCGC, for evaluation of Ehlers-Danlos syndrome.174 On August 24, 2020, MS DCGC Ball wrote a narrative letter explaining that she had performed testing on Plaintiff but that because of the restrictions of seeing patients in person she could only verify one of the three criteria necessary to diagnose Ehlers-Danlos syndrome and could not make a diagnosis at that time, but would refer Plaintiff to a geneticist in

Oregon or allow her doctor Dr. Bulfinch to make a diagnosis.175 On August 31, 2020, Plaintiff presented to Dr. Mannava for follow-up, reporting that she had discontinued all her migraine medications and was getting headaches daily with only 1-2 headache free days a month.176 On examination, Plaintiff was in no distress and all findings were normal.177 Plaintiff requested a

171 Id. 172 Id. 173 Id. 174 AR 637-640. 175 AR 635-636. 176 AR 755-756. 177 AR 756. Cefaly device but was advised that she could try one after a two month trial of Memantine.178 On October 7, 2020, Plaintiff presented to Dr. Bulfinch with an injury to her

right heel.179 On examination, all systems were normal, and there was no numbness or weakness of the foot, but there was tenderness on the posterior and lateral aspect of the calcaneus.180 Dr. Bulfinch noted that he wanted to discuss the report of Susie Ball that Ehlers-Danlos syndrome was possibly a condition but had not been diagnosed due to an inability to fully evaluate Plaintiff.181 An x-ray showed no fracture and unremarkable soft tissue findings.182 A follow-up visit on

December 11, 2020, yielded similar results.183 On January 11, 2021, Plaintiff presented to Jeffrey LeCheminant, DPM, with continued pain in her right heel.184 Dr. LeCheminant diagnosed Achilles tendinitis and prescribed physical therapy, as rest was not helpful in healing.185 At

178 Id. 179 AR 743-744. 180 Id. 181 AR 743. 182 AR 745. 183 AR 810. 184 AR 819. 185 Id. a follow-up visit on April 19, 2021, with Dr. Bulfinch, Plaintiff reported that she had taken physical therapy and was wearing a walking shoe but could still not walk for prolonged periods.186 Dr. Bulfinch prescribed hydrocodone-ibuprofen.187

On April 27, 2021, Plaintiff presented to Dr. Bulfinch requesting medication and a prescription for a parking pass, since she was now able to walk a quarter of a mile.188 Plaintiff advised that she only used the pain medication for migraines if they lasted for more than 6 hours, and that was rare.189 On July 20, 2021, Plaintiff presented to Dr. Bulfinch with pain in her neck and foot.190 Dr. Bulfinch noted that an Ehlers-Danlos support group had suggested carbidopa-levidopa for spasms and

he thought it seemed reasonable to prescribe it at Plaintiff’s request.191 He prescribed cabidopa-levidopa, Cymbalta, and hydrocodone-ibuprofen.192 On August 12, 2021, Plaintiff was examined by Anita Beck, MD, a specialist in genetic testing.193 Dr. Beck diagnosed a connective tissue disorder of unknown

186 AR 826. 187 AR 833. 188 AR 837. 189 Id. 190 AR 840. 191 Id. 192 Id. 193 AR 770. etiology.194 On examination, Dr. Beck noted that Plaintiff was distressed only when discussing her connective tissue disorder.195 Finding regarding Plaintiff’s HEENT, neck, thorax, respiratory system, cardiovascular system, abdomen, lymphatic

system, and back were all within normal limits.196 Skin was noted to be soft but not excessively stretchy, and on neurological examination it was noted there was pain with movement but good strength.197 A musculoskeletal examination revealed that Plaintiff could touch her right thumb to her forearm but not her left; and she did not have hyperextension in her knees or elbows but was able to touch her palms to the ground.198 Dr. Beck noted that this correlated to a Beighton score of 4/9.199 Dr.

Beck noted that the closest diagnosis she could get to without genetic testing was hypermobile Ehlers-Danlos Syndrome, but it was not a perfect fit, and she could only diagnosis a connective tissue disorder of unknown etiology.200

194 Id. 195 AR 772. 196 AR 772-773. 197 AR 773. 198 Id. 199 Id. A Beighton Score is a test for joint hypermobility and a score of 4 or more on a scale of 9 is considered positive. Cleveland Clinic, Beighton Score, www.clevelandclinic.org (last seen March 26, 2024). 200 AR 774-775. On September 29, 2021, Plaintiff presented to Dr. Bulfinch with complaints that she was out of breath and sleeping a lot.201 She reported that carbidopa- levidopa was helping with her Ehlers-Danlos Syndrome but stated that insurance

had denied her medication for hypersomnia.202 On November 30, 2021, Plaintiff presented to cardiologist Anindita Chowdhury, MD, on referral from Dr. Bulfinch for mild intermittent asthma.203 Dr. Chowdhury noted that Plaintiff’s main complaint was tiredness and noted deconditioning.204 Dr. Chowdhury diagnosed chronic shortness of breath, Ehlers- Danlos syndrome, obesity and tiredness, and counseled Plaintiff to lose weight and

exercise to reverse deconditioning.205 A chest x-ray was normal.206 On January 24, 2022, Plaintiff presented to Brenna Hayes for follow-up genetic counseling.207 Ms. Hayes indicated that on August 18, 2020, Plaintiff was seen by Anita Beck, MD, for a genetics medical consultation and that Dr. Beck

201 AR 850. 202 Id. 203 AR 922. 204 Id. 205 AR 923-924. 206 AR 925. 207 AR 768. recommended genetics testing.208 Ms. Hayes explained that the genetic testing was completed and was negative, indicating that no genetic changes were found which would explain Plaintiff’s features.209 Ms. Hayes noted that the test could not rule

out Ehlers-Danlos but did not support it.210 On February 8, 2022, Plaintiff presented to Dr. Mannava with reports that in January she had pain in her right eye, with colors being off and possibly blurred vision.211 Dr. Mannava ordered an MRI of the brain and referred Plaintiff to an ophthalmologist.212 On February 14, 2022, Plaintiff presented to Richard Ehlers, MD, for a

consultation for possible neuritis on Dr. Mannava’s referral for possible neuritis and was found to have possible retro bulbar optic neuritis.213 On examination, all findings were within normal limits.214 On February 15, 2022, Plaintiff presented to Dr. Bulfinch with paperwork for disability.215

208 Id. 209 AR 768-769. 210 Id. 211 AR 896-897. 212 AR 897. 213 AR 792-793. 214 Id. 215 AR 876. On March 16, 2022, Plaintiff presented to Dr. Bulfinch with complaints that she had chest pain and felt a growth in her throat.216 Dr. Bulfinch referred her to an ENT.217 An echocardiogram was normal.218

On March 18, 2021, an MRI of the brain showed no sign of optic neuritis but showed mild prominence of the fluid surrounding the optic nerve sheath, indicating possible idiopathic intracranial hypertension.219 On March 29, 2022, Plaintiff presented to Rick Gross, MD, with complaints of a growth in her throat.220 Dr. Gross diagnosed a pharyngeal cyst and opined that it should be excised but that a consultation would be needed due to Ehlers-Danlos

syndrome.221 On March 30, 2022, Plaintiff called stating that she reconsidered taking antibiotics and would like them prescribed.222 On May 9, 2022, Plaintiff returned and was seen by Aaron Shady, DO, who noted that the cyst had resolved without intervention.223

216 AR 879. 217 AR 880. 218 AR 883-884. 219 AR 894. 220 AR 916. 221 AR 917. 222 AR 919. 223 AR 920. On March 31, 2022, Plaintiff presented to Dr. Mannava for follow-up for headaches.224 Dr. Mannava noted that in January 2022 Plaintiff had presented with complaints of recent blurred vision, double vision, and difficulty

distinguishing colors but that an MRI of the brain had not shown evidence of optic nerve injury or demyelinating disease.225 On examination, Plaintiff was in no distress and all findings were within normal limits.226 On May 25, 2022, Plaintiff presented to Dr. Mannava for follow-up.227 Plaintiff reported that after treatment with Diamox she had a reduction in headaches and had 10 headache free days for the two prior months, and had only 3-4 migraines per month.228

4. The ALJ’s Findings The ALJ found Plaintiff’s statements concerning the intensity, persistence, and limiting effects of her conditions to be only partially consistent with the evidence for two reasons.229 She states that the first reason was that Plaintiff’s allegations were inconsistent with her activities of daily living.230 The ALJ

224 AR 889. 225 AR 890. 226 AR 890-891. 227 AR 935. 228 AR 936. 229 AR 26-33. 230 AR 26. articulated: First, though the claimant alleged that she is unable to work, she nevertheless is able to engage in many significant activities of daily living. This leads the undersigned to believe that she is less limited than alleged. Notably, in her Function Report – Adult (Ex. 3E) the claimant reported that she is able to water her lawn, stretch, go on a short walk, take a shower, do light chores, and help care for her pets; perform her personal care activities with some problems; prepare meals half of the time; do household chores, such as, laundry, light cleaning, and vacuuming; go outside daily; drive a car and ride in a car; go shopping in stores; pay bills, count change, handle a savings account, and use a checkbook/money orders; and do hobbies, such as, watch movies and read in small increments.231 The ALJ then went on to note that Plaintiff had never been fired from a job for failing to get along with others, had received unemployment benefits by certifying that she was ready willing and able to work, and had reported that a year ago she rode horses and was a sales director with 200 employees under her direction.232 The ALJ also found that the Plaintiff’s subjective complaints were inconsistent with the objective evidence and clinical findings.233 5. Analysis The Court will address the reasons given by the ALJ to find Plaintiff’s subjective complaints less than credible.

231 AR 26-27. 232 AR 27. 233 Id. a. The ALJ’s consideration of Plaintiff’s daily activities Plaintiff argues that the ALJ took Plaintiff’s daily activities out of context when considering that they were inconsistent with allegations of total disability.

The Court agrees that the ALJ has not considered the record as a whole when considering the activities cited by the ALJ. Plaintiff’s primary disabling condition is migraine headaches. None of the simple activities engaged in by Plaintiff require heavy exertion and she testified that they were performed at times when she was not suffering from a migraine headache and had modified such activities to make them safe for her to perform, such as the fact that she did not drive for more

than short distances or use a knife when preparing foods.234 The ALJ erred in considering sedentary activities as an indication Plaintiff could engage in greater activities particularly in light of Dr. Chowdhury’s finding that Plaintiff had suffered from severe deconditioning as a result of her sedentary activities.235 The ALJ erred in considering that Plaintiff had not been fired for a job due to difficulty getting along with others but ignoring the fact that Plaintiff had twice been fired from employment due to taking excessive leave because of migraine

headaches.236

234 AR 93, 98. 235 AR 923-924. 236 AR 87, 358. The fact that Plaintiff had at one point directed 200 people and had been able to ride horses was not a valid consideration for the ALJ to make. The record clearly reflected that those activities has occurred prior to the alleged onset date,

when Plaintiff alleged a worsening in both the frequency and intensity of her migraine headaches. Additionally, it was not proper for the ALJ to consider that Plaintiff applied for unemployment when such benefits do not require an applicant to assert that they are capable of working full-time, but only part-time. b. The ALJ’s reasoning that Plaintiff’s allegations are inconsistent with the medical record.

As is noted above, Plaintiff suffers from two separate conditions for which she has alleged physical disability—migraine headaches and Ehlers-Danlos syndrome. While her diagnosis of Ehlers-Danlos is relatively new and is equivocal according to the medical opinion of Dr. Beck,237 there was no indication that Plaintiff’s allegations regarding the frequency or intensity of her migraine headaches was in question. Objective medical evidence in the form of an MRI of the brain established that Plaintiff suffered from idiopathic intracranial

hypertension, which Dr. Mannava opined to be the source of Plaintiff’s migraine headaches.238 Indeed, the medical record supports that Plaintiff reported to medical providers that she suffered up to 20 migraine headaches in a month and,

237 AR 768-769. 238 AR 894, 936. that at its best level of control, Plaintiff suffered at least 3 migraine headaches a month.239 6. Summary

Because the ALJ did not give good reasons for discounting Plaintiff’s symptom reports about her headaches, a remand is warranted. B. Medical Opinion: Plaintiff establishes consequential error Plaintiff argues the ALJ erred in her evaluation of the medical opinions.240 Specifically, Plaintiff first argues that the ALJ erred in finding the opinions of Dr. Mannava and Dr. Bulfinch to be not persuasive and instead relying on the

opinions of the non-examining state agency evaluators. The Commissioner argues that Dr. Mannava did not provide a medical opinion and that Dr. Bulfinch’s medical opinion was lacking in supportability and consistency. 1. Standard The ALJ was required to consider and evaluate the persuasiveness of the medical opinions and prior administrative medical findings.241 The factors for

239 AR 936. 240 An ALJ must consider and articulate how persuasive she found each medical opinion, including whether the medical opinion was consistent with and supported by the record. 20 C.F.R. § 404.1520c(a)–(c); Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022). 241 20 C.F.R. § 404.1520c(a), (b). evaluating the persuasiveness of medical opinions and prior administrative medical findings include, but are not limited to, supportability, consistency, relationship with the claimant, and specialization.242 Supportability and

consistency are the most important factors,243 and the ALJ must explain how she considered the supportability and consistency factors when reviewing the medical opinions and support her explanation with substantial evidence.244 The ALJ may consider, but is not required to discuss the following additional factors: the source’s relationship to Plaintiff such as length of the treatment, purpose of the treatment relation and whether the source examined Plaintiff, as well as whether the source

had advanced training or experience to specialize in the area of medicine in which the opinion was being given.245 A medical opinion is statement from a medical source about what an individual can still do despite her limitations or restrictions in the abilities to do the following: perform the physical demands of work activities such as standing,

242 20 C.F.R. § 404.1520c(c)(1)–(5). 243 Id. § 404.1520c(b)(2). 244 Id. § 404.1520c(b)(2); Woods v. Kijakazi, 32 F.4th a at 785 (“The agency must articulate . . . how persuasive it finds all of the medical opinions from each doctor or other source and explain how it considered the supportability and consistency factors in reaching these findings.”) (cleaned up). 245 Id. walking, sitting, lifting, carrying, pushing, pulling, and performing manipulative or postural functions; perform the mental demands of work activities such as understanding, remembering, maintaining concentration, persistence, and pace;

interacting appropriately with others, and dealing with stress; performing other demands such as seeing, hearing, and using other senses; and the ability to adapt to environmental conditions such as temperature extremes.246 2. Plaintiff’s Testimony The Court hereby incorporates and refers to the Plaintiff testimony summarized above in its analysis of the prior issue.

3. Relevant Medical Records The Court hereby incorporates and refers to the relevant medical records summarized above in its analysis of the prior issue. 4. Analysis a. The ALJ’s consideration of Dr. Mannava’s opinions regarding Plaintiff’s environmental limitations Dr. Mannava treated Plaintiff for her migraine headaches and has,

according to the medical record, been successful in reducing the frequency and intensity of her migraines.247 Dr. Mannava’s treatment of Plaintiff began on January 31, 2020, and continued throughout the relevant period.

246 20 C.F.R. § 404.1513. 247 AR 936. On February 21, 2022, Dr. Mannava completed a questionnaire.248 She said that Plaintiff had a diagnosis of chronic migraine which she diagnosed based on notes from medical treatment with a neurologist since January 31, 2020.249

Dr. Mannava stated that the headaches met the criteria of chronic migraine and that her evaluation supports the diagnosis because if examination findings and failed treatment with prior medication, as well as sensitivity to light.250 Dr. Mannava opined that Plaintiff’s function might be limited because lights, noise, movement, and exertion may trigger or worsen headaches.251 The Court notes that the Commissioner errs in asserting that Dr. Mannava’s

statements do not constitute a medical opinion. Dr. Mannava noted specifically that Plaintiff has “significant problems due to light sensitivity and pain” and noted that “function” was limited “as lights, noise and movement/exertion may trigger or worsen headaches.”252 This constitutes a medical opinion, as Dr. Mannava was clearly rendering a statement regarding Plaintiff’s ability to function in environmental conditions.253

248 AR 758-759. 249 AR 758. 250 Id. 251 Id. 252 Id. 253 See 20 C.F.R. § 404.1513. The ALJ’s reasoning is flawed for two reasons. First, the ALJ did not properly consider that Dr. Mannava clearly explained her diagnosis and the fact that she based it upon her own examinations as well as those of the neurologist,

Dr. Lee. Additionally, there was little if any analysis as to the supportability of Dr. Mannava’s opinions. Moreover, the ALJ failed to consider that Dr. Mannava’s opinion was overwhelmingly consistent with and supported by the objective findings in the medical record and the finding of Plaintiff’s neurologist. The records indicate that Plaintiff’s function improved following her treatment with medication following a brain MRI indicating intracranial

hypertension. A claimant’s improvement with treatment is “an important indicator of the intensity and persistence of . . . symptoms.”254 Symptom improvement, however, must be weighed within the context of an “overall diagnostic picture.”255 Here, the record indicates that even after treatment with more effective

254 20 C.F.R. § 404.1529(c)(3). See Warre v. Comm'r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) (“Impairments that can be controlled effectively with medication are not disabling for the purpose of determining eligibility for SSI benefits.”). 255 Holohan v. Massanari, 246 F.3d1195, 1205 (9th Cir. 2001); see also Lester v. Chater, 81 F.3d 821, 833 (9th Cir. 1995) (“Occasional symptom-free periods ... are not inconsistent with disability.”). medication, Plaintiff still experienced at least three to four migraine headaches a month and there is no indication that lights and noise are no longer a trigger. The ALJ erred by failing to consider both Plaintiff’s symptom reports and

Dr. Mannava’s opinions regarding Plaintiff’s “significant” sensitivity to lights. While the ALJ provided for a limitation in the RFC to a work environment that was quiet, and characterized as office level, it made no provision limiting lights, or the use of computer screens. This is error. The Court concludes that remand is warranted for the ALJ to properly consider the opinion evidence and to evaluate the record as a whole.

b. The ALJ’s consideration of Dr. Bulfinch’s opinions On February 15, 2022, Dr. Bulfinch completed a medical questionnaire and noted that he diagnosed Plaintiff with Ehlers-Danlos syndrome and migraines based on her subjective reports and the fact that she saw a genetics counselor in the past.256 When asked about the objective findings supporting his diagnosis, Dr. Bulfinch stated that Plaintiff’s skin was a little stretchy and that there are no objective findings for migraines.257 Dr. Bulfinch stated that Plaintiff would have a

decreased ability to use electric screens and decreased exercise tolerance.258 Dr. Bulfinch competed a Medical Report Form as well, which he stated that

256 AR 760. 257 Id. 258 Id. Plaintiff was diagnosed with migraines and Ehlers-Danlos.259 He opined that Plaintiff could sit for 30 minutes at a time and a total of 4 hours; could stand for 15 minutes and stand or walk for a total of less than 2 hours; would need to take 4

breaks a day of 30 minutes to 2 hours; would require a job that allowed alternating between standing and sitting at will; and would be absent for more than 4 days month.260 He opined that Plaintiff’s symptoms would frequently interfere with attention and concentration; that she could occasionally carry less than ten pounds and could rarely carry ten pounds.261 He opined that Plaintiff could never do the following: bending, stooping, squatting, crouching, kneeling, and crawling.262 He

also opined that Plaintiff could rarely climb stairs, reach above the shoulders, or reach to floor level; and could occasionally handle and finger or reach to waist level.263 He opined that Plaintiff’s impairments began in 2014 and were chronic, that she was not a malingerer, and that she could perform her past work with accommodations and other work that met the restrictions.264

259 AR 761-762. 260 AR 761. 261 AR 762. 262 Id. 263 Id. 264 Id. Dr. Bulfinch’s opinions were not accompanied by the same explanation provided by Dr. Mannava. The sole explanation of his diagnosis that Plaintiff’s skin was a little stretchy is of itself not sufficient to explain the basis of his opinion.

Moreover, Dr. Bulfinch’s opinions were inconsistent with the record as a whole. It is notable that Dr. Bulfinch initially based his diagnosis of Ehler’s-Danlos syndrome on nothing more than Plaintiff’s subjective reports.265 Ms. Ball, Dr. Beck, and Ms. Hayes all declined to diagnose Ehler’s Danlos syndrome.266 Both PA Price and Dr. Beck found that there was no evidence of hypermobility in Plaintiff’s joints.267

The Court concludes that Plaintiff’s arguments as to the ALJ’s finding that Dr. Bulfinch’s opinions were lacking in supportability and consistency is without merit. Additionally, to the extent that the Court has remanded the case for consideration of Dr. Mannava’s opinions, the ALJ is required to reconsider the medical opinions in general. 5. Summary Because the ALJ did not give good reasons for her evaluation of the medical

opinions of Dr. Mannava, a remand is warranted.

265 AR 741. 266 AR 635-636, 647,774-775. 267 AR 585-586, 773. C. Step Five: The Court Finds the Issue Moot Plaintiff argues the ALJ erred at step five. As discussed above, the ALJ failed to properly evaluate Plaintiff’s subjective complaints and the medical

opinions of Dr. Mannava. Because the ALJ will be require to reevaluate the medical evidence and all testimony on remand, the Court finds this issue to be moot. D. Remand for Further Proceedings Plaintiff submits a remand for payment of benefits is warranted. The decision whether to remand a case for additional evidence, or simply to award

benefits, is within the discretion of the court.”268 When the court reverses an ALJ’s decision for error, the court “ordinarily must remand to the agency for further proceedings.”269

268 Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987) (citing Stone v. Heckler, 761 F.2d 530 (9th Cir. 1985)). 269 Leon v. Berryhill, 880 F.3d 1041, 1045 (9th Cir. 2017); Benecke 379 F.3d at 595 (“[T]he proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation”); Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099 (9th Cir. 2014). IV. Conclusion Plaintiff establishes the ALJ erred. On remand, the ALJ is to develop the record and reevaluate—with meaningful articulation and evidentiary support—the sequential process. Accordingly, IT IS HEREBY ORDERED: 1. The ALJ’s nondisability decision is REVERSED, and this matter is REMANDED to the Commissioner of Social Security for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g). 2. The Clerk’s Office shall TERM the parties’ briefs, ECF Nos. 8 and 13, enter JUDGMENT in favor of Plaintiff, and CLOSE the case. IT IS SO ORDERED. The Clerk’s Office is directed to file this order and provide copies to all counsel. DATED this 10* day of April, 2024. " Bed | he Senior United States District Judge

DISPOSITIVE ORDER - 50