1 2 3 4 5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 ZACHARY S D., 8 Plaintiff, Case No. C23-6107 RSM 9 v. ORDER REVERSING DENIAL OF 10 BENEFITS AND REMANDING COMMISSIONER OF SOCIAL SECURITY, FOR FURTHER PROCEEDINGS 11 Defendant. 12
13 Plaintiff seeks review of the denial of his applications for Supplemental Security Income 14 (SSI) and Disability Insurance Benefits (DIB). Plaintiff contends the ALJ erred by rejecting his 15 symptom testimony and medical opinion evidence. Dkt. 8. As discussed below, the Court 16 REVERSES the Commissioner’s final decision and REMANDS the matter for further 17 administrative proceedings under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is 31 years old, has at least a high school education, and has worked as a hand 20 packager. Admin. Record (AR) 27. In June 2021, Plaintiff applied for benefits, alleging 21 disability as of November 29, 2017. AR 66, 75, 85, 94. Plaintiff’s applications were denied 22 initially and on reconsideration. AR 73, 82, 91, 100. After conducting a hearing in March 2023 23 (AR 34–64), the ALJ issued a decision finding Plaintiff not disabled from his alleged onset date ORDER REVERSING DENIAL OF 1 through the date of the decision with regards to his SSI application, and not disabled prior to his 2 date last insured of December 31, 2019 with regards to his DIB application. See AR 14–33. 3 DISCUSSION 4 The Court may reverse the ALJ’s decision only if it is legally erroneous or not supported 5 by substantial evidence of record. Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The Court 6 must examine the record but cannot reweigh the evidence or substitute its judgment for the 7 ALJ’s. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When evidence is susceptible to 8 more than one interpretation, the Court must uphold the ALJ’s interpretation if rational. Ford, 9 950 F.3d at 1154. Also, the Court “may not reverse an ALJ’s decision on account of an error 10 that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012).
11 1. Plaintiff’s Symptom Testimony 12 Plaintiff testified he is unable to work because of severe social phobia. AR 50. He 13 explained he does not leave his home because he panics when around others. AR 51, 55. In his 14 function reports, Plaintiff wrote he has depression, mood swings, and issues with his memory 15 and concentration. AR 219, 224, 257, 264. 16 Where, as here, an ALJ determines a claimant has presented objective medical evidence 17 establishing underlying impairments that could cause the symptoms alleged, and there is no 18 affirmative evidence of malingering, the ALJ can only discount the claimant’s testimony as to 19 symptom severity by providing “specific, clear, and convincing” reasons supported by 20 substantial evidence. Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 2017). “The standard
21 isn’t whether our court is convinced, but instead whether the ALJ’s rationale is clear enough that 22 it has the power to convince.” Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022). 23 In this case, the ALJ rejected Plaintiff’s testimony, finding his statements regarding the ORDER REVERSING DENIAL OF 1 “intensity, persistence and limiting effects” of his symptoms inconsistent with his record. AR 2 23. The ALJ’s assessment is not entirely supported by substantial evidence. The ALJ first 3 discussed Plaintiff’s mental health treatment records from April 2018, but did not identify the 4 findings that negated Plaintiff’s testimony. See AR 24. The ALJ next pointed to Plaintiff’s 5 longitudinal mental status examinations, describing them as “generally within normal limits.” 6 AR 24–25. “When objective medical evidence in the record is inconsistent with the claimant’s 7 subjective testimony, the ALJ may indeed weigh it as undercutting such testimony.” Smartt, 53 8 F.4th at 498. Evidence highlighted by the ALJ shows Plaintiff was often frequently cooperative, 9 fully oriented with logical thought process, and demonstrated intact memory and concentration 10 with fair insight and judgment. See generally AR 454–564. While these findings would
11 reasonably discount Plaintiff’s testimony regarding his difficulties with concentration and his 12 memory, they do not necessarily speak to his testimony about his social phobia. The ALJ also 13 pointed out that although Plaintiff’s mood “was at times anxious and occasionally depressed,” he 14 also “often presented as euthymic.” AR 25. But the record shows that even with normal mental 15 status findings and a euthymic mood, Plaintiff’s depression or social phobia remained or 16 worsened. See AR 517 (mood euthymic but “continues to struggle with social phobia”), 528 17 (mood euthymic but “[s]till seeks to solitude when attending family events”), 533 (mood 18 euthymic but “continues to struggle with motivation to do things”), 543 (normal examination but 19 assessed with “ongoing” anxiety and depression and no interaction with others), 866 (mood 20 euthymic, depressed, and anxious), 1264 (mood euthymic but still struggling with anxiety and
21 depression). Reviewing the evidence cited by the ALJ, Plaintiff’s mental status examinations do 22 not appear to significantly undermine Plaintiff’s statements. In rejecting Plaintiff’s testimony 23 based its inconsistency with objective medical evidence, the ALJ erred. ORDER REVERSING DENIAL OF 1 The ALJ also rejected Plaintiff’s testimony based on his improvement from treatment. 2 AR 25. The effectiveness of medication and treatment is relevant to the evaluation of a 3 claimant’s alleged symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). However, the ALJ’s 4 assessment is only partially supported by the record. Most of the treatment notes cited by the 5 ALJ show reduction in Plaintiff’s depressive symptoms, but not with Plaintiff’s anxiety. See, 6 e.g., AR 483 (“made significant progress in reducing depressive symptoms” but anxiety remains 7 “[p]ersistent”), 510 (mild depression but anxiety exacerbated by irritability), 511 (“[d]epressive 8 symptoms responding fairly well to treatment” but anxiety remains “[p]ersistent”), 542 (mild 9 depression but anxiety worsened by visitors), 561–62 (moderate depression but severe anxiety). 10 Furthermore, any observations about Plaintiff’s anxiety lessening were explained by Plaintiff
11 avoiding interacting with others, not necessarily his medication, supporting Plaintiff’s 12 statements. See AR 1192, 1198. 13 Finally, the ALJ rejected Plaintiff’s testimony based on his activities of daily living. AR 14 25. An ALJ may discount a claimant’s symptom testimony when it is inconsistent with the 15 claimant’s general activity level. See Molina, 674 F.3d at 1112–13. The ALJ’s assessment is 16 lacking. The ALJ highlighted Plaintiff’s reports of his “adequate energy” to play video games 17 and help with household chores, but did not explain how Plaintiff’s capacity to partake in these 18 activities undermine his testimony regarding his inability to interact with others. See AR 25. 19 The ALJ also pointed out Plaintiff was able to attend college full time. Id. There are records, 20 however, implying Plaintiff stopped attending school. See AR 543, 723, 889, 940, 952, 967,
21 1057, 1126. Defendant counters Plaintiff did not allege becoming disabled after attending 22 college, but rather as of November 2017, therefore the ALJ reasonably found Plaintiff more 23 capable than alleged. Dkt. 12 at 6.
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1 2 3 4 5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 ZACHARY S D., 8 Plaintiff, Case No. C23-6107 RSM 9 v. ORDER REVERSING DENIAL OF 10 BENEFITS AND REMANDING COMMISSIONER OF SOCIAL SECURITY, FOR FURTHER PROCEEDINGS 11 Defendant. 12
13 Plaintiff seeks review of the denial of his applications for Supplemental Security Income 14 (SSI) and Disability Insurance Benefits (DIB). Plaintiff contends the ALJ erred by rejecting his 15 symptom testimony and medical opinion evidence. Dkt. 8. As discussed below, the Court 16 REVERSES the Commissioner’s final decision and REMANDS the matter for further 17 administrative proceedings under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is 31 years old, has at least a high school education, and has worked as a hand 20 packager. Admin. Record (AR) 27. In June 2021, Plaintiff applied for benefits, alleging 21 disability as of November 29, 2017. AR 66, 75, 85, 94. Plaintiff’s applications were denied 22 initially and on reconsideration. AR 73, 82, 91, 100. After conducting a hearing in March 2023 23 (AR 34–64), the ALJ issued a decision finding Plaintiff not disabled from his alleged onset date ORDER REVERSING DENIAL OF 1 through the date of the decision with regards to his SSI application, and not disabled prior to his 2 date last insured of December 31, 2019 with regards to his DIB application. See AR 14–33. 3 DISCUSSION 4 The Court may reverse the ALJ’s decision only if it is legally erroneous or not supported 5 by substantial evidence of record. Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The Court 6 must examine the record but cannot reweigh the evidence or substitute its judgment for the 7 ALJ’s. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When evidence is susceptible to 8 more than one interpretation, the Court must uphold the ALJ’s interpretation if rational. Ford, 9 950 F.3d at 1154. Also, the Court “may not reverse an ALJ’s decision on account of an error 10 that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012).
11 1. Plaintiff’s Symptom Testimony 12 Plaintiff testified he is unable to work because of severe social phobia. AR 50. He 13 explained he does not leave his home because he panics when around others. AR 51, 55. In his 14 function reports, Plaintiff wrote he has depression, mood swings, and issues with his memory 15 and concentration. AR 219, 224, 257, 264. 16 Where, as here, an ALJ determines a claimant has presented objective medical evidence 17 establishing underlying impairments that could cause the symptoms alleged, and there is no 18 affirmative evidence of malingering, the ALJ can only discount the claimant’s testimony as to 19 symptom severity by providing “specific, clear, and convincing” reasons supported by 20 substantial evidence. Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 2017). “The standard
21 isn’t whether our court is convinced, but instead whether the ALJ’s rationale is clear enough that 22 it has the power to convince.” Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022). 23 In this case, the ALJ rejected Plaintiff’s testimony, finding his statements regarding the ORDER REVERSING DENIAL OF 1 “intensity, persistence and limiting effects” of his symptoms inconsistent with his record. AR 2 23. The ALJ’s assessment is not entirely supported by substantial evidence. The ALJ first 3 discussed Plaintiff’s mental health treatment records from April 2018, but did not identify the 4 findings that negated Plaintiff’s testimony. See AR 24. The ALJ next pointed to Plaintiff’s 5 longitudinal mental status examinations, describing them as “generally within normal limits.” 6 AR 24–25. “When objective medical evidence in the record is inconsistent with the claimant’s 7 subjective testimony, the ALJ may indeed weigh it as undercutting such testimony.” Smartt, 53 8 F.4th at 498. Evidence highlighted by the ALJ shows Plaintiff was often frequently cooperative, 9 fully oriented with logical thought process, and demonstrated intact memory and concentration 10 with fair insight and judgment. See generally AR 454–564. While these findings would
11 reasonably discount Plaintiff’s testimony regarding his difficulties with concentration and his 12 memory, they do not necessarily speak to his testimony about his social phobia. The ALJ also 13 pointed out that although Plaintiff’s mood “was at times anxious and occasionally depressed,” he 14 also “often presented as euthymic.” AR 25. But the record shows that even with normal mental 15 status findings and a euthymic mood, Plaintiff’s depression or social phobia remained or 16 worsened. See AR 517 (mood euthymic but “continues to struggle with social phobia”), 528 17 (mood euthymic but “[s]till seeks to solitude when attending family events”), 533 (mood 18 euthymic but “continues to struggle with motivation to do things”), 543 (normal examination but 19 assessed with “ongoing” anxiety and depression and no interaction with others), 866 (mood 20 euthymic, depressed, and anxious), 1264 (mood euthymic but still struggling with anxiety and
21 depression). Reviewing the evidence cited by the ALJ, Plaintiff’s mental status examinations do 22 not appear to significantly undermine Plaintiff’s statements. In rejecting Plaintiff’s testimony 23 based its inconsistency with objective medical evidence, the ALJ erred. ORDER REVERSING DENIAL OF 1 The ALJ also rejected Plaintiff’s testimony based on his improvement from treatment. 2 AR 25. The effectiveness of medication and treatment is relevant to the evaluation of a 3 claimant’s alleged symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). However, the ALJ’s 4 assessment is only partially supported by the record. Most of the treatment notes cited by the 5 ALJ show reduction in Plaintiff’s depressive symptoms, but not with Plaintiff’s anxiety. See, 6 e.g., AR 483 (“made significant progress in reducing depressive symptoms” but anxiety remains 7 “[p]ersistent”), 510 (mild depression but anxiety exacerbated by irritability), 511 (“[d]epressive 8 symptoms responding fairly well to treatment” but anxiety remains “[p]ersistent”), 542 (mild 9 depression but anxiety worsened by visitors), 561–62 (moderate depression but severe anxiety). 10 Furthermore, any observations about Plaintiff’s anxiety lessening were explained by Plaintiff
11 avoiding interacting with others, not necessarily his medication, supporting Plaintiff’s 12 statements. See AR 1192, 1198. 13 Finally, the ALJ rejected Plaintiff’s testimony based on his activities of daily living. AR 14 25. An ALJ may discount a claimant’s symptom testimony when it is inconsistent with the 15 claimant’s general activity level. See Molina, 674 F.3d at 1112–13. The ALJ’s assessment is 16 lacking. The ALJ highlighted Plaintiff’s reports of his “adequate energy” to play video games 17 and help with household chores, but did not explain how Plaintiff’s capacity to partake in these 18 activities undermine his testimony regarding his inability to interact with others. See AR 25. 19 The ALJ also pointed out Plaintiff was able to attend college full time. Id. There are records, 20 however, implying Plaintiff stopped attending school. See AR 543, 723, 889, 940, 952, 967,
21 1057, 1126. Defendant counters Plaintiff did not allege becoming disabled after attending 22 college, but rather as of November 2017, therefore the ALJ reasonably found Plaintiff more 23 capable than alleged. Dkt. 12 at 6. That Plaintiff stopped attending school after his alleged onset ORDER REVERSING DENIAL OF 1 date would not necessarily detract from his testimony, given there are some records that imply 2 Plaintiff stopped attending because of his mental health. See AR 889, 1126. Further, the record 3 indicates Plaintiff was no longer attending by June 2018, prior to his date last insured and 4 therefore during the time period that he must establish disability for his DIB application. See 5 Vertigan v. Halter, 260 F.3d 1044, 1047 n.1 (9th Cir. 2001). Therefore, the ALJ cannot 6 reasonably discount Plaintiff’s testimony for this reason. 7 In sum, the ALJ erred in failing to provide at least one valid reason, supported by 8 substantial evidence, to reject Plaintiff’s symptom testimony. This error is not harmless, as a 9 proper evaluation of Plaintiff’s testimony could have led to a different residual functionality 10 (RFC) assessment and thus change the ALJ’s decision that Plaintiff was not disabled. As the
11 ultimate disability determination may have changed, the ALJ’s error is not harmless and requires 12 reversal. 13 2. Dr. Anderson and Dr. Fitterer 14 Under the applicable rules, the ALJ must “articulate how [he] considered the medical 15 opinions” and “how persuasive [he] find[s] all of the medical opinions” by considering 16 their supportability, consistency, relationship with the claimant, specialization, and other factors. 17 20 C.F.R. §§ 404.152c(c), 416.920c(c). The ALJ is specifically required to consider the two 18 most important factors, supportability and consistency. 20 C.F.R. §§ 404.1520c(a), 416.920c(a). 19 The supportability factor requires the ALJ to consider the relevance of the objective medical 20 evidence and the supporting explanations presented by the medical source to justify their
21 opinion. 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1). The consistency factor involves 22 consideration of how consistent a medical opinion is with the other record evidence. 20 C.F.R. 23 §§ 404.1520c(c)(2), 416.920c(c)(2). Further, under the new regulations, “an ALJ cannot reject ORDER REVERSING DENIAL OF 1 an examining or treating doctor’s opinion as unsupported or inconsistent without providing an 2 explanation supported by substantial evidence.” Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 3 2022). 4 Both Dr. Anderson and Dr. Fitterer opined Plaintiff is moderately limited in several 5 concentration and persistence, as well as social interaction, functionalities. AR 71, 80, 89–90, 6 98–99. They explained that “due to waxing and waning symptoms of depression and social 7 anxiety,” Plaintiff is moderately limited “in performing activities within a schedule, 8 maintain[ing] regular attendance; sustain[ing] an ordinary routine without special supervision; 9 work[ing] in coordination with or in proximity to others without being distracted by them and … 10 complet[ing] a normal workday/workweek without interruptions from psychologically based
11 symptoms.” Id. They also opined that due to his social anxiety, Plaintiff “should not work 12 directly with public,” though he does have the ability to interact with supervisors. Id. 13 The ALJ found their opinions “inconsistent with and unsupported by the medical 14 evidence and [Plaintiff’s] demonstrated functioning,” but the ALJ’s assessment is not supported 15 by substantial evidence. See AR 26–27. First, the ALJ’s supportability analysis did not identify 16 which of the doctors’ findings failed to support their opinions. See 20 C.F.R. § 404.1520c(c)(1), 17 416.920c(c)(1) (“The more relevant the objective medical evidence and supporting explanations 18 presented by a medical source are to support his or her medical opinion(s) or prior administrative 19 medical finding(s), the more persuasive the medical opinions or prior administrative medical 20 finding(s) will be.”). Second, in finding the doctors’ opinions inconsistent with the record, the
21 ALJ referenced the same objective medical evidence in rejecting Plaintiff’s symptom testimony. 22 However, as discussed above, most of Plaintiff’s examinations do not address Plaintiff’s inability 23 to interact with others and are not necessarily reliable in showing Plaintiff’s mental health given ORDER REVERSING DENIAL OF 1 Plaintiff could present normally while concurrently displaying depression and anxiety symptoms. 2 The ALJ also cited to Plaintiff’s activities of daily living and ability to attend school, but again, 3 the ALJ provided no explanation how such activities would necessarily relate to Plaintiff’s social 4 phobia and there are conflicting records about Plaintiff’s school attendance. In sum, because the 5 ALJ’s rejection of Dr. Anderson’s and Dr. Fitterer’s opinions fails to meet the substantial 6 evidence standard, the ALJ erred. 7 3. Other Issues1 8 Plaintiff suggests the ALJ erred by failing to develop his record after his hearing. Dkt. 8 9 at 2. Plaintiff also contends the ALJ’s erroneous evaluation of medical opinion evidence led to 10 an erroneous residual functional capacity (RFC) assessment. Id. at 7. The Court need not
11 address these arguments at this time as the ALJ’s error in evaluating Plaintiff’s testimony 12 necessitates remanding this case for further proceedings. 13 CONCLUSION 14 For the foregoing reasons, the Commissioner’s final decision is REVERSED and this 15 case is REMANDED for further administrative proceedings under sentence four of 42 U.S.C. § 16 405(g). On remand, the ALJ should reevaluate Plaintiff’s symptom testimony and the medical 17 opinion evidence, reassess Plaintiff’s RFC, proceed with the rest of the sequential analysis, and if 18 necessary, take appropriate measures to ensure the record is complete. 19 DATED this 4th day of June, 2024. A 20 21 RICARDO S. MARTINEZ UNITED STATES DISTRICT JUDGE 22
23 1 Plaintiff’s counsel is reminded to comply with the Court’s briefing requirements as these assignments of error were not included on the first page of his Opening Brief. See Dkt. 7 at 2. ORDER REVERSING DENIAL OF