1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 SOUTHERN DISTRICT OF CALIFORNIA 10 11 RUSSELL C., Case No. 20-cv-256-MMA (RBM)
12 Plaintiff, ORDER OVERRULING 13 v. COMMISSIONER’S OBJECTION; ADOPTING REPORT AND 14 ANDREW SAUL, Commissioner of RECOMMENDATION; GRANTING Social Security, 15 IN PART AND DENYING IN PART Defendant. PLAINTIFF’S MOTION FOR 16 SUMMARY JUDGMENT; AND 17 REMANDING ACTION TO SOCIAL SECURITY ADMINISTRATION 18
19 [Doc. Nos. 11, 14, 15] 20 21 On February 11, 2020, Russell C. (“Plaintiff”) filed this social security appeal 22 challenging the denial of his application for disability benefits. See Doc. No. 1.1 The 23 Court referred all matters arising in this social security appeal to the assigned Magistrate 24 Judge for report and recommendation (“R&R”) pursuant to 28 U.S.C. § 636(b)(1)(B) and 25 Civil Local Rule 72.1. See Doc. No. 7. Plaintiff filed a motion for summary judgment. 26
27 1 Citations generally refer to the pagination assigned by the CM/ECF system. However, “AR” refers to 28 1 See Doc. Nos. 11. The Magistrate Judge has issued a R&R recommending that the Court 2 (1) grant in part and deny in part Plaintiff’s motion and (2) remand the Administrative 3 Law Judge’s (“ALJ”) decision. See Doc. No. 14 at 17. Andrew Saul, Commissioner of 4 Social Security, (“Commissioner”) objects to a portion of the R&R, and Plaintiff replied. 5 See Doc. Nos. 15, 16. Upon due consideration and for the reasons set forth below, the 6 Court OVERRULES the Commissioner’s objection, ADOPTS the Magistrate Judge’s 7 R&R, GRANTS in part and DENIES in part Plaintiff’s motion for summary judgment, 8 and REMANDS this matter to the Social Security Administration. 9 I. BACKGROUND 10 Seeking judicial review to challenge the denial of his application for disability 11 insurance benefits, Plaintiff filed the present action pursuant to 42 U.S.C. § 405(g). See 12 Doc. No. 1 ¶ 1. Plaintiff moved for summary judgment, arguing that (1) the “ALJ was 13 estopped from redetermining [Plaintiff’s] residual functional capacity [(“RFC”)] in the 14 Title II claim,” (2) the ALJ’s decision was not supported by substantial evidence, and (3) 15 the ALJ erred by supplanting a physician’s assessment with his own. Doc. No. 11-1 at 16 13, 17. 17 The Magistrate Judge issued an R&R on Plaintiff’s motion for summary judgment, 18 in which she recommends granting in part and denying in part Plaintiff’s motion. See 19 Doc. No. 11-1 at 17. In particular, the Magistrate Judge recommends remanding the 20 ALJ’s decision regarding Plaintiff’s RFC. See id. The Magistrate Judge determined that 21 “the ALJ’s RFC assessment did not rely upon any physician’s opinion to provide an 22 opinion regarding limitations, mental or physical.” Id. at 15 (citing AR 22–29). The 23 Magistrate Judge found that the ALJ’s decision was not supported by substantial 24 evidence and the record should be more “developed with respect to Plaintiff’s RFC.” Id. 25 at 17. 26 The Commissioner now objects to the Magistrate Judge’s R&R. See Doc. No. 15. 27 II. LEGAL STANDARD 28 1 The duties of the district court in connection with a magistrate judge’s R&R are set 2 forth in Rule 72(b) of the Federal Rules of Civil Procedure and 28 U.S.C. § 636(b)(1). 3 Where the parties object to a R&R, “[a] judge of the [district] court shall make a de novo 4 determination of those portions of the [R&R] to which objection is made.” 28 U.S.C. 5 § 636(b)(1); see Thomas v. Arn, 474 U.S. 140, 149–50 (1985). A district judge may 6 “accept, reject, or modify, in whole or in part, the findings or recommendations made by 7 the magistrate judge.” 28 U.S.C. § 636(b)(1); see also Wilkins v. Ramirez, 455 F. Supp. 8 2d 1080, 1088 (S.D. Cal. 2006). 9 III. DISCUSSION 10 The Commissioner objects to the Magistrate Judge’s R&R on one issue: “the 11 finding of error as to the ALJ’s RFC finding.” Doc. No. 15 at 1. The Commissioner 12 states that “because the RFC finding is a legal finding, not a medical one, the ALJ alone 13 is responsible” for determining Plaintiff’s RFC. Id. In response to the Magistrate 14 Judge’s finding that “the ALJ’s RFC assessment did not rely upon any physician’s 15 opinion to provide an opinion regarding [Plaintiff’s] limitations, mental or physical,” 16 Doc. No. 14 at 15 (citing AR at 22–29), the Commissioner asserts that “there is no 17 regulatory or legal requirement that the RFC finding track a specific medical opinion.” 18 Doc. No. 15 at 3. The Commissioner further states that to the extent there were 19 conflicting statements or ambiguity in the record, the ALJ properly exercised his role as 20 fact-finder by resolving these issues. See id. at 5. Furthermore, the Commissioner 21 contends that the “substantial evidence” requirement is not a high threshold and the 22 ALJ’s analysis of the medical evidence in the record satisfies this requirement. Id. 23 Plaintiff responds that the ALJ’s decision is not supported by substantial evidence. 24 See Doc. No. 16 at 2 (citing Doc. No. 11). Plaintiff argues that because the ALJ does not 25 rely on a medical opinion or examination to determine Plaintiff’s functional limitations, 26 the RFC assessment is “nothing more than the ALJ’s own ‘exploration and assessment’ 27 of [Plaintiff’s] impairments.” See Doc. No. 11 at 18 (quoting McAnally v. Berryhill, No. 28 3:18-cv-02272-GPC-RNB, 2020 WL 1443734, at *7 (S.D. Cal. Mar. 25, 2020)). Plaintiff 1 claims that the ALJ “formulated his own independent determination that [Plaintiff] is 2 capable of medium work.” Doc. No. 11 at 18 (citing AR 22). Plaintiff further contends 3 that the ALJ violated his “special duty to develop the record and retain a medical expert 4 or retain an examining physician,” and the absence of any medical opinion regarding 5 Plaintiff’s functional limitations yields a RFC that is not supported by substantial 6 evidence. See Doc. No. 16 at 3 (citing Hayes v. Colvin, No. 3:16-cv-00140-JLS-MDD, 7 2016 WL 11281409, at *2, *6, *8 (S.D. Cal. Dec. 19, 2016), report and recommendation 8 adopted, 2017 WL 781580 (S.D. Cal. Mar. 1, 2017)). 9 A RFC assessment is the most a plaintiff can do despite existing physical, mental, 10 and other limitations. 20 C.F.R. § 404.1545(a)(1). See generally SSR 96-8p, S.S.R. 11 Cum. Ed. (July 2, 1996). An ALJ considers all relevant medical and other evidence when 12 conducting a RFC assessment. 20 C.F.R. § 404.1545(a)(3). If an ALJ chooses to give 13 minimal weight to a medical opinion, the ALJ must provide specific, legitimate reasons 14 for his decision. See Lester v. Chater, 81 F.3d 821, 830 (9th Cir.1996) (citing Murray v. 15 Heckler 722 F.2d 499, 502 (9th Cir. 1983)). 16 To the extent that there are conflicting statements or ambiguities in the 17 administrative record, it is the ALJ’s duty to fully develop the record to resolve the 18 conflicting statements and ambiguities. See Tonapetyan v. Halter,
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1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 SOUTHERN DISTRICT OF CALIFORNIA 10 11 RUSSELL C., Case No. 20-cv-256-MMA (RBM)
12 Plaintiff, ORDER OVERRULING 13 v. COMMISSIONER’S OBJECTION; ADOPTING REPORT AND 14 ANDREW SAUL, Commissioner of RECOMMENDATION; GRANTING Social Security, 15 IN PART AND DENYING IN PART Defendant. PLAINTIFF’S MOTION FOR 16 SUMMARY JUDGMENT; AND 17 REMANDING ACTION TO SOCIAL SECURITY ADMINISTRATION 18
19 [Doc. Nos. 11, 14, 15] 20 21 On February 11, 2020, Russell C. (“Plaintiff”) filed this social security appeal 22 challenging the denial of his application for disability benefits. See Doc. No. 1.1 The 23 Court referred all matters arising in this social security appeal to the assigned Magistrate 24 Judge for report and recommendation (“R&R”) pursuant to 28 U.S.C. § 636(b)(1)(B) and 25 Civil Local Rule 72.1. See Doc. No. 7. Plaintiff filed a motion for summary judgment. 26
27 1 Citations generally refer to the pagination assigned by the CM/ECF system. However, “AR” refers to 28 1 See Doc. Nos. 11. The Magistrate Judge has issued a R&R recommending that the Court 2 (1) grant in part and deny in part Plaintiff’s motion and (2) remand the Administrative 3 Law Judge’s (“ALJ”) decision. See Doc. No. 14 at 17. Andrew Saul, Commissioner of 4 Social Security, (“Commissioner”) objects to a portion of the R&R, and Plaintiff replied. 5 See Doc. Nos. 15, 16. Upon due consideration and for the reasons set forth below, the 6 Court OVERRULES the Commissioner’s objection, ADOPTS the Magistrate Judge’s 7 R&R, GRANTS in part and DENIES in part Plaintiff’s motion for summary judgment, 8 and REMANDS this matter to the Social Security Administration. 9 I. BACKGROUND 10 Seeking judicial review to challenge the denial of his application for disability 11 insurance benefits, Plaintiff filed the present action pursuant to 42 U.S.C. § 405(g). See 12 Doc. No. 1 ¶ 1. Plaintiff moved for summary judgment, arguing that (1) the “ALJ was 13 estopped from redetermining [Plaintiff’s] residual functional capacity [(“RFC”)] in the 14 Title II claim,” (2) the ALJ’s decision was not supported by substantial evidence, and (3) 15 the ALJ erred by supplanting a physician’s assessment with his own. Doc. No. 11-1 at 16 13, 17. 17 The Magistrate Judge issued an R&R on Plaintiff’s motion for summary judgment, 18 in which she recommends granting in part and denying in part Plaintiff’s motion. See 19 Doc. No. 11-1 at 17. In particular, the Magistrate Judge recommends remanding the 20 ALJ’s decision regarding Plaintiff’s RFC. See id. The Magistrate Judge determined that 21 “the ALJ’s RFC assessment did not rely upon any physician’s opinion to provide an 22 opinion regarding limitations, mental or physical.” Id. at 15 (citing AR 22–29). The 23 Magistrate Judge found that the ALJ’s decision was not supported by substantial 24 evidence and the record should be more “developed with respect to Plaintiff’s RFC.” Id. 25 at 17. 26 The Commissioner now objects to the Magistrate Judge’s R&R. See Doc. No. 15. 27 II. LEGAL STANDARD 28 1 The duties of the district court in connection with a magistrate judge’s R&R are set 2 forth in Rule 72(b) of the Federal Rules of Civil Procedure and 28 U.S.C. § 636(b)(1). 3 Where the parties object to a R&R, “[a] judge of the [district] court shall make a de novo 4 determination of those portions of the [R&R] to which objection is made.” 28 U.S.C. 5 § 636(b)(1); see Thomas v. Arn, 474 U.S. 140, 149–50 (1985). A district judge may 6 “accept, reject, or modify, in whole or in part, the findings or recommendations made by 7 the magistrate judge.” 28 U.S.C. § 636(b)(1); see also Wilkins v. Ramirez, 455 F. Supp. 8 2d 1080, 1088 (S.D. Cal. 2006). 9 III. DISCUSSION 10 The Commissioner objects to the Magistrate Judge’s R&R on one issue: “the 11 finding of error as to the ALJ’s RFC finding.” Doc. No. 15 at 1. The Commissioner 12 states that “because the RFC finding is a legal finding, not a medical one, the ALJ alone 13 is responsible” for determining Plaintiff’s RFC. Id. In response to the Magistrate 14 Judge’s finding that “the ALJ’s RFC assessment did not rely upon any physician’s 15 opinion to provide an opinion regarding [Plaintiff’s] limitations, mental or physical,” 16 Doc. No. 14 at 15 (citing AR at 22–29), the Commissioner asserts that “there is no 17 regulatory or legal requirement that the RFC finding track a specific medical opinion.” 18 Doc. No. 15 at 3. The Commissioner further states that to the extent there were 19 conflicting statements or ambiguity in the record, the ALJ properly exercised his role as 20 fact-finder by resolving these issues. See id. at 5. Furthermore, the Commissioner 21 contends that the “substantial evidence” requirement is not a high threshold and the 22 ALJ’s analysis of the medical evidence in the record satisfies this requirement. Id. 23 Plaintiff responds that the ALJ’s decision is not supported by substantial evidence. 24 See Doc. No. 16 at 2 (citing Doc. No. 11). Plaintiff argues that because the ALJ does not 25 rely on a medical opinion or examination to determine Plaintiff’s functional limitations, 26 the RFC assessment is “nothing more than the ALJ’s own ‘exploration and assessment’ 27 of [Plaintiff’s] impairments.” See Doc. No. 11 at 18 (quoting McAnally v. Berryhill, No. 28 3:18-cv-02272-GPC-RNB, 2020 WL 1443734, at *7 (S.D. Cal. Mar. 25, 2020)). Plaintiff 1 claims that the ALJ “formulated his own independent determination that [Plaintiff] is 2 capable of medium work.” Doc. No. 11 at 18 (citing AR 22). Plaintiff further contends 3 that the ALJ violated his “special duty to develop the record and retain a medical expert 4 or retain an examining physician,” and the absence of any medical opinion regarding 5 Plaintiff’s functional limitations yields a RFC that is not supported by substantial 6 evidence. See Doc. No. 16 at 3 (citing Hayes v. Colvin, No. 3:16-cv-00140-JLS-MDD, 7 2016 WL 11281409, at *2, *6, *8 (S.D. Cal. Dec. 19, 2016), report and recommendation 8 adopted, 2017 WL 781580 (S.D. Cal. Mar. 1, 2017)). 9 A RFC assessment is the most a plaintiff can do despite existing physical, mental, 10 and other limitations. 20 C.F.R. § 404.1545(a)(1). See generally SSR 96-8p, S.S.R. 11 Cum. Ed. (July 2, 1996). An ALJ considers all relevant medical and other evidence when 12 conducting a RFC assessment. 20 C.F.R. § 404.1545(a)(3). If an ALJ chooses to give 13 minimal weight to a medical opinion, the ALJ must provide specific, legitimate reasons 14 for his decision. See Lester v. Chater, 81 F.3d 821, 830 (9th Cir.1996) (citing Murray v. 15 Heckler 722 F.2d 499, 502 (9th Cir. 1983)). 16 To the extent that there are conflicting statements or ambiguities in the 17 administrative record, it is the ALJ’s duty to fully develop the record to resolve the 18 conflicting statements and ambiguities. See Tonapetyan v. Halter, 242 F.3d 1144, 1150 19 (9th Cir. 2001) (quoting Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir.1996)) (citing 20 Armstrong v. Comm’r of Soc. Sec. Admin., 160 F.3d 587, 590 (9th Cir. 1998)) 21 (“Ambiguous evidence, or the ALJ’s own finding that the record is inadequate to allow 22 for proper evaluation of the evidence, triggers the ALJ’s duty to ‘conduct an appropriate 23 inquiry.’”). If evidence from the medical source is insufficient to determine if the 24 claimant is disabled, an ALJ may recontact the medical source to determine if additional 25 needed information is readily available. See 20 C.F.R. § 404.1520b(b)(2)(i); see also 20 26 C.F.R. § 404.1512(b)(1) (stating the Commissioner is responsible for developing 27 Plaintiff’s complete medical history). The record will be considered “inadequate” or 28 “ambiguous” when a medical source has provided a medical opinion that is not supported 1 by the evidence. See Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 2005) (first 2 citing 20 C.F.R. §§ 404.1512(e), 416.912(3) (amended 2012); and then citing Thomas v. 3 Barnhart, 278 F.3d 947, 958 (9th Cir. 2002)) (“An ALJ is required to recontact a doctor 4 only if the doctor’s report is ambiguous or insufficient for the ALJ to make a disability 5 determination.”). It is for the ALJ to determine credibility, resolve conflicts in testimony, 6 and resolve ambiguities in the record, but his findings must be supported by specific and 7 cogent reasons. See Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998) (first citing 8 Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995); and then citing Rashad v. 9 Sullivan, 903 F.2d 1229, 1231 (9th Cir. 1990)). 10 Courts may set aside the denial of disability insurance benefits when the ALJ’s 11 findings are based on legal error or are not supported by substantial evidence in the 12 record as a whole. See Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993) (citing 13 Brawner v. Sec’y of Health & Human Servs., 839 F.2d 432, 433 (9th Cir. 1988)). 14 “Substantial evidence means more than a mere scintilla but less than a preponderance; it 15 is such relevant evidence as a reasonable mind might accept as adequate to support a 16 conclusion.” Andrews, 53 F.3d at 1039 (citing Magallanes v. Bowen, 881 F.2d 747, 750 17 (9th Cir. 1989)). 18 Here, the ALJ gave “no weight” to the medical opinion statements of the state 19 agency consultants because their analysis was for the Title XVI application and was 20 insufficient evidence to evaluate Plaintiff’s present Title II disability claim. AR at 16. 21 Further, the ALJ gave “minimal weight” to opinion statements in Plaintiff’s Veterans 22 Affairs (“VA”) records. See id. at 27. The ALJ reasoned that these VA opinion 23 statements were “largely unsupported and overall inconsistent with the longitudinal 24 evidence,” such as “[VA] records themselves.” Id. In particular, the ALJ noted the 25 following evidence from VA records: Plaintiff getting a key to the exercise room and 26 planning on using the exercise room three or four time per week; Plaintiff completing “at 27 least two stress/exercise tests with at least one lasting over 8 minutes”; Plaintiff being 28 counseled on the importance of regular exercise and on the lack of a cardiac reason to 1 have a handicap placard; and Plaintiff swimming and playing basketball. Id. 2 Additionally, the ALJ noted that Plaintiff “denied exercise intolerance”; was advised to 3 exercise at least three times for thirty minutes per week; had “5 out of 5 strength in the 4 bilateral lower and upper extremities”; and swept, picked up trash, and cleaned at his 5 current job. Id. Delving into other VA records, the ALJ pointed to a slew of information: 6 attendance at psychotherapy and therapy skills sessions where he was alert, oriented, and 7 engaged; involvement in career classes and a “Transactional Work event”; notation of 8 only mild agitation and aggression at an appointment; and a description of a situation 9 where Plaintiff controlled his anger. Id. at 27–28. 10 Overall, the ALJ found that the “objective medical evidence and other evidence of 11 the record shows the claimant’s symptoms do not reduce the claimant’s capacity to 12 perform work-related activities to the extent that the claimant alleges.” Id. at 23. The 13 ALJ found that Plaintiff’s statements “are generally inconsistent with the objective 14 medical evidence of [the] record and other evidence.” Id. at 23; see also id. 26, 27, 29. 15 The Commissioner objects to the R&R’s assessment of the RFC. The 16 Commissioner criticizes the Magistrate Judge for faulting the ALJ for not relying on a 17 specific medical finding in developing the RFC. See Doc. No. 15. However, the 18 Magistrate Judge highlighted this issue in pointing to a larger problem: the ALJ’s RFC 19 findings reveal unresolved inconsistencies in the record. See Doc. No. 14 at 15–16. The 20 Court proceeds by reviewing whether substantial evidence supports the ALJ’s RFC 21 finding. The ALJ found that Plaintiff had the RFC to do the following: 22 23 lift, carry, push and pull up to 50 pounds occasionally and 25 pounds frequently in medium work as defined in 20 CFR 404.1567(c) except he can 24 stand and/or walk 6 hours in an 8-hour day. He can sit 6 hours in an 8-hour 25 day. He may frequently climb ramps and stairs, stoop, kneel, crouch and crawl. He may occasionally climb ladders, ropes and scaffolds. He must 26 avoid more than occasional exposure to extreme cold and heat. He can 27 learn, remember and perform simple, routine and repetitive work tasks, which are performed in a routine, predictable, and low stress work 28 1 environment (defined as one in which there are no rapid production pace work tasks or high quota requirements, few work place changes, and no 2 close personal supervision). He may attend and concentrate for 2 hours at a 3 time with normal breaks. He may have occasional contact with supervisors. He may have occasional and superficial contact with coworkers. He should 4 have no contact with the public. 5 6 AR at 22. In making this RFC determination, the ALJ did not rely on a medical opinion 7 that assessed how Plaintiff’s impairments impact his ability to work. See Rivera v. 8 Berryhill, No. ED CV 16-791-SP, 2017 WL 5054656, at *5 (C.D. Cal. Oct. 31, 2017) 9 (“The absence of a medical opinion is not necessarily fatal, but the RFC determination 10 still must be supported by substantial evidence.”). 11 ALJ found Plaintiff could handle fifty pounds occasionally and twenty-five pounds 12 frequently. Id. at 22. However, during a May 2018 VA visit, a nurse practitioner noted 13 several limitations. AR at 555. The nurse noted that Plaintiff should “avoid repetitive 14 pushing/pulling, bending/squatting/twisting; avoid any activities that involve heavy 15 vibration; allow for alternation of sitting/standing; allow for stretching breaks; no 16 prolonged walking; avoid stairs; no lifting > 10 pounds.” Id. Although the ALJ did not 17 give weight to the state agency consultant opinion statements, the May 2018 VA visit 18 appears to be consistent with the July 2016 state opinion statement. Compare id., with id. 19 at 84–85. For example, a physician assessing Plaintiff’s physical RFC for a Title XVI 20 application found that Plaintiff could occasionally lift or carry twenty pounds; frequently 21 lift or carry ten pounds; stand and sit for six hours; occasionally climb ramps and stairs; 22 never climb ladders, ropes, and scaffolds; and occasionally balance, stoop, kneel, crouch, 23 and crawl. See id. at 84–85. The bulk of the Commissioner’s proffered evidence in the 24 objection and shown in the ALJ’s decision is unclearly related to Plaintiff’s ability to 25 handle a certain number of pounds. See Doc. No. 15 at 3; AR 24. 26 In part, the ALJ’s RFC finding regarding weight-handling relies on a VA staff 27 physician noting that Plaintiff had “5/5” strength in his extremities as well as other 28 “longitudinal evidence.” AR at 367, 673. However, the ALJ does not explain how the 1 extremity strength test correlates with Plaintiff’s exertional capacity to handle “medium 2 work” of twenty-five to fifty pounds or how it correlates with endurance. For example, 3 the evidence leaves open the question of how the 5/5 strength test and other longitudinal 4 evidence precludes a finding of “heavy” or “very heavy” work in excess of fifty pounds. 5 See 20 C.F.R. § 404.1567. The ALJ improperly interpreted the raw medical data of the 6 strength test and then extrapolated its meaning based on peripheral physical activity. See 7 Rivera, 2017 WL 5054656, at *4 (quoting Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 8 1999)). Thus, the ALJ’s reliance on the strength test to show Plaintiff’s work level 9 appears arbitrary at worst and inconsistent or ambiguous when paired with the medical 10 opinions at best. As the Magistrate Judge correctly noted, “the strength test created an 11 ambiguity in the record that required further inquiry.” Doc. No. 14 at 16 (citing McLeod 12 v. Astrue, 640 F.3d 881, 885 (9th Cir. 2011)). 13 Indeed, the ALJ remarked on this inconsistency. See AR at 27. The ALJ noted 14 that the VA opinions of “poor functional capacity,” a ten-pound lifting limit, and 15 decreased exertional capacity were inconsistent with the “longitudinal evidence”: the 16 stress tests,2 “plans on going [to the VA exercise room] 3-4 times a week” despite not 17 being cleared by cardiology, the explanation on the importance of exercise and the 18 unnecessary handicap placard, and Plaintiff’s swimming and basketball playing during 19 free time. See id. at 27. Although the ALJ states the evidence reveals an “inconsistency” 20 with the VA opinions, see id., the ALJ does not resolve the inconsistency. The 21 “longitudinal evidence” of vague, undescribed exercise patterns fails to amount to 22 substantial evidence to show how the ALJ reached the weight-related RFC determination. 23 The lack of a relied-upon medical opinion coupled with the ALJ’s analysis reveals the 24 ALJ’s weight-related RFC finding “is evidently nothing more than the ALJ’s ‘own 25 26 27 2 As the ALJ found, the exercise stress test, which stopped at eight minutes and thirty-three seconds, adds a layer to the inconsistency. See AR at 27. The test includes a comment that Plaintiff’s functional 28 1 exploration and assessment’ of Plaintiff’s impairments.” McAnally, 2020 WL 1443734, 2 at *7; see also Banks v. Barnhart, 434 F. Supp. 2d 800, 805 (C.D. Cal. 2006) (first 3 quoting Balsamo v. Chater, 142 F.3d 75, 81 (2d Cir. 1998); and then quoting Rohan v. 4 Chater, 98 F.3d 966, 970 (7th Cir. 1996)) (citing Day v. Weinberger, 522 F.2d 1154, 5 1156 (9th Cir. 1975)) (“An ‘ALJ cannot arbitrarily substitute his own judgment for 6 competent medical opinion’ . . . [,] and he ‘must not succumb to the temptation to play 7 doctor and make [his] own independent medical findings.’”). 8 Thus, the ALJ’s determination regarding Plaintiff’s capacity to handle medium 9 work weight is unsupported by substantial evidence. Similarly, the ALJ’s RFC 10 determinations regarding Plaintiff’s ability to “frequently climb ramps and stairs, stoop, 11 kneel, crouch and crawl . . . [and] occasionally climb ladders, ropes and scaffolds” is 12 unsupported by substantial evidence. AR at 22. A VA nurse practitioner noted that 13 Plaintiff should avoid these activities in repetition. Id. at 555; see also id. AR 84–85 14 (revealing similar limitations in the state agency evaluation assessing Plaintiff’s physical 15 RFC for the Title XVI application). As with the medium work finding, the ALJ’s RFC 16 finding on these activities is not supported by substantial evidence and there is ambiguity 17 in the record that required further development. 18 The Court now turns to the ALJ’s RFC determination regarding Plaintiff’s ability 19 to “learn, remember and perform simple, routine and repetitive work tasks.” Id. at 22. 20 A February 2018 VA psychiatry appointment revealed he was agitated and aggressive. 21 See AR at 595. The psychiatrist provided the following opinions: Plaintiff’s military 22 trauma resulted in “severe PTSD” that has a “very severe” effect on his overall 23 functioning, which “rendered him unable to work” and “permanently and completely 24 disabled.” 3 Id. at 596; see also id. at 644, 621, 595–56 (noting that Plaintiff appeared 25 “mildly agitated and aggressive” and “[c]onstricted, anxious, and agitated” despite being 26
27 3 As the Commissioner correctly notes, this ultimate conclusion addresses a dispositive issue reserved to 28 1 well-dressed, well-groomed, and having a “[c]alm and cooperative attitude,” while 2 additionally noting the “very severe” effect of Plaintiff’s mental impairments in 3 December 2017, January 2018, and February 2018 psychiatrist appointment notes). 4 Notably, the ALJ found several severe mental impairments at step two of the analysis— 5 generalized anxiety disorder, PTSD, depression/depressive disorder—and then found 6 Plaintiff capable of completing “simple, routine and repetitive work tasks.” Compare id. 7 at 19, 22 (noting the severe impairments), with 20 C.F.R. § 404.1520(c) (stating that a 8 severe impairment is one that “significantly limits your physical or mental ability to do 9 basic work activities”), SSR 85-28, S.S.R. Cum. Ed. (“Examples of [basic work 10 activities] are walking, standing, sitting, lifting, pushing, pulling, reaching, carrying or 11 handling; seeing, hearing, and speaking; understanding, carrying out, and remembering 12 simple instructions; use of judgment, responding appropriately to supervision, coworkers, 13 and usual work situations; and dealing with changes in a routine work setting.”), and SSR 14 96-8p (providing similar activities for “nonexertional capacity” and work-related mental 15 activities as applied to RFC). 16 However, the ALJ came to a different conclusion than the VA psychiatrist. See 17 AR at 22, 24–26. The ALJ relied upon evidence showing progress in appearance and 18 behavior; engagement in group psychotherapy sessions, therapy skills sessions, and work 19 therapy programs; and self-employment through selling things online and employment 20 with a parking company. Id. at 24–26. Despite Plaintiff demonstrating improvement in 21 his group sessions, see id. at 629, 623, 604, 597, 591, 586, 585, 584, 562, 558, 552–53, 22 547, 545–46 (spanning various group sessions from January 2018 to May 2018), the 23 record indicates he still experienced some effects of his mental disorders, see id. at 591 24 (becoming “quickly angry and frazzled” in engaging with a group activity in February 25 2018), 585 (attributing his isolation to his PTSD in March 2018), 545–46 (sharing that he 26 continues to struggle with managing his anger despite some improvement in May 2018). 27 The ALJ appears to have brushed aside several individual psychiatric assessment notes in 28 favor of conflicting subjective observations taken from various sources. 1 The ALJ did not look into the significance of Plaintiff’s severe mental impairments 2 through a consultative examination that could have considered his progress, the basis for 3 the remarks by the psychiatrist during the February 2018 VA visit, and the various 4 changes in Plaintiff’s treatment—such as the extent his prescription regime affects his 5 ability to work. Reports of improvement regarding mental health issues “must be 6 interpreted with an understanding of the patient’s overall well-being and the nature of 7 [his] symptoms” and “must also be interpreted with an awareness that improved 8 functioning while being treated and while limiting environmental stressors does not 9 always mean that a claimant can function effectively in a workplace.” See Garrison v. 10 Colvin, 759 F.3d 995, 1017 (9th Cir. 2014). An inference of improved functioning is 11 especially cautioned where “no doctor or other medical expert has opined, on the basis of 12 a full review of all relevant records, that a mental health patient is capable of working or 13 is prepared to return to work.” Id. at 2017–18. 14 The Court finds that the record reveals an ambiguity that the ALJ did not resolve. 15 Given the circumstances, the conflicting nature of the VA opinion statements and other 16 evidence in the record triggered the ALJ’s duty to fully and fairly develop the record. 17 See McLeod, 640 F.3d at 885 (quoting Mayes v. Massanari, 276 F.3d 453, 459–60 (9th 18 Cir. 2001)); see also Davis v. Comm’r of Soc. Sec., No. 2:18-cv-2415-WBS-KJN, 2020 19 WL 1451551, at *4–5 (E.D. Cal. Mar. 25, 2020), report and recommendation adopted, 20 2020 WL 1865686 (E.D. Cal. Apr. 14, 2020) (finding that the ALJ had a duty to develop 21 the record further based on a few compelling facts that favor remand). Where “the record 22 contains conflicting medical evidence, the ALJ is charged with determining credibility 23 and resolving the conflict.” Banks 434 F. Supp. 2d at 805 (quoting Benton v. Barnhart, 24 331 F.3d 1030, 1040 (9th Cir. 2003)) (citing Batson v. Comm’r of Soc. Sec. Admin., 359 25 F.3d 1190, 1195 (9th Cir. 2004)); see also Molina v. Berryhill, No. 2:17-cv-01991 CKD, 26 2018 WL 6421287, at *3 (E.D. Cal. Dec. 6, 2018) (quoting Tonapetyan, 242 F.3d at 27 1150) (“Ambiguous evidence . . . triggers the ALJ’s duty to ‘conduct an appropriate 28 inquiry.’”). In light of the ambiguity in the evidence, the Court finds there is a lack of 1 |/substantial evidence to support the ALJ’s RFC finding on Plaintiff's capacity to learn, 2 ||remember, and perform simple, routine, and repetitive work tasks. 3 IV. CONCLUSION 4 For the foregoing reasons, the Court OVERRULES the Commissioner’s 5 ||objection, ADOPTS the Magistrate Judge’s R&R, and GRANTS in part and DENIES 6 ||in part Plaintiff's motion for summary judgment. The Court REMANDS this matter to 7 ||the Social Security Administration pursuant to sentence four of 42 U.S.C. § 405(g) for 8 ||further administrative proceedings consistent with this Court’s Order and the Magistrate 9 || Judge’s R&R. The Court DIRECTS the Clerk of Court to enter judgment accordingly 10 close the case. 11 IT IS SO ORDERED. 12 13 ||}Dated: March 24, 2021 14 . i 16 United States District Judge 17 18 19 20 21 22 23 24 25 26 27 28