Georgia F. v. SSA Commissioner

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 GEORGIA F., Case No. 24-cv-09072-EKL

8 Plaintiff, ORDER REVERSING AND 9 v. REMANDING

10 SSA COMMISSIONER, Re: Dkt. No. 11 Defendant. 11

12 13 Plaintiff Georgia F.1 appeals a final decision of the Commissioner of Social Security 14 (“Commissioner”) denying her application for disability insurance benefits under Title II of the 15 Social Security Act (“Act”), 42 U.S.C. § 423 et seq. The Court carefully reviewed the parties’ 16 briefs and the complete administrative record. Administrative Record, ECF No. 8 (“AR”). For 17 the reasons set forth below, this case is REVERSED and REMANDED for further administrative 18 proceedings consistent with this Order. 19 I. BACKGROUND 20 A. Factual Background 21 In July 2022, Plaintiff filed an application for Title II disability insurance benefits. AR 22 197. Plaintiff’s application was denied both initially and on reconsideration. AR 93, 101. The 23 Administrative Law Judge (“ALJ”) held a hearing and subsequently issued an unfavorable 24 decision on June 5, 2024. AR 14, 31. Plaintiff requested review of the unfavorable decision by 25 the Appeals Council, which was also denied. AR 1-3. Plaintiff now seeks judicial review of the 26

27 1 Because this Order contains potentially sensitive medical information, Plaintiff’s name is 1 decision denying her application for benefits. 2 Plaintiff was 64 years old as of her alleged disability onset date.2 She alleges she is 3 disabled due to the following impairments: cervical and lumbar radiculopathy, carpal tunnel 4 syndrome, trigger finger of the fourth digit, asthma, COPD, sleep apnea, GERD, coronary artery 5 disease, hypertension, irritable bowel syndrome, diabetes mellitus, dysfunction of the left pupil, 6 and major depressive disorder (recurring). AR 20, 221. Plaintiff completed college in the 7 Philippines, AR 222, and has a long work history in the health care industry in the United States, 8 AR 223. Plaintiff worked as a nurse from 1991 to 2006, and then as the director of patient care 9 services for a hospital from 2006 to her alleged disability onset date. AR 223. 10 B. Summary of ALJ Findings 11 In the unfavorable decision, the ALJ determined that Plaintiff met the insured status 12 requirements of the Act through the date of the decision. AR 18. At step one of the sequential 13 evaluation process,3 the ALJ found that Plaintiff has not engaged in substantial gainful activity 14 since her alleged onset date. AR 20. At step two,4 the ALJ concluded that Plaintiff has the 15 following severe impairments: “right carpal tunnel syndrome, trigger finger of the 4th digit, [and] 16 lumbar and cervical spine disorder.” AR 20. The ALJ found that these medically determinable 17 impairments significantly limit Plaintiff’s ability to perform basic work activities. AR 20. The 18 ALJ determined that Plaintiff’s remaining impairments are not severe. AR 20-21. At step three,5 19 the ALJ concluded that Plaintiff does not have an impairment or combination of impairments that 20 meets or medically equals the severity of one of the impairments listed in the Commissioner’s 21

22 2 Plaintiff alleges a disability onset date of November 1, 2021. AR 17, 63. 3 In determining whether an individual is disabled under the Act, the ALJ is required to follow a 23 five-step sequential evaluation process. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). At step one, the ALJ must determine whether the claimant has engaged in substantial gainful activity since 24 the alleged onset of the disability. Id. § 404.1520(a)(4)(i). 25 4 At step two, the ALJ must determine if the claimant has an impairment or combination of impairments that are “severe,” meaning that the impairment or impairments “significantly limit[] 26 the claimant’s ‘physical or mental ability to do basic work activities.’” Ford v. Saul, 950 F.3d 1141, 1148 (9th Cir. 2020) (quoting 20 C.F.R. § 404.1522(a)). 27 5 At step three, the ALJ determines whether the claimant has an impairment or combination of 1 regulations. AR 21. At step four,6 the ALJ found that Plaintiff has the residual functional 2 capacity (“RFC”) to perform a full range of medium work, without any non-exertional or 3 environmental limitations. AR 21-24. The ALJ determined that Plaintiff has past relevant work 4 “as a composite job consisting of a registered nurse/general duty nurse (DOT 075.364-010) a 5 medium exertion level skilled job with an SVP-7 and a director of patient care/health care facility 6 administrator (DOT 187-117-010) a light (performed at light, and medium, and heavy) exertion 7 level skilled job with an SVP-8.” AR 24. Based on vocational expert testimony, the ALJ 8 determined that Plaintiff cannot perform her past relevant work as it was actually performed. AR 9 24. At step five,7 the ALJ found that jobs exist in the national economy that Plaintiff can perform, 10 including packager, cleaner, and food service worker. AR 25. Accordingly, the ALJ concluded 11 that Plaintiff was not disabled, as defined by the Act, from the alleged onset date through the date 12 of the decision. AR 25. Plaintiff timely appealed the ALJ’s unfavorable decision, and the case 13 was reassigned to this Court. 14 II. LEGAL STANDARD 15 Pursuant to 42 U.S.C. § 405(g), this Court has the authority to review the Commissioner’s 16 decision to deny benefits. The Court can affirm, modify, or reverse the agency’s decision, with or 17 without remanding the case for a rehearing. See 42 U.S.C. § 405(g). The ALJ’s decision may be 18 reversed only if it is not supported by substantial evidence or if the ALJ committed a legal error. 19 Ahearn v. Saul, 988 F.3d 1111, 1115-16 (9th Cir. 2021) (citation omitted). Substantial evidence 20 means “more than a mere scintilla but may be less than a preponderance.” Id. (quoting Molina v. 21 Astrue, 674 F.3d 1104, 1110-11 (9th Cir. 2012), superseded by regulation on other grounds). It is 22 “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 23 24 6 At step four, the ALJ assesses the claimant’s residual functional capacity, which is the most a claimant can do despite their limitations. The ALJ must determine whether the claimant has the 25 capacity to do their past relevant work. If the claimant is unable to do any past relevant work or does not have any past relevant work, the analysis proceeds to step five. 26 7 At step five, the ALJ must determine whether the claimant can perform “other work” that exists in “significant numbers in the national economy.” 20 C.F.R. §§ 404.1520(a)(4)(v), 404.1560(c). 27 In making this determination, the ALJ may rely on the Medical-Vocational Guidelines, 20 C.F.R. 1 Biestek v. Berryhill, 587 U.S. 97, 103 (2019). 2 When determining whether substantial evidence exists to support the Commissioner’s 3 decision, the court must “consider the entire record as a whole and may not affirm simply by 4 isolating a specific quantum of supporting evidence.” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 5 882 (9th Cir. 2006) (citation modified). If the evidence supports more than one rational 6 interpretation, the court must defer to the Commissioner’s decision. Ahearn, 988 F.3d at 1115-16 7 (citation omitted). “Finally, the court will not reverse an ALJ’s decision for harmless error, which 8 exists when it is clear from the record that the ALJ’s error was inconsequential to the ultimate 9 nondisability determination.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008) (citation 10 modified). 11 III. DISCUSSION 12 On appeal, Plaintiff argues that the ALJ’s RFC determination is not supported by 13 substantial evidence.8 Pl.’s Br. at 5-7, ECF No. 11. The Court agrees. 14 A. RFC Determination 15 “The RFC is an administrative assessment of the extent to which an individual’s medically 16 determinable impairment(s), including any related symptoms, such as pain, may cause physical or 17 mental limitations or restrictions that may affect his or her capacity to do work-related physical 18 and mental activities.” Laborin v. Berryhill, 867 F.3d 1151, 1153 (9th Cir. 2017) (citation 19 modified). Here, the ALJ found that Plaintiff, who was 64 years old as of her alleged onset date 20 and was diagnosed with degenerative disease of the lumbar spine, carpal tunnel syndrome, and 21 asthma/COPD, can perform “the full range of medium work,” without any non-exertional or 22 environmental limitations. AR 21. 23 The ALJ erred in at least three regards when formulating Plaintiff’s RFC. First, the ALJ 24 erred in evaluating the objective medical evidence. Second, the ALJ erred in rejecting Plaintiff’s 25 subjective symptom testimony. Third, the ALJ erred by failing to consider all of Plaintiff’s 26

27 8 Plaintiff also argues that the ALJ erred at step two in finding that Plaintiff’s mental health 1 impairments. As a result of these errors, the ALJ’s RFC determination is not supported by 2 substantial evidence. 3 1. Evaluation of the Objective Medical Evidence 4 The ALJ’s determination that the objective medical evidence is consistent with medium 5 work is not supported by substantial evidence. As an initial matter, Plaintiff’s objective medical 6 records indicating numbness in her arms and hands and pain with walking and range of motion 7 exercises do not appear to be consistent with the requirements of medium work. Medium work 8 requires standing or walking “for a total of approximately 6 hours in an 8-hour work day,” 9 frequently “lifting or carrying objects weighing up to 25 pounds,” use of arms and hands “to 10 grasp, hold, and turn objects,” and frequent bending or stooping. SSR 83-10. “In most medium 11 jobs, being on one’s feet for most of the workday is critical.” Id. 12 The objective medical evidence establishes that Plaintiff has a history of pain that impacts 13 her ability to stand, balance, and walk. Most notably, Plaintiff has been diagnosed with 14 degenerative disease of the lumbar spine, lumbar radiculopathy, and degenerative changes of the 15 pubic symphysis. Records reflect that these conditions have been present and worsening since at 16 least 2020. See, e.g., AR 503 (10/14/20 – “chronic” and “worsening” low back pain with bilateral 17 radicular symptoms), 574-75 (9/17/21 – CT finding “[m]ultilevel degenerative changes of the 18 spine”), 784 (7/28/22 – “history of lumbar radiculopathy [and] degenerative joint disease”), 849 19 (5/12/23 – Patient “presents with chronic low back pain,” “signs and symptoms consistent with 20 lumbar radiculopathy,” “decreased lumbar range,” “decreased sensation on the left lower 21 extremity,” and “pain with PIVMS to L1/2-L4/5,” requiring “skilled PT intervention to address 22 her current impairments”), 1476 (1/20/23 – x-ray finding degenerative disease of the lumbar spine 23 and pubic symphysis), 1523-24 (7/30/21 – CT finding degenerative disc disease with 24 spondylolisthesis at L4/5). Providers have noted abnormal gait, decreased balance, coordination, 25 and range of motion, as well as pain with all range of motion testing and walking. See, e.g., AR 26 501, 503, 846, 1239. The record further reflects that these conditions cause “an impaired 27 functional ability to walk and sleep.” AR 503. Consequently, Plaintiff has engaged in physical 1 prescribed 650 mg of Tylenol every six hours. See, e.g., AR 721, 784, 813, 843. 2 In addition, Plaintiff has a history of shoulder pain and chronic, severe abdominal pain that 3 further erodes her functional capacity to stand, walk, and lift or carry objects up to 25 pounds. As 4 for her shoulder pain, Plaintiff has undergone two shoulder surgeries and testified that she has 5 declined additional surgeries because the two prior surgeries did not help. See AR 22. As for her 6 abdominal pain, Plaintiff has repeatedly sought treatment, undergone various forms of imaging, 7 and has been prescribed pain medication beginning a few months before her alleged onset date and 8 continuing through the date of medical records available in the administrative record. See, e.g., 9 AR 841 (2023), 889-90 (2022), 942 (2021), 948 (2021), 979 (2021). Finally, Plaintiff has been 10 diagnosed with carpal tunnel syndrome and trigger finger, resulting in pain and numbness in her 11 arm, wrist, and fingers. AR 1209 (noting fourth finger locks in place), 1210 (noting decreased 12 tissue mobility and grip strength). 13 Given the objective medical records, the ALJ’s RFC findings are unsupported. Rather, it 14 appears that the ALJ acted as his own medical expert by independently assessing clinical findings. 15 Black v. Bisignano, No. 24-CV-01303, 2025 WL 1683872, at *4 (E.D. Cal. June 16, 2025) 16 (collecting cases) (“Ninth Circuit courts have found that ‘barring a few exceptions, an ALJ must 17 have a doctor’s opinion of a claimant’s functional capacity in order for there to be substantial 18 evidence supporting the decision[].’”). For example, the ALJ concluded that reducing Plaintiff to 19 medium work addresses limitations – including “manipulative limitations” – relating to her carpal 20 tunnel syndrome and trigger finger because the condition is “mild.” AR 24. The ALJ made this 21 determination without any medical opinion of record to that effect, and despite the record 22 reflecting reduced grip strength, pain, and numbness. AR 1209-10. In doing so, the ALJ erred. 23 Black, 2025 WL 1683872, at *4 (collecting cases) (“[A]n ALJ is not permitted to render their own 24 medical opinions or independently assess clinical findings.”). 25 Because the ALJ assessed Plaintiff’s RFC without any medical opinions and did so in a 26 manner that appears facially inconsistent with the objective medical evidence, the ALJ’s RFC 27 determination is not supported by substantial evidence. 1 2. Evaluation of Plaintiff’s Subjective Symptom Testimony 2 Plaintiff’s subjective symptom testimony is incompatible with medium work, and the ALJ 3 did not provide “clear and convincing” reasons for rejecting her testimony. At the hearing, 4 Plaintiff testified that she can only stand or walk for 5-10 minutes before needing to sit and rest, 5 that she cannot carry more than 10 pounds, and that she experiences shortness of breath when 6 performing household chores such as washing the dishes. AR 42-44. She further testified that she 7 had an accommodation at her previous job that restricted her to lifting or carrying no more than 10 8 pounds at a time. AR 44. The ALJ concluded that this testimony is not supported by Plaintiff’s 9 “conservative” course of treatment.9 AR 23. The Court disagrees on two bases. 10 First, Plaintiff’s course of treatment has not been conservative. Plaintiff has undergone 11 two shoulder surgeries, has been referred to pain management and acupuncture, and has been 12 prescribed opioid pain medication as well as 650 mg Tylenol every six hours. See, e.g., AR 721, 13 813, 1223. This does not indicate conservative treatment. See, e.g., Contreras v. Colvin, No. 13- 14 CV-01237, 2015 WL 859626, at *11 (E.D. Cal. Feb. 27, 2015) (“[S]urgery is not considered 15 conservative treatment.” (citing Ritchotte v. Astrue, 281 F. App’x 757, 759 (9th Cir. 2008))); Rose 16 P. v. Comm’r of SSA, 414 F. Supp. 3d 1339, 1344 (W.D. Wash. 2019) (holding that claimant’s 17 course of treatment was not a clear and convincing reason to discredit her testimony when she 18 received opioid pain medication and trigger point injections). In addition, the ALJ has not pointed 19 to any non-conservative treatment options that would address Plaintiff’s multifaceted conditions 20 and complex symptomatology. Plaintiff “cannot be discredited for failing to pursue non- 21 conservative treatment options where none exist.”10 Lapeirre-Gutt v. Astrue, 382 F. App’x 662, 22

23 9 The ALJ also discredited Plaintiff’s testimony regarding “shortness of breath” as unsupported by the medical record. This was error because the medical record reflects symptoms of shortness of 24 breath supporting Plaintiff’s testimony. See, e.g., AR 363-64 (cardiac stress test terminated due to shortness of breath and chest pain), 470 (positive for shortness of breath), 614 (albuterol nebulizer 25 prescribed every 4 hours as needed for shortness of breath), 728 (same). 10 In support of his conclusion that Plaintiff’s “conservative” treatment is inconsistent with her 26 symptom testimony, the ALJ states that Plaintiff had “no significant treatment until May 2023.” AR 23. However, this statement ignores her prior treatment, and that Plaintiff began taking opioid 27 medication for pain in July 2021. AR 1174. The ALJ does not explain how this is not “significant 1 664 (9th Cir. 2010) (rejecting an adverse credibility determination where “the record [did] not 2 reflect that more aggressive treatment options are appropriate or available”). 3 In support of his conclusion that Plaintiff’s “conservative” treatment is inconsistent with 4 her symptom testimony, the ALJ states that Plaintiff “did not complete physical therapy.” AR 22- 5 23. However, the ALJ does not engage with Plaintiff’s explanations for not completing physical 6 therapy on two occasions. Although “unexplained, or inadequately explained, failure to seek 7 treatment or follow a prescribed course of treatment” can cast doubt on a claimant’s sincerity, 8 Spindel v. Comm’r Soc. Sec. Admin., 333 F. App’x 174, 176 (9th Cir. 2009), here, the ALJ does 9 not address the reasons Plaintiff offered for not completing physical therapy. In July 2022, 10 Plaintiff declined to restart physical therapy, but Plaintiff explained to her provider that she 11 preferred to do exercises that she learned in prior rounds of physical therapy on her own. See AR 12 884. After eventually restarting physical therapy, Plaintiff stopped physical therapy after one of 13 her appointments in September 2023, because she was leaving to visit the Philippines for several 14 months, to attempt to sell her parent’s house. See AR 1199, 1210. Moreover, because medical 15 records are only available through November 2023, it is unclear whether Plaintiff completed 16 additional physical therapy upon return home. Thus, the ALJ’s conclusion that Plaintiff’s 17 symptom testimony is inconsistent with her “conservative” treatment is not supported by 18 substantial evidence. 19 Second, regardless of how the ALJ characterizes Plaintiff’s course of treatment, “the 20 critical question . . . is whether substantial evidence supports the ALJ’s inference that” Plaintiff’s 21 symptoms are not as severe as she alleges because she failed to undergo more aggressive 22 treatment. Brown v. Colvin, No. ED CV 14-101-E, 2014 WL 5330722, at *3 (C.D. Cal. Oct. 20, 23 2014). Here, the objective evidence detailed above appears entirely consistent with Plaintiff’s 24 testimony, and the ALJ offered no explanation for how Plaintiff’s course of treatment is 25 inconsistent with her testimony that she cannot walk for more than 5-10 minutes before needing to 26

27 cannot accurately be described as ‘conservative’ treatment’”); Tina S. v. Comm’r of Soc. Sec., No. 1 rest and that she cannot carry more than 10 pounds. Cf. Streeter v. Saul, 835 F. App’x 305, 306 2 (9th Cir. 2021) (explaining that “[s]ubstantial evidence supported the ALJ’s findings” where 3 plaintiff’s testimony “was inconsistent with [her] conservative course of treatment[.]”). Even if 4 the objective evidence did not support these allegations – though it does – a claimant’s subjective 5 testimony “cannot be rejected solely because the objective medical evidence does not support the 6 severity of [plaintiff’s] impairment.” Thomas v. Barnhart, 278 F.3d 947, 960 (9th Cir. 2002). 7 * * * 8 In sum, the ALJ did not provide clear and convincing reasons for rejecting Plaintiff’s 9 symptom testimony. 10 3. Consideration of Plaintiff’s Non-Severe Impairments 11 In formulating the RFC, an ALJ must consider all medically determinable impairments, 12 including those that are not “severe.” 20 C.F.R. § 404.1545(a)(2) (“We will consider all of your 13 medically determinable impairments of which we are aware, including your medically 14 determinable impairments that are not ‘severe[.]’”); see also Weiskopf v. Berryhill, 693 F. App’x 15 539, 541-42 (9th Cir. 2017) (citation omitted). Here, the ALJ did not meaningfully assess the 16 extent to which Plaintiff’s “non-severe” impairments would impact her RFC. For example, the 17 record reflects that Plaintiff has a variety of additional conditions that may not amount to severe 18 impairments individually, but must nevertheless be considered as part of Plaintiff’s RFC. These 19 include but are not limited to Plaintiff’s asthma/COPD, depression, anxiety, visual impairments, 20 and balance issues. As to Plaintiff’s asthma and COPD, the ALJ did not provide for any 21 environmental restrictions, such as avoiding fumes, dust, and poor ventilation. See SSR 85-15; 22 see also AR 363-64, 614, 728 (medical records supporting shortness of breath). The ALJ likewise 23 provided for no limitations in climbing, balancing, stooping, kneeling, crouching, reaching, or 24 handling, each of which potentially erode the availability of jobs in the national economy. SSR 25 85-15 (explaining that an inability to stoop from one-third to two-thirds of the time would 26 substantially effect the availability of medium work). 27 * * * 1 inconsistent with the objective medical evidence and Plaintiff’s credible symptom testimony. 2 Accordingly, remand is required. 3 B. Remand for Further Proceedings 4 On remand, the ALJ must reassess Plaintiff’s RFC consistent with this Order. Specifically, 5 the ALJ must account for Plaintiff’s severe and non-severe impairments in formulating her RFC. 6 Those impairments include: cervical and lumbar radiculopathy, carpal tunnel syndrome, trigger 7 finger of the fourth digit, chronic and recurring abdominal pain, asthma, COPD, sleep apnea, 8 GERD, coronary artery disease, hypertension, irritable bowel syndrome, diabetes mellitus, 9 dysfunction of the left pupil, and major depressive disorder (recurring). AR 20. The ALJ must 10 also consider all relevant exertional, non-exertional, and environmental limitations. For example, 11 the ALJ must consider the extent to which Plaintiff’s combined impairments and pain impact her 12 ability to stand or walk during an eight-hour workday, lift or carry objects, climb, balance, stoop, 13 kneel, and crouch. 14 To the extent Plaintiff’s subjective testimony regarding her limitations is consistent with 15 the medical evidence in the record, when evaluating her RFC, the ALJ must incorporate those 16 limitations, including an inability to stand or walk for more than 5-10 minutes or carry more than 17 10 pounds. The ALJ must further consider the extent to which Plaintiff’s shoulder impairment, 18 cervical and lumbar radiculopathy, carpal tunnel, and trigger finger impact Plaintiff’s ability to 19 reach, handle, finger, and feel. See SSR 85-15 (explaining that reaching and handling are 20 “activities required in almost all jobs”). In addition, the ALJ must consider the extent to which 21 Plaintiff’s blurred vision impairs her ability to perform work at all exertional levels. See, e.g., AR 22 1034, 1202, 1207. Finally, the ALJ must consider the extent to which Plaintiff’s mental health 23 conditions impair her ability to maintain full-time employment at any exertion level. To 24 determine whether there are clear and convincing reasons to not fully credit Plaintiff’s subjective 25 testimony, the ALJ may need to further develop the record before formulating her RFC. Mayes v. 26 Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001) (“An ALJ’s duty to develop the record further is 27 triggered . . . when the record is inadequate to allow for proper evaluation of the evidence.”). 1 IV. DISPOSITION 2 For the foregoing reasons, the case is REMANDED to the Commissioner for further 3 || proceedings consistent with this Order. 4 IT IS SO ORDERED. 5 Dated: March 17, 2026 6 7 umi K. Lee 8 United States District Judge 9 10 1] a 12

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