Marisa P. v. Frank Bisignano, Commissioner of Social Security

Opinion

1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 CENTRAL DISTRICT OF CALIFORNIA 9

11 MARISA P., No. 5:25-cv-02292-AYP

12 Plaintiff, MEMORANDUM OPINION AND 13 v. ORDER

14 FRANK BISIGNANO, 15 Commissioner of Social Security, 16 Defendant. 17

18 Plaintiff Marisa P.1 seeks review of the Commissioner’s denial of her 19 application for disability insurance benefits under Title II of the Social Security 20 Act. (Dkt. No. 1.) The parties consented to proceed before the magistrate judge 21 and thereafter filed briefs addressing the disputed issues. (Dkt. Nos. 6, 9, 12, 22 14, 15.) The Court took the matter under submission without oral argument. 23 For the reasons discussed below, the Court finds that the Commissioner’s 24 decision should be reversed and this matter remanded for further proceedings 25 26 1 Plaintiff’s name is partially redacted in accordance with Federal Rule of 27 Civil Procedure 5.2(c)(2)(B) and the recommendation of the Committee on Court Administration and Case Management of the Judicial Conference of the 28 United States. 1 consistent with this Order. 2 I. BACKGROUND 3 On November 25, 2022, Plaintiff applied for disability insurance benefits, 4 claiming that she had been unable to work since September 22, 2021, due 5 primarily to spinal impairments. (Administrative Record (“AR”) 18, 93.) After 6 her application was denied initially and on reconsideration, she requested a 7 hearing before an administrative law judge (“ALJ”). (AR 93-98, 100-05.) The 8 ALJ conducted a hearing on August 1, 2024, at which Plaintiff appeared with 9 counsel and testified. (AR 37-52.) A vocational expert (“VE”) also testified. (AR 10 52-57.) 11 On September 3, 2024, the ALJ issued a decision denying benefits. (AR 12 15-34.) Following the five-step sequential evaluation process applicable to 13 disability determinations,2 the ALJ found that Plaintiff had the following 14 “severe” impairments: lumbar spine disorder with post laminectomy syndrome, 15 cervical spine disorder with radiculopathy, hypertension, and 16 headaches/migraines. (AR 20.) The ALJ determined that Plaintiff nevertheless 17 retained the residual functional capacity (“RFC”) to perform light work with the 18 following specific limitations: she would need the opportunity to change 19 positions every 30 minutes for one to two minutes; could never climb ladders, 20 ropes, or scaffolds; could not be exposed to dangerous work hazards; could 21 occasionally perform postural activities; could occasionally reach overhead 22 bilaterally; could have only occasional exposure to extreme heat and humidity; 23 could not perform work involving a production-quota pace, such as an assembly- 24

25 2 The ALJ determines disability using a five-step sequential evaluation 26 process, which examines whether (1) the claimant engaged in substantial gainful activity, (2) the claimant has a severe impairment, (3) the impairment 27 meets or equals a listed impairment, (4) the claimant is able to do past relevant work, and (5) the claimant is able to do any other work. 20 C.F.R. § 28 404.1520(a)(4). 1 line environment where one worker’s pace affects others down the line; and 2 could be off task 3% of the workday due to momentary symptom distractions. 3 (AR 23.) 4 At step four, the ALJ found that Plaintiff could not perform her past 5 relevant work as a sales attendant or cashier II. (AR 28.) At step five, relying 6 on the VE’s testimony, the ALJ found that Plaintiff could perform other jobs 7 existing in significant numbers in the national economy, including office helper, 8 router, and escort vehicle driver. (AR 29.) As a result, the ALJ concluded that 9 Plaintiff was not disabled during the relevant period, from her alleged onset 10 date of September 22, 2021, through the date of the ALJ’s decision, September 11 3, 2024. (AR 30.) 12 On October 24, 2024, Plaintiff filed a request with the Appeals Council for 13 review of the ALJ’s decision. (AR 180-82.) The Appeals Council subsequently 14 denied Plaintiff’s request for review. (AR 1-6.) 15 II. STANDARD OF REVIEW 16 Under 42 U.S.C. § 405(g), this Court reviews the Commissioner’s decision 17 to determine whether it is supported by substantial evidence and whether the 18 proper legal standards were applied. Moncada v. Chater, 60 F.3d 521, 523 (9th 19 Cir. 1995). “Substantial evidence” is “more than a mere scintilla,” and means 20 only “such relevant evidence as a reasonable mind might accept as adequate to 21 support a conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (citations 22 omitted). In determining whether substantial evidence supports the ALJ’s 23 findings, the Court must review the administrative record as a whole, weighing 24 both the evidence that supports and the evidence that detracts from the ALJ’s 25 conclusion. Ahearn v. Saul, 988 F.3d 1111, 1115-16 (9th Cir. 2021). When the 26 evidence can rationally be interpreted in more than one way, the Court must 27 uphold the Commissioner’s decision. Id.; Attmore v. Colvin, 827 F.3d 872, 875 28 (9th Cir. 2016). 1 III. DISCUSSION 2 Plaintiff contends that the ALJ improperly rejected the consultative 3 examiner Jonathan Schwartz, M.D.’s opinion that Plaintiff could stand and/or 4 walk for only four hours in an eight-hour workday. (Dkt. No. 12 at 8-15.) As 5 discussed below, the Court agrees. 6 Dr. Schwartz evaluated Plaintiff in November 2023 in connection with her 7 disability claim. (AR 1135-41.) Although Plaintiff demonstrated intact 8 sensation, full strength, and negative straight-leg raising, Dr. Schwartz also 9 observed an antalgic gait, decreased muscle mass involving the left lower 10 extremity, and decreased range of motion of the lumbar and cervical spine. (AR 11 1138-39.) Dr. Schwartz diagnosed Plaintiff with back and neck pain secondary 12 to degenerative changes of the spine, status post lumbar spine surgeries. (AR 13 1139.) Based on these examination findings, Dr. Schwartz opined that Plaintiff 14 could perform a reduced range of light work, except that she could stand and/or 15 walk for only four hours in an eight-hour workday and could stoop only 16 occasionally. (AR 1139-40.) 17 The ALJ found Dr. Schwartz’s opinion only partially persuasive. (AR 27.) 18 The ALJ accepted Dr. Schwartz’s limitations to light work and only occasional 19 stooping. The ALJ found that these limitations were “well supported” by Dr. 20 Schwartz’s examination findings, including a mildly antalgic gait, decreased 21 muscle mass in the left lower extremity, and decreased range of motion of the 22 lumbar and cervical spine, but otherwise benign examination findings. (Id.) 23 However, the ALJ found that the same examination findings did not support 24 Dr. Schwartz’s opinion that Plaintiff could stand and/or walk for only four hours 25 in an eight-hour workday. The ALJ further found that the four-hour stand/walk 26 limitation was inconsistent with more recent evidence showing normal gait and 27 range of motion, mildly abnormal physical examination findings, and no 28 1 weakness. (Id.) 2 Because Plaintiff filed her claim after March 27, 2017, the ALJ was 3 required to evaluate the persuasiveness of Dr. Schwartz’s opinion using the 4 factors set forth in 20 C.F.R. § 404.1520c. Under the revised regulations, 5 supportability and consistency are the “most important factors” in evaluating 6 medical opinion evidence. 20 C.F.R. § 404.1520c(b)(2). “Supportability” 7 concerns the extent to which a medical source supports the opinion with 8 objective medical evidence and supporting explanations, and “consistency” 9 concerns how consistent the opinion is with evidence from other medical and 10 nonmedical sources in the record. 20 C.F.R. § 404.1520c(c)(1)-(2). Although the 11 revised regulations eliminated the requirement that ALJs defer to treating and 12 examining physicians’ opinions, an ALJ must still provide an explanation 13 supported by substantial evidence when rejecting a medical opinion as 14 unsupported or inconsistent with the record. See Woods v. Kijakazi, 32 F.4th 15 785, 792 (9th Cir. 2022). The ALJ’s reasoning must be sufficiently specific to 16 permit meaningful judicial review. See id.; see also Social Security Ruling 17 (“SSR”) 96-8p, 1996 WL 374184, at *7 (July 2, 1996) (“If the RFC assessment 18 conflicts with an opinion from a medical source, the adjudicator must explain 19 why the opinion was not adopted.”). 20 In this case, the ALJ did not adequately explain why Dr. Schwartz’s 21 examination findings supported limitations to light work and occasional 22 stooping, but not Dr. Schwartz’s additional limitation that Plaintiff could stand 23 and/or walk for only four hours in an eight-hour workday. The ALJ 24 acknowledged examination findings including a mildly antalgic gait, decreased 25 muscle mass involving the left lower extremity, and decreased range of motion 26 of the lumbar and cervical spine, yet concluded without further explanation that 27 those same findings did not support the four-hour stand/walk limitation. (AR 28 27.) Under Woods, the ALJ was required to provide more than the conclusory 1 statement that the limitation “was not supported by this evidence.” (Id.); see 2 Woods, 32 F.4th at 792. 3 The ALJ also did not adequately explain the consistency finding 4 underlying her rejection of Dr. Schwartz’s four-hour stand/walk limitation. The 5 longitudinal record reflected both abnormal and relatively benign findings 6 relating to Plaintiff’s lumbar impairment and ability to stand and walk. 7 Treatment records documented lumbar degenerative disc disease and post- 8 laminectomy syndrome following two lumbar spine surgeries, as well as 9 epidural injections and ongoing treatment with Norco and morphine for chronic 10 pain. (AR 370, 390-91, 440, 683, 715.) The record also reflected repeated 11 findings of antalgic gait, painful lumbar and cervical range of motion, calf 12 atrophy, absent ankle reflexes, altered sensation in the left foot, and 13 intermittent lower extremity weakness. (AR 367, 391, 673, 715, 821, 835, 847, 14 874, 963, 1138-39.) And more recent records continued to document 15 compensated or antalgic gait and painful lumbar range of motion. (AR 1153, 16 1173.) To be sure, the record also contained some benign findings, including 17 normal strength, intact sensation, and some normal gait findings. (AR 386-87, 18 391, 808, 821, 835.) However, given this mixed record, the ALJ was required to 19 more fully explain why Dr. Schwartz’s four-hour stand/walk limitation was 20 inconsistent with the evidence.3 See Woods, 32 F.4th at 792; SSR 96-8p, 1996 21 22

23 3 The Court further notes that several of the records that the ALJ cited in support of her inconsistency finding provide only limited support for the ALJ’s 24 conclusion that Dr. Schwartz’s four-hour stand/walk limitation was 25 inconsistent with the longitudinal record. For example, some of the cited records documented antalgic or compensated gait and painful cervical and 26 lumbar range of motion testing. (AR 715, 874, 1153.) Another cited record reflected normal gait but continued to document moderate cervical pain and 27 mild lumbar pain with motion. (AR 1173.) And the February 2024 record reflecting normal range of motion arose in the context of a wound evaluation 28 rather than treatment for Plaintiff’s spinal impairments. (AR 1254.) 1 WL 374184, at *7. 2 Moreover, the ALJ’s error was not harmless. If the ALJ had properly 3 accounted for Dr. Schwartz’s four-hour stand/walk limitation, Plaintiff could not 4 perform the light occupations identified by the VE and relied upon by the ALJ 5 at step five. Nor has Defendant established that Plaintiff could nevertheless 6 perform the remaining sedentary occupation of escort vehicle driver, which 7 appears inconsistent with the RFC’s requirement that Plaintiff have a position 8 change opportunity every 30 minutes for one to two minutes. Accordingly, the 9 Court cannot conclude that the ALJ’s error was harmless. See Garcia v. Comm’r 10 of Soc. Sec. Admin., 768 F.3d 925, 932 (9th Cir. 2014); see also Stout v. Comm’r 11 Soc. Sec. Admin., 454 F.3d 1050, 1055-56 (9th Cir. 2006). Thus, remand is 12 warranted. 13 IV. REMEDY 14 The decision whether to remand for further proceedings or for an 15 immediate award of benefits is within the Court’s discretion. See Treichler v. 16 Comm’r Soc. Sec. Admin., 775 F.3d 1090, 1099-1102 (9th Cir. 2014). When there 17 are outstanding issues that must be resolved before a disability determination 18 can be made and it is not clear from the record that the ALJ would be required 19 to find the claimant disabled if the evidence were properly evaluated, remand 20 for further proceedings is appropriate. Id. In contrast, an immediate award of 21 benefits is appropriate only where further proceedings would serve no useful 22 purpose and the record has been fully developed. Id. 23 Here, the Court finds that further administrative proceedings are 24 warranted because it is not clear from the record that the ALJ would be required 25 to find Plaintiff disabled if Dr. Schwartz’s opinion were properly evaluated. 26 Although the record reflects significant lumbar impairments and related 27 limitations, it also contains mixed objective findings, including intact strength, 28 intact sensation, and normal gait at various examinations. Accordingly, further 1 || administrative proceedings would serve the useful purpose of allowing the ALJ 2 || to properly evaluate Dr. Schwartz’s opinion and reassess Plaintiff's RFC and 3 || ability to perform work existing in significant numbers in the national 4 || economy.* See Treichler, 775 F.3d at 1101-05. 5 V. ORDER 6 For the foregoing reasons, IT IS ORDERED that the decision of the 7 || Commissioner is reversed and this matter is remanded for further proceedings 8 || consistent with this opinion. 9 IT IS SO ORDERED. 10 Il || DATED: June 3, 2026 12 AD. 3 ANNA Y. PARK UNITED STATES MAGISTRATE JUDGE 14 15 16 17 18 19 20 21 22 23 24 25 26 27 4 Because remand is warranted on the ground discussed above, the Court 28 need not reach Plaintiff s remaining claim of error. See Hiler v. Astrue, 687 F.3d 1208, 1212 (9th Cir. 2012).